1
|
Shung DL, Laine L. Review article: Upper gastrointestinal bleeding - review of current evidence and implications for management. Aliment Pharmacol Ther 2024; 59:1062-1081. [PMID: 38517201 DOI: 10.1111/apt.17949] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Revised: 10/27/2023] [Accepted: 03/04/2024] [Indexed: 03/23/2024]
Abstract
BACKGROUND Acute upper gastrointestinal bleeding (UGIB) is a common emergency requiring hospital-based care. Advances in care across pre-endoscopic, endoscopic and post-endoscopic phases have led to improvements in clinical outcomes. AIMS To provide a detailed, evidence-based update on major aspects of care across pre-endoscopic, endoscopic and post-endoscopic phases. METHODS We performed a structured bibliographic database search for each topic. If a recent high-quality meta-analysis was not available, we performed a meta-analysis with random effects methods and odds ratios with 95% confidence intervals. RESULTS Pre-endoscopic management of UGIB includes risk stratification, a restrictive red blood cell transfusion policy unless the patient has cardiovascular disease, and pharmacologic therapy with erythromycin and a proton pump inhibitor. Patients with cirrhosis should be treated with prophylactic antibiotics and vasoactive medications. Tranexamic acid should not be used. Endoscopic management of UGIB depends on the aetiology. For peptic ulcer disease (PUD) with high-risk stigmata, endoscopic therapy, including over-the-scope clips (OTSCs) and TC-325 powder spray, should be performed. For variceal bleeding, treatment should be customised by severity and anatomic location. Post-endoscopic management includes early enteral feeding for all UGIB patients. For high-risk PUD, PPI should be continued for 72 h, and rebleeding should initially be evaluated with a repeat endoscopy. For variceal bleeding, high-risk patients or those with further bleeding, a transjugular intrahepatic portosystemic shunt can be considered. CONCLUSIONS Management of acute UGIB should include treatment plans for pre-endoscopic, endoscopic and post-endoscopic phases of care, and customise treatment decisions based on aetiology and severity of bleeding.
Collapse
Affiliation(s)
| | - Loren Laine
- Yale School of Medicine, New Haven, Connecticut, USA
- West Haven Veterans Affairs Medical Center, West Haven, Connecticut, USA
| |
Collapse
|
2
|
Khalifa A, Rockey DC. Role of Endoscopy in the Diagnosis, Grading, and Treatment of Portal Hypertensive Gastropathy and Gastric Antral Vascular Ectasia. Gastrointest Endosc Clin N Am 2024; 34:263-274. [PMID: 38395483 DOI: 10.1016/j.giec.2023.09.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/25/2024]
Abstract
Portal hypertensive gastropathy (PHG) and gastric antral vascular ectasia (GAVE) are 2 distinct gastric vascular abnormalities that may present with acute or chronic blood loss. PHG requires the presence of portal hypertension and is typically associated with chronic liver disease, whereas there is controversy about the association of GAVE with chronic liver disease and/or portal hypertension. Distinguishing between GAVE and PHG is crucial because their treatment strategies differ. This review highlights characteristic endoscopic appearances and the clinical features of PHG and GAVE, which, in turn, aid in their appropriate management.
Collapse
Affiliation(s)
- Ali Khalifa
- Digestive Disease Research Center, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Don C Rockey
- Digestive Disease Research Center, Medical University of South Carolina, Charleston, South Carolina, USA.
