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Tripathi D, Patch D, Mehrzad H, Yu D, Aspinall RJ, Armstrong MJ, Stanley A, Ireland H, Travis S, Hayes P, Lomax M, Roslund N, Lam E, Slinn G, Jowett S, Moakes C, Maher A, Brettell E, Sehmi S. Study protocol for a Randomised controlled trial of EArly transjugular intrahepatiC porTosystemic stent-shunt in Acute Variceal Bleeding (REACT-AVB trial). BMJ Open Gastroenterol 2024; 11:e001314. [PMID: 38519049 DOI: 10.1136/bmjgast-2023-001314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2023] [Accepted: 02/16/2024] [Indexed: 03/24/2024] Open
Abstract
INTRODUCTION In liver cirrhosis, acute variceal bleeding (AVB) is associated with a 1-year mortality rate of up to 40%. Data on early or pre-emptive transjugular intrahepatic portosystemic stent-shunt (TIPSS) in AVB is inconclusive and may not reflect current management strategies. Randomised controlled trial of EArly transjugular intrahepatiC porTosystemic stent-shunt in AVB (REACT-AVB) aims to investigate the clinical and cost-effectiveness of early TIPSS in patients with cirrhosis and AVB after initial bleeding control. METHODS AND ANALYSIS REACT-AVB is a multicentre, randomised controlled, open-label, superiority, two-arm, parallel-group trial with an internal pilot. The two interventions allocated randomly 1:1 are early TIPSS within 4 days of diagnostic endoscopy or secondary prophylaxis with endoscopic therapy in combination with non-selective beta blockers. Patients aged ≥18 years with cirrhosis and Child-Pugh Score 7-13 presenting with AVB with endoscopic haemostasis are eligible for inclusion. The primary outcome is transplant-free survival at 1 year post randomisation. Secondary endpoints include transplant-free survival at 6 weeks, rebleeding, serious adverse events, other complications of cirrhosis, Child-Pugh and Model For End-Stage Liver Disease (MELD) scores at 6 and 12 months, health-related quality of life, use of healthcare resources, cost-effectiveness and use of cross-over therapies. The sample size is 294 patients over a 4-year recruitment period, across 30 hospitals in the UK. ETHICS AND DISSEMINATION Research ethics committee of National Health Service has approved REACT-AVB (reference number: 23/WM/0085). The results will be submitted for publication in a peer-reviewed journal. A lay summary will also be emailed or posted to participants before publication. TRIAL REGISTRATION NUMBER ISRCTN85274829; protocol version 3.0, 1 July 2023.
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Affiliation(s)
- Dhiraj Tripathi
- Liver Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, Birmingham, UK
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - David Patch
- Hepatology and Liver Transplantation, Royal Free Hampstead NHS Trust, London, UK
| | - Homoyon Mehrzad
- Interventional Radiology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, Birmingham, UK
| | - Dominic Yu
- Department of Radiology, Royal Free London NHS Foundation Trust, London, UK
| | - Richard J Aspinall
- Gastroenterology and Hepatology, Portsmouth Hospitals NHS Trust, Portsmouth, UK
| | - Matthew J Armstrong
- Liver Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, Birmingham, UK
| | | | - Hamish Ireland
- Department of Radiology, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Simon Travis
- Department of Radiology, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Peter Hayes
- Hepatology, Royal Infirmary of Edinburgh, Edinburgh, UK
| | | | | | - Emily Lam
- GI and Liver PPI Group, University Hospitals Birmingham NHS Foundation Trust, Birmingham, Birmingham, UK
| | - Gemma Slinn
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, West Midlands, UK
| | - Sue Jowett
- Institute of Applied Health Research, University of Birmingham, Birmingham, West Midlands, UK
| | - Catherine Moakes
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, West Midlands, UK
| | - Alisha Maher
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, West Midlands, UK
| | - Elizabeth Brettell
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, West Midlands, UK
| | - Sukhwant Sehmi
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, West Midlands, UK
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Yang TC, Chen WC, Hou MC, Chen PH, Lee PC, Chang CY, Lu HS, Chen YJ, Hsu SJ, Huang HC, Luo JC, Huang YH, Lee FY. Endoscopic variceal ligation versus propranolol for the primary prevention of oesophageal variceal bleeding in patients with hepatocellular carcinoma: an open-label, two-centre, randomised controlled trial. Gut 2024; 73:682-690. [PMID: 38123994 DOI: 10.1136/gutjnl-2023-330419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2023] [Accepted: 11/21/2023] [Indexed: 12/23/2023]
Abstract
