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

Bougie-Facilitated Tamponade Balloon Placement for Massive Esophagogastric Variceal Hemorrhage: A Case Series and Novel Procedural Technique Description

BACKGROUND

Balloon tamponade of esophagogastric variceal hemorrhage is a lifesaving but challenging procedure. One difficulty that often arises is coiling of the tube in the oropharynx. We describe a novel use of the bougie as an external stylet to help guide placemat of the balloon to help overcome this challenge.

DISCUSSION

We describe four cases in which the bougie was successfully utilized as an external stylet to place a tamponade balloon (3 Minnesota tubes, 1 Sengstaken-Blakemore tube) without any apparent complication. The straight end of the bougie is inserted approximately 0.5 cm into the most proximal of the gastric aspiration ports. The tube is then inserted into the esophagus under direct or video laryngoscopic visualization using the bougie to help "push" the tube into place as an external stylet. Once the gastric balloon is fully inflated and withdrawn to the gastroesophageal junction, the bougie is gently removed.

CONCLUSION

The bougie may be considered as an adjunct for placement of tamponade balloons for massive esophagogastric variceal hemorrhage when placement proves refractory to traditional techniques. We think this can be a valuable tool in the emergency physician's procedural repertoire.

The current knowledge about the therapeutic use of endoscopic sclerotherapy and endoscopic tissue adhesives in variceal bleeding

Introduction: The most recent guidelines vary in their approach to the management of variceal bleeding especially with the use of endoscopic sclerotherapy (ES) and endoscopic tissue adhesive (ETA). This review highlights their clinical use for variceal bleeding from different guidelines perspectives. Areas covered: A comprehensive literature review of three major guidelines including the American Association for the Study of Liver Diseases (AASLD) 2017, United Kingdom (UK) guidelines 2015 and Baveno VI Consensus workshop guidelines in 2015 on the use of ES and ETA in variceal bleeding. Expert opinion: While endoscopic band ligation (EBL) completely replaced endoscopic sclerotherapy (ES) for esophageal varices. There is a valuable use of endoscopic sclerotherapy (ES) and endoscopic tissue adhesive (ETA) especially for patients with gastroesophageal varices (GOV2) and isolated gastric varices (IGV2). The current standard of care heading toward portosystemic shunting with Trans-jugular-Intrahepatic Portosystemic Shunt (TIPS) and balloon retrograde transvenous obliteration (BRTO). However, recent advancement in endoscopic ultrasound (EUS) allowing direct injection of sclerosant and tissue adhesive into the varix bringing promising results in achieving hemostasis and lowering the risk of complications. Also, ES and ETA have great clinical value in achieving hemostasis for isolated (ectopic) varices and stomal varices.

Prophylactic Endoscopic Therapy for Variceal Bleeding in Patients with Hepatocellular Carcinoma

Background & Aims: To evaluate the efficacy and timing of secondary prophylactic endoscopic therapy for variceal bleeding. To determine the long-term survival and identify the prognostic factors in patients with hepatocellular carcinoma.

Methods: A Retrospective study was conducted. We included patients with concurrent hepatic carcinoma who received endoscopic therapy for variceal bleeding. A Kaplan-Meier survival analysis was performed. Potential factors for prediction were compared with Cox's proportional hazard model analysis.

Results: 192 patients were included between January 2008 and December 2014. During follow-up (median 17 months), 102 patients presented with an episode of rebleeding. The cumulative 6-month, 1- and 5-year rebleeding rates were 40.9%, 49.3% and 71.2%. A total of 98 patients died during follow-up. The overall 6-month, 1-and 5-year cumulative mortality rates were 33.5%, 45.8% and 65.7%. BCLC C/D stage (P=0.035, HR=1.53, 95% CI 1.003-2.327) was an independent predictor of bleeding relapse, while BCLC C/D staging (P=0.035, HR=1.59, 95% CI 1.033-2.454) and male gender (P=0.007, HR=1.58, 95% CI 1.135-2.198) predicted shorter survival times. Combination ligation and cyanoacrylate was associated with a decreased rebleeding and mortality rate in patients with both esophageal and gastric varices (P=0.003). The start time of the initial endoscopic procedure did not affect treatment efficacy.

Conclusions: Ligation combined with cyanoacrylate could be preferred for HCC patients presented with both esophageal and gastric varices. BCLC C/D stage predicted shorter survival times and bleeding relapse, while male gender was an independent predictor of poor survival.

Terlipressin for the treatment of acute variceal bleeding: A systematic review and meta-analysis of randomized controlled trials

BACKGROUND AND AIM

Acute variceal bleeding (AVB) is life-threatening. We aimed to systematically review the current evidence regarding the efficacy and safety of terlipressin for AVB in liver cirrhosis.

METHODS

We searched the PubMed, EMBASE, and Cochrane Library databases. The reference list was also hand-searched. Using a random-effect model, we combined the data obtained according to the different time points when the events developed. Odds ratio (OR) and weighted mean difference (WMD) were calculated. Quality of evidence was evaluated by the GRADE methodology.

RESULTS

Thirty randomized controlled trials with 3344 patients were included. Compared with no vasoactive drug, terlipressin significantly improved the control of bleeding within 48 hours (OR = 2.94, P = .0008) and decreased the in-hospital mortality (OR = 0.31, P = .008). Compared with somatostatin, terlipressin had a significantly higher risk of complications (OR = 2.44, P = .04). Compared with octreotide, terlipressin had a significantly inferior control of bleeding within 24 hours (OR = 0.37, P = .007). Compared with vasopressin, terlipressin had a significantly lower risk of complications (OR = 0.15, P = .02). Compared with terlipressin combined with endoscopic variceal ligation, terlipressin alone had significantly higher 5-day treatment failure (OR = 14.46, P = .01) and transfusion requirements within 49 to 120 hours (WMD = 1.20, P = .002). No outcome was significantly different between terlipressin and sclerotherapy. Compared with balloon tamponade, terlipressin significantly decreased the 30-day rebleeding (OR = 0.05, P = .001) and transfusion requirements (WMD = -2.70, P = .02). Quality of evidence was very low to moderate.

CONCLUSION

Our findings were in accordance with the current recommendations regarding terlipressin for the treatment of AVB in cirrhosis. However, due to low quality of evidence, further studies are recommended.

Innovative Technique for Endoscopic Placement of Sengstaken-Blakemore Tube

OBJECTIVES

The Sengstaken-Blakemore (SB) tube is used in cases of uncontrolled variceal bleeding. Because of the complexity of the procedure and the lack of visualization, various techniques have been described to avoid blind placement. We report an innovative and simple technique for placement of the SB tube under direct endoscopic visualization.

METHODS

A grasp-and-place technique for endoscopic placement of SB tubes is described and a retrospective cohort study chart review of endoscopies done for variceal bleeding in our medical center is reported. All patients with uncontrolled variceal bleeding who required placement of an SB tube from July 1, 2013 through December 31, 2015 were included. The primary outcome analyses were technical success of tube placement and achievement of hemostasis.

RESULTS

Of 143 endoscopies done for variceal bleeding, 10 were managed with SB tubes placed endoscopically after initial endoscopic therapy was unsuccessful. Successful placement of the tube was achieved in all of the patients. Hemostasis was achieved in 9 of the 10 patients.

CONCLUSIONS

We propose a new grasp-and-place technique for endoscopic placement of SB tubes. Review of our experience shows that massive variceal bleeding can be managed effectively with this technique.