| |
Collapse
|
3
|
Meyers MH, Rodriguez L, Kriss MS. A Practical Approach to the Management of Gastric Antral Vascular Ectasia. Am J Gastroenterol 2023; 118:1532-1535. [PMID: 37040555 DOI: 10.14309/ajg.0000000000002290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Accepted: 04/07/2023] [Indexed: 04/13/2023]
Affiliation(s)
- Matthew H Meyers
- Department of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Laura Rodriguez
- Department of Internal Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Michael S Kriss
- Department of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| |
Collapse
|
4
|
Che CC, Shiu SI, Ko CW, Tu YK, Chang CH. Comparisons Between Endoscopic Band Ligation, Radiofrequency Ablation and Endoscopic Thermal Therapy for Gastric Antral Vascular Ectasia: A Meta-Analysis. Dig Dis Sci 2023; 68:3534-3541. [PMID: 37490152 PMCID: PMC10444674 DOI: 10.1007/s10620-023-08028-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2022] [Accepted: 04/25/2023] [Indexed: 07/26/2023]
Abstract
BACKGROUND Endoscopic band ligation (EBL) and radiofrequency ablation (RFA) have emerged as alternative therapies of gastric antral vascular ectasia (GAVE) in addition to endoscopic thermal therapy (ETT), but the optimum choice remains inconclusive. AIM We conducted a meta-analysis in order to compare these three treatments for GAVE. METHODS We searched the electronic databases of PubMed, Embase and Cochrane Central Register of Controlled Trials without any language restrictions and also performed a manual literature search of bibliographies located in both retrieved articles and published reviews for eligible publications prior to December 8, 2021. We included comparative trials which had evaluated the efficacy and safety of interventions in adults (aged ≥ 18 years) diagnosed with symptomatic GAVE and was confirmed according to clinical backgrounds and upper gastrointestinal endoscopy. We included reports that compared three interventions, ETT, EBL, and RFA. The study was comprised of adults diagnosed with GAVE and focused on overall mortality, bleeding cessation, endoscopic improvement, complications, hospitalization, hemoglobin improvement, number of sessions and transfusion requirements. RESULTS Twelve studies were performed involving a total of 571 participants for analysis. When compared with ETT, EBL achieved better bleeding cessation (OR 4.48, 95% CI 1.36-14.77, p = 0.01), higher hemoglobin improvement (MD 0.57, 95% CI 0.31-0.83, p < 0.01) and lower number of sessions (MD - 1.44, 95% CI - 2.54 to - 0.34, p = 0.01). Additionally, EBL was superior to ETT in endoscopic improvement (OR 6.00, 95% CI 2.26-15.97, p < 0.01), hospitalization (MD - 1.32, 95% CI - 1.91 to - 0.74, p < 0.01) and transfusion requirement (MD - 2.66, 95% CI - 4.67 to - 0.65, p = 0.01) with statistical significance, with the exception of mortality (OR 0.58, 95% CI 0.19-1.77, p = 0.34) and complication rate (OR 5.33, 95% CI 0.58-48.84, p = 0.14). CONCLUSION For GAVE, we suggest that EBL be initially recommended, and APC and RFA be used as alternative treatment choices based upon a very low quality of evidence.
Collapse
Affiliation(s)
- Cheng-Che Che
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Sz-Iuan Shiu
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
- Department of Critical Care Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
- Evidence-Based Practice and Policymaking Committee, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Chung-Wang Ko
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Yu-Kang Tu
- Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan
- Heath Data Research Center, National Taiwan University, Taipei, Taiwan
- Department of Dentistry, National Taiwan University Hospital and School of Dentistry, National Taiwan University, Taipei, Taiwan
| | - Chung-Hsin Chang
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
| |
Collapse
|
5
|
Vanderschueren E, Trebicka J, Laleman W. Endoscopic Advances in Hepatology. Semin Liver Dis 2023; 43:176-188. [PMID: 37192654 DOI: 10.1055/s-0043-1769009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/18/2023]
Abstract
Endoscopy is and remains an indispensable tool in diagnosing and managing liver disease and its complications. Due to the progress in advanced endoscopy, endoscopy has become an alternative route for many surgical, percutaneous, and angiographic interventions, not only as a backup tool when conventional interventions fail but increasingly as a first-line choice. The term endo-hepatology refers to the integration of advanced endoscopy in the practice of hepatology. Endoscopy is key in the diagnosis and management of esophageal and gastric varices, portal hypertensive gastropathy, and gastric antral vascular ectasia. Endoscopic ultrasound (EUS) can be used for the evaluation of the liver parenchyma, liver lesions, and surrounding tissues and vessels, including targeted biopsy and complemented with new software functions. Moreover, EUS can guide portal pressure gradient measurement, and assess and help manage complications of portal hypertension. It is crucial that each present-day hepatologist is aware of the (rapidly increasing) full spectrum of diagnostic and therapeutic tools that exist within this field. In this comprehensive review, we would like to discuss the current endo-hepatology spectrum, as well as future directions for endoscopy in hepatology.