OBJECTIVE This randomised trial aimed to address whether endoscopic variceal ligation (EVL) or propranolol (PPL) is more effective at preventing initial oesophageal variceal bleeding (EVB) in patients with hepatocellular carcinoma (HCC). DESIGN Patients with HCC and medium-to-large oesophageal varices (EVs) but without previous EVB were randomised to receive EVL (every 3-4 weeks until variceal eradication) or PPL (up to 320 mg daily) at a 1:1 ratio. Long-term follow-up data on EVB, other upper gastrointestinal bleeding (UGIB), non-bleeding liver decompensation, overall survival (OS) and adverse events (AEs) were analysed using competing risk regression. RESULTS Between June 2011 and April 2021, 144 patients were randomised to receive EVL (n=72) or PPL (n=72). In the EVL group, 7 patients experienced EVB, and 30 died; in the PPL group, 19 patients had EVB, and 40 died. The EVL group had a lower cumulative incidence of EVB (Gray's test, p=0.009) than its counterpart, with no mortality difference (Gray's test, p=0.085). For patients with Barcelona Clinic Liver Cancer (BCLC) stage A/B, EVL was better than PPL in reducing EVB (p<0.001) and mortality (p=0.003). For patients beyond BCLC stage B, between-group outcomes were similar. Other UGIB, non-bleeding liver decompensation and AEs did not differ between groups. A competing risk regression model confirmed the prognostic value of EVL. CONCLUSION EVL is superior to PPL in preventing initial EVB in patients with HCC. The benefits of EVL on EVB and OS may be limited to patients with BCLC stage A/B and not to those with BCLC stage C/D. TRIAL REGISTRATION NUMBER NCT01970748.
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Affiliation(s)
- Tsung-Chieh Yang
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Therapeutic and Research Center of Liver Cirrhosis and Portal Hypertension, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Wen-Chi Chen
- School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Division of Gastroenterology and Hepatology, Department of Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
- Department of Post-Baccalaureate Medicine, National Sun Yat-sen University, Kaohsiung, Taiwan
| | - Ming-Chih Hou
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Therapeutic and Research Center of Liver Cirrhosis and Portal Hypertension, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Ping-Hsien Chen
- School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Endoscopy Center for Diagnosis and Treatment, Taipei Veterans General Hospital, Taipei, Taiwan
- Division of Gastroenterology and Hepatology, Department of Medicine, West Garden Hospital, Taipei, Taiwan
| | - Pei-Chang Lee
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Therapeutic and Research Center of Liver Cirrhosis and Portal Hypertension, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Chung-Yu Chang
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Therapeutic and Research Center of Liver Cirrhosis and Portal Hypertension, Taipei Veterans General Hospital, Taipei, Taiwan
- Healthcare and Services Center, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Hsiao-Sheng Lu
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Therapeutic and Research Center of Liver Cirrhosis and Portal Hypertension, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Yu-Jen Chen
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Therapeutic and Research Center of Liver Cirrhosis and Portal Hypertension, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Shao-Jung Hsu
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Therapeutic and Research Center of Liver Cirrhosis and Portal Hypertension, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Hui-Chun Huang
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Therapeutic and Research Center of Liver Cirrhosis and Portal Hypertension, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Jiing-Chyuan Luo
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Yi-Hsiang Huang
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Healthcare and Services Center, Taipei Veterans General Hospital, Taipei, Taiwan
- Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Fa-Yauh Lee
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Therapeutic and Research Center of Liver Cirrhosis and Portal Hypertension, Taipei Veterans General Hospital, Taipei, Taiwan
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Mansour D, Masson S, Corless L, Douds AC, Shawcross DL, Johnson J, Leithead JA, Heneghan MA, Rahim MN, Tripathi D, Ross V, Hammond J, Grapes A, Hollywood C, Botterill G, Bonner E, Donnelly M, McPherson S, West R. British Society of Gastroenterology Best Practice Guidance: outpatient management of cirrhosis - part 2: decompensated cirrhosis. Frontline Gastroenterol 2023; 14:462-473. [PMID: 37862447 PMCID: PMC10579554 DOI: 10.1136/flgastro-2023-102431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2023] Open
Abstract
There are two distinct phases in the natural history of cirrhosis: compensated disease (corresponding to Child Pugh A and early Child Pugh B disease), where the patient may be largely asymptomatic, progressing with increasing portal hypertension and liver dysfunction to decompensated disease (corresponding to Child Pugh late B-C), characterised by the development of overt clinical signs, including jaundice, hepatic encephalopathy (HE), ascites, renal dysfunction and variceal bleeding. The transition from compensated cirrhosis to decompensated cirrhosis (DC) heralds a watershed in the nature and prognosis of the disease. DC is a systemic disease, characterised by multiorgan/system dysfunction, including haemodynamic and immune dysfunction. In this second part of our three-part series on the outpatient management of cirrhosis, we address outpatient management of DC, including management of varices, ascites, HE, nutrition, liver transplantation and palliative care. We also introduce an outpatient DC care bundle. For recommendations on screening for osteoporosis, hepatocellular carcinoma surveillance and vaccination see part one of the guidance. Part 3 of the guidance focusses on special circumstances encountered in patients with cirrhosis, including surgery, pregnancy, travel, management of bleeding risk for invasive procedures and portal vein thrombosis.
