Rupture de varices œsophagiennes chez les malades atteints de cirrhose : quelles sont les questions encore sans réponse ?

Sudden death related to the gastrointestinal system in Tunisia: A 13 year autopsy study

Sudden gastrointestinal (GI) death is an unexpected death due to digestive system causes mainly found after autopsy. The literature is rich in articles that studied sudden death due to cardiac causes while sudden GI deaths remain less well-documented. We retrospectively investigated all cases of gastrointestinal death at the Department of Forensic Medicine in Tunis, over 13 years (January 1, 2006 to December 31, 2018). Two hundred and eight cases were collected. The mean age of our series was 51.06 ± 20.99 years. No history of digestive disorders was reported in 78.4%, and no family history of sudden death was found in any cases. A male predominance was found in most epidemiological characteristics of the sample with a significant statistical rate in some features. Non-specific abdominal pain was the most described symptom (n = 92). Perforation of GI tract was the common mechanism involved in the death of 55 cases, of which 44 were related to ulcer perforation. These ulcer perforations were statistically more reported in smokers and people suffering from schizophrenia. Intestinal obstruction was the second commonest cause of death, mainly found in the elderly. Sudden death in children was most frequently caused by acute intussusception. This study highlights that systematic study of sudden death due to GI causes might provide opportunities to identify avenues for overall health improvement.

Recalibrated MELD and hepatic encephalopathy are prognostic factors in cirrhotic patients with acute variceal bleeding

BACKGROUND & AIMS

Early TIPS placement must be considered in patients with Child-Pugh B and active bleeding at endoscopy or in patients with Child-Pugh C 10-13 and variceal bleeding. However, active bleeding at endoscopy is a subjective criterion. Moreover, a previous study has shown that a MELD-based score accurately predicted 6-week mortality and helped to stratify patients. Using a prospective series of patients included in a multicentre study before the era of early TIPS, we aimed (i) to identify factors associated with 6-week mortality, focusing on the prognostic value of active bleeding; and (ii) to assess whether a recalibrated MELD-based score accurately predicted 6-week mortality.

METHODS

Ancillary study of the prospective multicentre Baveno IV study, including patients with acute variceal bleeding.

RESULTS

Two hundred and nineteen patients were analysed (Child-Pugh A/B/C = 18/45/37%). The overall actuarial likelihood of survival on day 42 was 84%. The variability for the diagnosis of active bleeding at endoscopy was high (range, 41.4% to 84.6% among the centres). Active bleeding at endoscopy was not associated with 6-week mortality in the entire population or in Child-Pugh B patients. In a multivariate analysis, independent factors associated with mortality were liver function, infection, HE and HCC. The recalibrated MELD-based score was accurate in predicting 6-week mortality (AUROC = 0.787). The recalibrated MELD-based score demonstrated better performance compared to the MELD score.

CONCLUSION

The recalibrated MELD-based score accurately predicted mortality in our prospective cohort. Active bleeding at endoscopy had no prognostic value in cirrhotic patients presenting with acute variceal bleeding. Standardizing active bleeding assessment at endoscopy is warranted.

Early-TIPSS placement prevents rebleeding in high-risk patients with variceal bleeding, without improving survival

BACKGROUND

Early-TIPSS (transjugular intrahepatic portosystemic shunt) placement may improve rebleeding and reduce 1-year mortality, compared to standard management in high-risk patients with cirrhosis and variceal bleeding.

AIM

To obtain external validation of this therapeutic approach.

METHODS

We performed a prospective study including all consecutive patients with Child-Pugh C 10-13 cirrhosis or Child-Pugh B with active bleeding at endoscopy admitted to our ICU between March 2011 and February 2013 for variceal bleeding. TIPSS were placed within 72 h after stabilisation. Patients were matched for gender, age, Child-Pugh score, MELD score and to patients from a historical cohort hospitalised before March 2011.

RESULTS

31/128 patients with cirrhosis (77.4% men, mean age 53.2 ± 9.0 years old, MELD score 20.9 ± 6.9, Child-Pugh C: 77.4%) admitted for acute variceal bleeding between March 2011 and February 2013 (TIPSS+ group) were matched to 31 historical patients (TIPSS- group). Uncontrolled bleeding occurred in 1/31 patients in the TIPSS+ group vs. 2/31 patients in TIPSS- group (P = 0.55). The 1-year probability of being free of rebleeding was higher in the TIPSS+ group (97% vs. 51%, P < 0.001). Actuarial 1-year survival was not different between the two groups (66.8 ± 9.4% vs. 74.2 ± 7.8%, P = 0.78). Acute cardiac failure occurred more frequently in the TIPSS+ group (25.8% vs. 6.4%, P = 0.03).

CONCLUSIONS

Early-TIPSS placement effectively prevents rebleeding in high-risk patients with variceal bleeding but does not significantly improve survival. This might be due to the high proportion of patients with Child-Pugh C cirrhosis in our series. Cardiac failure may play a role and must be investigated before the procedure, when possible.