Collapse
Affiliation(s)
- Emma Vanderschueren
- Department of Gastroenterology and Hepatology, University Hospital Leuven, Leuven, Belgium
- Department of Chronic Diseases, Metabolism and Aging (CHROMETA), Catholic University of Leuven, Leuven, Belgium
| | - Jonel Trebicka
- Department of Gastroenterology and Hepatology, Universitätsklinikum Münster, Münster, Germany
- European Foundation for the Study of Chronic Liver Failure, Barcelona, Spain
| | - Wim Laleman
- Department of Gastroenterology and Hepatology, University Hospital Leuven, Leuven, Belgium
- Department of Chronic Diseases, Metabolism and Aging (CHROMETA), Catholic University of Leuven, Leuven, Belgium
- Department of Gastroenterology and Hepatology, Universitätsklinikum Münster, Münster, Germany
| |
Collapse
|
6
|
Gairing SJ, Schleicher EM, Müller L, Labenz C, Darstein F, Grimm D, Sivanathan V, Weinmann A, Wörns MA, Kloeckner R, Pitton MB, Thieringer F, Rahman KF, Galle PR, Schattenberg JM, Foerster F. Bevacizumab in combination with octreotide rescues a patient with liver cirrhosis, GAVE syndrome and refractory hemorrhage - a case report. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2023; 61:275-279. [PMID: 36379462 DOI: 10.1055/a-1959-2660] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Gastric antral vascular ectasia (GAVE) syndrome is a rare but often challenging etiology of upper gastrointestinal bleeding (UGIB).We report on a 60-year-old patient with liver cirrhosis, GAVE syndrome and recurrent and refractory GAVE-related UGIB. During a 5-month hospital stay, the patient required a total of 82 packed red blood cells (pRBCs) and 23 gastroscopies. All endoscopic approaches, including multiple argon plasma coagulation and band ligation sessions, remained unsuccessful. Antrectomy was waived because of the high perioperative mortality risk in Child-Pugh B liver cirrhosis. TIPS insertion also failed to control the bleeding. Only continuous intravenous octreotide infusion slowed the bleeding, but this forced the patient to be hospitalized. After 144 inpatient days, administration of subcutaneous octreotide allowed the patient to be discharged. However, the patient continued to require two pRBCs every 2-3 weeks. Based on recently published data, we treated the patient with bevacizumab (anti-VEGF antibody) off-label at a dose of 7.5 mg/kg body weight every three weeks in nine single doses over six months. Since the first administration, the patient has remained transfusion-free, has not required hospitalization, and leads an active life, working full-time. He remains on octreotide, which has been reduced but not yet discontinued. Additionally, no adverse events were observed.Thus, in patients with liver cirrhosis and refractory GAVE-related hemorrhage, bevacizumab combined with subcutaneous octreotide should be considered as an effective and durable pharmacological treatment option.