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Affiliation(s)
- Dina Mansour
- Gateshead Health NHS Foundation Trust, Gateshead, UK
- Newcastle University, Newcastle upon Tyne, UK
| | - Steven Masson
- The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle, UK
| | - Lynsey Corless
- Gastroenterology, Hull University Teaching Hospitals NHS Trust, Hull, UK
| | - Andrew C Douds
- Gastroenterology, Queen Elizabeth Hospital, Kings Lynn, UK
| | | | - Jill Johnson
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Joanna A Leithead
- Addenbrooke's Hospital, Cambridge, UK
- Forth Valley Royal Hospital, Larbert, UK
| | - Michael A Heneghan
- Institute of Liver Studies, King's College Hospital NHS Foundation Trust, London, UK
| | | | - Dhiraj Tripathi
- University Hospitals Birmingham NHS Foundation Trust, Liver Unit, Birmingham, UK
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | | | - John Hammond
- Hepatopancreatobiliary Multidisciplinary Team, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | | | - Coral Hollywood
- Gloucestershire Hospitals NHS Foundation Trust, Cheltenham, UK
| | | | | | | | - Stuart McPherson
- Newcastle University, Newcastle upon Tyne, UK
- Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
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Mansour D, Masson S, Shawcross DL, Douds AC, Bonner E, Corless L, Leithead JA, Hammond J, Heneghan MA, Rahim MN, Tripathi D, West R, Johnson J, Botterill G, Hollywood C, Ross V, Donnelly M, Compston JE, McPherson S, Grapes A. British Society of Gastroenterology Best Practice Guidance: outpatient management of cirrhosis - part 1: compensated cirrhosis. Frontline Gastroenterol 2023; 14:453-461. [PMID: 37862444 PMCID: PMC10579555 DOI: 10.1136/flgastro-2023-102430] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2023] Open
Abstract
The prevalence of cirrhosis has risen significantly over recent decades and is predicted to rise further. Widespread use of non-invasive testing means cirrhosis is increasingly diagnosed at an earlier stage. Despite this, there are significant variations in outcomes in patients with cirrhosis across the UK, and patients in areas with higher levels of deprivation are more likely to die from their liver disease. This three-part best practice guidance aims to address outpatient management of cirrhosis, in order to standardise care and to reduce the risk of progression, decompensation and mortality from liver disease. Here, in part one, we focus on outpatient management of compensated cirrhosis, encompassing hepatocellular cancer surveillance, screening for varices and osteoporosis, vaccination and lifestyle measures. We also introduce a compensated cirrhosis care bundle for use in the outpatient setting. Part two concentrates on outpatient management of decompensated disease including management of ascites, encephalopathy, varices, nutrition as well as liver transplantation and palliative care. The third part of the guidance covers special circumstances encountered in managing people with cirrhosis: surgery, pregnancy, travel, managing bleeding risk for invasive procedures and portal vein thrombosis.
