Diagnosis and Treatment Algorithms of Acute Variceal Bleeding

Neutrophil percentage-to-albumin ratio as predictor for mortality in patients undergoing endoscopic intervention for variceal hemorrhage

BACKGROUND

Variceal bleeding (VB) is a serious condition that can lead to increased hospital costs and mortality rates. The neutrophil percentage-to-albumin ratio (NPAR) has been recognized as a predictor of mortality in various diseases. However, the use of NPAR as a predictor of hospital mortality in patients with VB has not been studied previously.

AIM

To assess the effectiveness of NPAR in predicting mortality in VB patients undergoing endoscopic treatment.

METHODS

This study included 415 cirrhotic patients who were hospitalized for an upper gastrointestinal bleeding and had endoscopy. NPAR was computed at index admission in blood samples. Using the receiver operator characteristic curve (ROC), the sensitivity and specificity of the NPAR for predicting mortality in patients with VB were calculated.

RESULTS

Out of 415 cirrhotic patients, 322 patients with variceal bleeding as the sole culprit bleeding lesion were included in the study, while 93 patients with different bleeding lesions were excluded. Among the 322 patients included in the study, 29 (9%) patients died in hospital. The predictors of death for the cases were NPAR (p = 0.0001, AOR: 1.11, 95% CI 1.06-1.16), hospital stay (p = 0.006, AOR: 1.39, 95% CI 1.10-1.76), and pulse rate (p = 0.0001, AOR: 0.936, 95% CI 0.907-0.965). ROC analyses showed that NPAR at a cut-off value of 27.8 had optimal discriminative power for differentiating between alive and deceased cases with a sensitivity of 82.8%, specificity of 65.9%, PPV of 19.4%, NPV of 97.5%, and an accuracy of 67.4% (p < 0.001).

CONCLUSIONS

NPAR may be a useful predictor of mortality in patients with VB.

Ultrarapid Development of Ruptured Esophageal Varices in a Patient With a History of Heller Myotomy

Esophageal varices commonly affect cirrhotic patients as a result of elevated portal system resistance. Blood pools within esophageal portosystemic collateral vessels, which can eventually rupture, leading to life-threatening hemorrhage. To prevent this, cirrhotic patients without a history of varices undergo endoscopic surveillance for varices every 2-3 years. We present an unusual case of variceal hemorrhage in a patient who was seen to have no varices on endoscopic evaluation only a month earlier.

Emergent Transjugular Intrahepatic Portosystemic Shunt Creation in Acute Variceal Bleeding

Emergent transjugular intrahepatic portosystemic shunt (TIPS) creation is most commonly employed in the setting of acute variceal hemorrhage. Given a propensity for decompensation, these patients often require a multidisciplinary, multimodal approach involving prompt diagnosis, pharmacologic therapy, and endoscopic intervention. While successful in the majority of cases, failure to medically control initial bleeding can prompt interventional radiology consultation for emergent portal decompression via TIPS creation. This article discusses TIPS creation in emergent, acute variceal hemorrhage, reviewing the natural history of gastroesophageal varices, presentation and diagnosis of acute variceal hemorrhage, pharmacologic therapy, endoscopic approaches, patient selection and risk stratification for TIPS, technical considerations for TIPS creation, adjunctive embolotherapy, and the role of salvage TIPS versus early TIPS in acute variceal hemorrhage.