Collapse
Affiliation(s)
- Simon Johannes Gairing
- Department of Internal Medicine I, University Medical Centre of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Eva Maria Schleicher
- Department of Internal Medicine I, University Medical Centre of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Lukas Müller
- Department of Diagnostic and Interventional Radiology, University Medical Centre of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Christian Labenz
- Department of Internal Medicine I, University Medical Centre of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Felix Darstein
- Department of Internal Medicine I, University Medical Centre of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Daniel Grimm
- Department of Internal Medicine I, University Medical Centre of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Visvakanth Sivanathan
- Department of Internal Medicine I, University Medical Centre of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Arndt Weinmann
- Department of Internal Medicine I, University Medical Centre of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Marcus-Alexander Wörns
- Department of Gastroenterology, Hematology, Oncology and Endocrinology, Hospital Dortmund, Dortmund, Germany
| | - Roman Kloeckner
- Department of Diagnostic and Interventional Radiology, University Medical Centre of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Michael B Pitton
- Department of Diagnostic and Interventional Radiology, University Medical Centre of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Florian Thieringer
- Department of Internal Medicine I, University Medical Centre of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Khan Fareed Rahman
- Department of Internal Medicine I, University Medical Centre of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Peter Robert Galle
- Department of Internal Medicine I, University Medical Centre of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Jörn M Schattenberg
- Department of Internal Medicine I, University Medical Centre of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Friedrich Foerster
- Department of Internal Medicine I, University Medical Centre of the Johannes Gutenberg University Mainz, Mainz, Germany
| |
Collapse
|
7
|
Mohan BP, Toy G, Kassab LL, Ponnada S, Chandan S, Parbhu S, Chandna S, Adler DG. Endoscopic band ligation in the treatment of gastric antral vascular ectasia: a systematic review and meta-analysis. Gastrointest Endosc 2021; 94:1021-1029.e10. [PMID: 34480922 DOI: 10.1016/j.gie.2021.08.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Accepted: 08/14/2021] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Gastric antral vascular ectasia (GAVE) is typically treated by endoscopic thermal therapies. Endoscopic band ligation (EBL) has been reported in the treatment of GAVE with encouraging results. However, EBL is not widely used to this end. METHODS We conducted a comprehensive search of several databases (inception to May 2021) to identify studies reporting on the use of EBL in the treatment of GAVE. A random-effects model was used to calculate the pooled rates; I2 values and 95% prediction intervals were calculated to assess the heterogeneity. RESULTS Ten studies (194 patients) were included in the final analysis. The pooled rate of treatment responders with EBL in GAVE was 81% (95% confidence interval [CI], 62.2-91.7), and GAVE recurrence was 15.4% (95% CI, 4.5-41.3). The pooled mean number of treatment sessions required was 2.4 (95% CI, 2.2-2.7), and the number of bands used to achieve eradication per patient was 15.1 (95% CI, 10.7-19.4). The pooled mean difference of pre- to post-treatment hemoglobin was 1.5 (95% CI, .9-2.2; P = .001), pre- to post-treatment units of packed red blood cells transfused was 1.1 (95% CI, .4-1.9; P = .002), and pre- to post-treatment hospital length of stay was .5 days (95% CI, .1-.9; P = .01). The pooled rate of overall adverse events was 15.9% (95% CI, 10.4-23.7). CONCLUSIONS EBL demonstrated excellent clinical outcomes in the treatment of GAVE with minimal adverse events. Multicenter randomized controlled trials comparing EBL and other modalities as initial therapy are warranted.
Collapse
Affiliation(s)
- Babu P Mohan
- Department of Gastroenterology & Hepatology, University of Utah Health School of Medicine, Salt Lake City, Utah, USA
| | - Gregory Toy
- Department of Internal Medicine, University of Utah Health School of Medicine, Salt Lake City, Utah, USA
| | - Lena L Kassab
- Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Suresh Ponnada
- Department of Internal Medicine, Carilion Roanoke Medical Center, Roanoke, Virginia, USA
| | - Saurabh Chandan
- CHI Creighton University Medical Center, Omaha, Nebraska, USA
| | - Sheeva Parbhu
- Department of Gastroenterology & Hepatology, University of Utah Health School of Medicine, Salt Lake City, Utah, USA
| | - Shaun Chandna
- Department of Hepatology & Liver Transplant, University of Utah Health School of Medicine, Salt Lake City, Utah, USA
| | - Douglas G Adler
- Center for Advanced Therapeutic Endoscopy, Centura Health, Denver, Colorado, USA
| |
Collapse
|