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Affiliation(s)
- Dina Mansour
- Newcastle Medical School, Newcastle University, Newcastle upon Tyne, UK
- Gastroenterology and hepatology, Gateshead Health NHS Foundation Trust, Gateshead, UK
| | - Steven Masson
- Newcastle Medical School, Newcastle University, Newcastle upon Tyne, UK
- Hepatology, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle, UK
| | | | - Andrew C Douds
- Gastroenterology, Queen Elizabeth Hospital, Kings Lynn, UK
| | - Emily Bonner
- Anaesthetics, Freeman Hospital, Newcastle upon Tyne, UK
| | - Lynsey Corless
- Gastroenterology, Hull Royal Infirmary, Hull, UK
- Hull York Medical School, Hull, UK
| | - Joanna A Leithead
- Gastroenterology and Hepatology, Forth Valley Royal Hospital, Larbert, UK
| | - John Hammond
- Hepatopancreatobiliary Multidisciplinary Team, Newcastle upon Tyne Hospitals NHS Foundation Trust, Freeman Hospital, Newcastle upon Tyne, UK
| | - Michael A Heneghan
- Institute of Liver Studies, King's College Hospital NHS Foundation Trust, London, UK
| | | | - Dhiraj Tripathi
- Liver Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | | | - Jill Johnson
- Dietetics, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | | | - Coral Hollywood
- Hepatology, Gloucestershire Hospitals NHS Foundation Trust, Cheltenham, UK
| | - Valerie Ross
- Pharmacy, Barts and The London NHS Trust, London, UK
| | | | - Juliet E Compston
- Medicine, University of Cambridge School of Clinical Medicine, Cambridge, UK
| | - Stuart McPherson
- Newcastle Medical School, Newcastle University, Newcastle upon Tyne, UK
- Hepatology, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Allison Grapes
- Gastroenterology and hepatology, Gateshead Health NHS Foundation Trust, Gateshead, UK
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Lim S, Haboubi HN, Anderson SHC, Dawson P, Machado AP, Mangsat E, Santos S, Wong T, Zeki S, Dunn J. Transnasal endoscopy: moving from endoscopy to the clinical outpatient-blue sky thinking in oesophageal testing. Frontline Gastroenterol 2022; 13:e65-e71. [PMID: 35812036 PMCID: PMC9234731 DOI: 10.1136/flgastro-2022-102129] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Accepted: 05/03/2022] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND COVID-19 has severely affected UK endoscopy services with an estimate 86% loss of activity during the first wave. Subsequent delays in diagnostic and surveillance procedures highlight the need for novel solutions to tackle the resultant backlog. Transnasal endoscopy (TNE) provides an attractive option compared with conventional upper gastrointestinal endoscopy given its limited use of space, no sedation and reduced nursing resources. OUR EXPERIENCE We describe piloting and then establishing an outpatient model TNE service in the pandemic era and the implications on resource allocation, training and workforce. We also discuss our experiences and outline ways in which services can evolve to undertake more complex endoscopic diagnostic and therapeutic work. Over 90% of patients describe no discomfort and those who have previously experienced conventional transoral endoscopy preferred the transnasal approach. We describe a low complication rate (0.8%) comprising two episodes of mild epistaxis. The average procedure duration was reasonable (9.9±5.0 min) with full adherence to Joint Advisory Group quality standards. All biopsies assessed were deemed sufficient for diagnosis including those for surveillance procedures. DISCUSSION TNE can offer a safe, tolerable, high-quality service outside of a conventional endoscopy setting. Expanding procedural capacity without impacting on the current endoscopy footprint has great potential in recovering endoscopy services following the COVID-19 pandemic. Looking forward, TNE has potential to be used both within the endoscopy suite as part of therapeutic procedures, or outside of the endoscopy unit in outpatient clinics, community hospitals, or mobile units and to achieve this in a more sustainable and environmentally friendly way.
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Affiliation(s)
- Samuel Lim
- Gastroenterology Department, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Hasan Nadim Haboubi
- Gastroenterology, University Hospital Llandough, Cardiff, UK,Institute of Life Sciences, Swansea University, Swansea, UK
| | - Simon H C Anderson
- Gastroenterology Department, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Patrick Dawson
- Gastroenterology Department, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Ana Paula Machado
- Gastroenterology Department, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Edna Mangsat
- Gastroenterology Department, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Sara Santos
- Gastroenterology Department, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Terry Wong
- Gastroenterology Department, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Sebastian Zeki
- Gastroenterology Department, Guy's and St Thomas' NHS Foundation Trust, London, UK,Comprehensive Cancer Centre, King's College London, London, UK
| | - Jason Dunn
- Gastroenterology Department, Guy's and St Thomas' NHS Foundation Trust, London, UK,Comprehensive Cancer Centre, King's College London, London, UK
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Jeyanesan D, Balachandrakumar VK, Hogan B. Guideline review: transjugular intrahepatic portosystemic stent-shunt in the management of portal hypertension-a BSG guideline. Frontline Gastroenterol 2022; 13:531-534. [PMID: 36250168 PMCID: PMC9555133 DOI: 10.1136/flgastro-2022-102151] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2022] [Accepted: 05/03/2022] [Indexed: 02/04/2023] Open
Abstract
The decision-making around transjugular intrahepatic portosystemic shunt (TIPSS) placement in the management of patients with chronic liver disease and portal hypertension (PH) is a regular challenge for hepatologists. In the UK, access has improved, with more than 35 hospitals now offering this service. However, its role in acute variceal bleeding, refractory ascites and other complications of PH continues to be redefined and expanded. In particular, the role of pre-emptive TIPSS has become more established and requires re-evaluation of pathways to enable equitable access for patients. Here, we summarise the key recommendations from the recently published British Society of Gastroenterology guidelines and expand on the challenges posed.
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Affiliation(s)
- Dhaarica Jeyanesan
- Institute of Liver Studies, King's College Hospital Liver Unit, London, UK
| | | | - Brian Hogan
- Institute of Liver Studies, King's College Hospital Liver Unit, London, UK
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Bhardwaj A, Kedarisetty CK, Vashishtha C, Bhadoria AS, Jindal A, Kumar G, Choudhary A, Shasthry SM, Maiwall R, Kumar M, Bhatia V, Sarin SK. Carvedilol delays the progression of small oesophageal varices in patients with cirrhosis: a randomised placebo-controlled trial. Gut 2017; 66:1838-1843. [PMID: 27298379 DOI: 10.1136/gutjnl-2016-311735] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2016] [Accepted: 05/20/2016] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIMS Carvedilol is effective in the primary prophylaxis for large oesophageal varices. We investigated its use in preventing progression of small to large oesophageal varices. METHODS Consecutive cirrhotics with small oesophageal varices were prospectively randomised to either carvedilol (n=70) or placebo (n=70) and followed up for a minimum of 24 months. Endoscopy was done at baseline and six monthly intervals. Hepatic vein pressure gradient (HVPG) was measured at baseline and at 12 months. The primary endpoint was development of large varices. RESULTS Baseline characteristics in two groups were comparable. The predominant aetiology of cirrhosis was non-alcoholic fatty liver disease in both the groups. The mean dose of carvedilol administered was 12±1.67 mg/day and the target heart rate achieved was 58±3 bpm. A higher proportion of patients in carvedilol group had non-progression to large varices than placebo (79.4% vs 61.4%; p=0.04); the mean time of non-progression to large varices was 20.8 months (95% CI 19.4 to 22.4) in carvedilol group and 18.7 months (95% CI 17.1 to 20.4) in placebo group (p=0.04). There was a modest reduction of HVPG at 1 year in carvedilol group (-8.64%) compared with placebo (+0.33%) (p=0.22). None of the patients in either group died of variceal bleeding or liver-related causes. No major adverse events were observed in either group. CONCLUSIONS Carvedilol is safe and effective in delaying the progression of small to large oesophageal varices in patients with cirrhosis. TRIAL REGISTRATION NUMBER NCT01196507; post-results.
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Affiliation(s)
- Ankit Bhardwaj
- Clinical Research, Institute of Liver and Biliary Sciences, New Delhi, Delhi, India
| | - Chandan Kumar Kedarisetty
- Hepatic Hemodynamic Laboratory, Departments of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, Delhi, India
| | - Chitranshu Vashishtha
- Hepatic Hemodynamic Laboratory, Departments of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, Delhi, India
| | - Ajeet Singh Bhadoria
- Clinical Research, Institute of Liver and Biliary Sciences, New Delhi, Delhi, India
| | - Ankur Jindal
- Hepatic Hemodynamic Laboratory, Departments of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, Delhi, India
| | - Guresh Kumar
- Clinical Research, Institute of Liver and Biliary Sciences, New Delhi, Delhi, India
| | - Ashok Choudhary
- Hepatic Hemodynamic Laboratory, Departments of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, Delhi, India
| | - S M Shasthry
- Hepatic Hemodynamic Laboratory, Departments of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, Delhi, India
| | - Rakhi Maiwall
- Hepatic Hemodynamic Laboratory, Departments of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, Delhi, India
| | - Manoj Kumar
- Hepatic Hemodynamic Laboratory, Departments of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, Delhi, India
| | - Vikram Bhatia
- Hepatic Hemodynamic Laboratory, Departments of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, Delhi, India
| | - Shiv Kumar Sarin
- Hepatic Hemodynamic Laboratory, Departments of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, Delhi, India
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Nishikawa H, Iwata Y, Ishii A, Enomoto H, Yuri Y, Ishii N, Miyamoto Y, Hasegawa K, Nakano C, Takata R, Nishimura T, Yoh K, Aizawa N, Sakai Y, Ikeda N, Takashima T, Iijima H, Nishiguchi S. Effect of dexmedetomidine in the prophylactic endoscopic injection sclerotherapy for oesophageal varices: a study protocol for prospective interventional study. BMJ Open Gastroenterol 2017; 4:e000149. [PMID: 28761693 PMCID: PMC5508803 DOI: 10.1136/bmjgast-2017-000149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2017] [Revised: 05/14/2017] [Accepted: 05/15/2017] [Indexed: 11/29/2022] Open
Abstract
Background Dexmedetomidine (DEX) is a novel, highly selective α2-adrenoceptor agonist that elicits sedative, amnestic, sympatholytic and analgesic effects in patients. Several Japanese investigators have reported the clinical usefulness of DEX for sedation in endoscopic therapies for gastrointestinal malignancies; however, there have been limited data regarding the usefulness and safety of DEX for sedation during endoscopic procedures for oesophageal varices (OVs), such as endoscopic injection sclerotherapy (EIS). In this prospective, single-arm interventional study, we aimed to elucidate these issues. Methods Patients who require two or more sessions of prophylactic EIS for the treatment of OVs will be enrolled in this prospective interventional study. EIS procedures include two methods: (1) sedation during endoscopic procedures will be performed using conventional methods (pentazocine (PNZ) and midazolam (MDZ)), and (2) sedation during endoscopic procedures will be performed using PNZ, low-dose MDZ and DEX. These two methods were randomly assigned in the first and second EIS. The effect and safety of these two procedures with respect to patient sedation are to be compared with the degree of sedation evaluated using the Bispectral Index monitoring system (Aspect Medical Systems, Norwood, Massachusetts, USA). Ethics and dissemination This study received approval from the Institutional Review Board at Hyogo College of Medicine (approval no. 2324). The authors are committed to publishing the study results as widely as possible in peer-reviewed journals, and to ensuring that appropriate recognition is provided to everyone who is working on this study. Trial registration number UMIN000026688; Pre-results.
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Affiliation(s)
- Hiroki Nishikawa
- Division of Hepatobiliary and Pancreatic disease, Department of Internal Medicine, Hyogo College of Medicine, Hyogo, Japan
| | - Yoshinori Iwata
- Division of Hepatobiliary and Pancreatic disease, Department of Internal Medicine, Hyogo College of Medicine, Hyogo, Japan
| | - Akio Ishii
- Division of Hepatobiliary and Pancreatic disease, Department of Internal Medicine, Hyogo College of Medicine, Hyogo, Japan
| | - Hirayuki Enomoto
- Division of Hepatobiliary and Pancreatic disease, Department of Internal Medicine, Hyogo College of Medicine, Hyogo, Japan
| | - Yukihisa Yuri
- Division of Hepatobiliary and Pancreatic disease, Department of Internal Medicine, Hyogo College of Medicine, Hyogo, Japan
| | - Noriko Ishii
- Division of Hepatobiliary and Pancreatic disease, Department of Internal Medicine, Hyogo College of Medicine, Hyogo, Japan
| | - Yuho Miyamoto
- Division of Hepatobiliary and Pancreatic disease, Department of Internal Medicine, Hyogo College of Medicine, Hyogo, Japan
| | - Kunihiro Hasegawa
- Division of Hepatobiliary and Pancreatic disease, Department of Internal Medicine, Hyogo College of Medicine, Hyogo, Japan
| | - Chikage Nakano
- Division of Hepatobiliary and Pancreatic disease, Department of Internal Medicine, Hyogo College of Medicine, Hyogo, Japan
| | - Ryo Takata
- Division of Hepatobiliary and Pancreatic disease, Department of Internal Medicine, Hyogo College of Medicine, Hyogo, Japan
| | - Takashi Nishimura
- Division of Hepatobiliary and Pancreatic disease, Department of Internal Medicine, Hyogo College of Medicine, Hyogo, Japan
| | - Kazunori Yoh
- Division of Hepatobiliary and Pancreatic disease, Department of Internal Medicine, Hyogo College of Medicine, Hyogo, Japan
| | - Nobuhiro Aizawa
- Division of Hepatobiliary and Pancreatic disease, Department of Internal Medicine, Hyogo College of Medicine, Hyogo, Japan
| | - Yoshiyuki Sakai
- Division of Hepatobiliary and Pancreatic disease, Department of Internal Medicine, Hyogo College of Medicine, Hyogo, Japan
| | - Naoto Ikeda
- Division of Hepatobiliary and Pancreatic disease, Department of Internal Medicine, Hyogo College of Medicine, Hyogo, Japan
| | - Tomoyuki Takashima
- Division of Hepatobiliary and Pancreatic disease, Department of Internal Medicine, Hyogo College of Medicine, Hyogo, Japan
| | - Hiroko Iijima
- Division of Hepatobiliary and Pancreatic disease, Department of Internal Medicine, Hyogo College of Medicine, Hyogo, Japan
| | - Shuhei Nishiguchi
- Division of Hepatobiliary and Pancreatic disease, Department of Internal Medicine, Hyogo College of Medicine, Hyogo, Japan
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Mandorfer M, Peck-Radosavljevic M, Reiberger T. Prevention of progression from small to large varices: are we there yet? An updated meta-analysis. Gut 2017; 66:1347-1349. [PMID: 27694143 DOI: 10.1136/gutjnl-2016-312814] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2016] [Revised: 08/30/2016] [Accepted: 09/06/2016] [Indexed: 12/16/2022]
Affiliation(s)
- Mattias Mandorfer
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria.,Vienna Hepatic Hemodynamic Lab, Medical University of Vienna, Vienna, Austria
| | - Markus Peck-Radosavljevic
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria.,Vienna Hepatic Hemodynamic Lab, Medical University of Vienna, Vienna, Austria
| | - Thomas Reiberger
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria.,Vienna Hepatic Hemodynamic Lab, Medical University of Vienna, Vienna, Austria
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10
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Waddell KM, Stanley AJ, Morris AJ. Endoscopy for upper gastrointestinal bleeding: where are we in 2017? Frontline Gastroenterol 2017; 8:94-97. [PMID: 28839892 PMCID: PMC5369448 DOI: 10.1136/flgastro-2016-100791] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2016] [Accepted: 12/11/2016] [Indexed: 02/04/2023] Open
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Arnold F, Patch D, Yu D, Westbrook RH. When banding fails; investigation hails. Gut 2017; 66:322. [PMID: 27340193 DOI: 10.1136/gutjnl-2016-311515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2016] [Revised: 06/06/2016] [Accepted: 06/07/2016] [Indexed: 12/08/2022]
Affiliation(s)
| | - D Patch
- Hepatology Department, Royal Free Hospital, London, UK
| | - D Yu
- Radiology Department, Royal Free Hospital, London, UK
| | - R H Westbrook
- Hepatology Department, Royal Free Hospital, London, UK
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12
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Blasco-Algora S, Masegosa-Ataz J, Alonso S, Gutiérrez ML, Fernández-Rodriguez C. Non-selective β-blockers in advanced cirrhosis: a critical review of the effects on overall survival and renal function. BMJ Open Gastroenterol 2016; 3:e000104. [PMID: 28074149 PMCID: PMC5174812 DOI: 10.1136/bmjgast-2016-000104] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2016] [Revised: 07/23/2016] [Accepted: 07/29/2016] [Indexed: 12/12/2022] Open
Abstract
Introduction Non-selective β-blockers (NSBBs) are widely prescribed in patients with cirrhosis for primary and secondary prophylaxis of bleeding oesophageal varices. Furthermore, it has been suggested that the clinical benefits of NSBBs may extend beyond their haemodynamic effects. Recently, a potentially harmful effect has been described in patients with refractory ascites or spontaneous bacterial peritonitis. Methodology A comprehensive literature search on β-blockers and cirrhosis survival using the electronic databases PubMed/MEDLINE, AMED, CINAHL and the Cochrane Central Register of Controlled Trials. Full-text manuscripts published over more than 35 years, from 1980 to April 2016 were reviewed for relevance and reference lists were cross-checked for additional pertinent studies regarding potential NSBB effects, especially focused on those concerned with survival and/or acute kidney injury (AKI). Discussion The proposed review will be able to provide valuable evidence to help decision making in the use of NSBB for the treatment of advanced cirrhosis and highlights some limitations in existing evidence to direct future research.
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Affiliation(s)
- Sara Blasco-Algora
- Gastroenterology Unit, Hospital Universitario Fundación Alcorcon, Madrid, Spain; University Rey Juan Carlos, Madrid, Spain
| | - José Masegosa-Ataz
- Gastroenterology Unit, Hospital Universitario Fundación Alcorcon, Madrid, Spain; University Rey Juan Carlos, Madrid, Spain
| | - Sonia Alonso
- Gastroenterology Unit, Hospital Universitario Fundación Alcorcon, Madrid, Spain; University Rey Juan Carlos, Madrid, Spain
| | - Maria-Luisa Gutiérrez
- Gastroenterology Unit, Hospital Universitario Fundación Alcorcon, Madrid, Spain; University Rey Juan Carlos, Madrid, Spain
| | - Conrado Fernández-Rodriguez
- Gastroenterology Unit, Hospital Universitario Fundación Alcorcon, Madrid, Spain; University Rey Juan Carlos, Madrid, Spain
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13
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Parker C, Alexandridis E, Plevris J, O'Hara J, Panter S. Transnasal endoscopy: no gagging no panic! Frontline Gastroenterol 2016; 7:246-256. [PMID: 28839865 PMCID: PMC5369487 DOI: 10.1136/flgastro-2015-100589] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2015] [Revised: 06/01/2015] [Accepted: 06/10/2015] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Transnasal endoscopy (TNE) is performed with an ultrathin scope via the nasal passages and is increasingly used. This review covers the technical characteristics, tolerability, safety and acceptability of TNE and also diagnostic accuracy, use as a screening tool and therapeutic applications. It includes practical advice from an ear, nose, throat (ENT) specialist to optimise TNE practice, identify ENT pathology and manage complications. METHODS A Medline search was performed using the terms "transnasal", "ultrathin", "small calibre", "endoscopy", "EGD" to identify relevant literature. RESULTS There is increasing evidence that TNE is better tolerated than standard endoscopy as measured using visual analogue scales, and the main area of discomfort is nasal during insertion of the TN endoscope, which seems remediable with adequate topical anaesthesia. The diagnostic yield has been found to be similar for detection of Barrett's oesophagus, gastric cancer and GORD-associated diseases. There are some potential issues regarding the accuracy of TNE in detecting small early gastric malignant lesions, especially those in the proximal stomach. TNE is feasible and safe in a primary care population and is ideal for screening for upper gastrointestinal pathology. It has an advantage as a diagnostic tool in the elderly and those with multiple comorbidities due to fewer adverse effects on the cardiovascular system. It has significant advantages for therapeutic procedures, especially negotiating upper oesophageal strictures and insertion of nasoenteric feeding tubes. CONCLUSIONS TNE is well tolerated and a valuable diagnostic tool. Further evidence is required to establish its accuracy for the diagnosis of early and small gastric malignancies. There is an emerging role for TNE in therapeutic endoscopy, which needs further study.
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Affiliation(s)
- Clare Parker
- South Tyneside NHS Foundation Trust, South Tyneside District Hospital, South Shields, UK
| | | | - John Plevris
- Centre for Liver and Digestive Disorders, The Royal Infirmary, University of Edinburgh, Edinburgh, UK
| | - James O'Hara
- Department of Otolaryngology, Newcastle upon Tyne NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Simon Panter
- Department of Gastroenterology, South Tyneside NHS Foundation Trust, Newcastle upon Tyne, UK
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14
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Affiliation(s)
- Sauid Ishaq
- Gastroenterology Department, DGH, Birmingham City University, Dudley, UK,SGU Grenada West Indies
| | - Lois Nunn
- Gastroenterology Department, DGH, Birmingham City University, Dudley, UK
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15
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Thorhauge KH, Lindvig KP, Laleman W, Angeli P, Singh SP, Krag A. Lack of consensus for usage of β-blockers in end-stage liver disease. Gut 2016; 65:1058-60. [PMID: 26933172 DOI: 10.1136/gutjnl-2016-311573] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2016] [Accepted: 02/09/2016] [Indexed: 01/29/2023]
Affiliation(s)
- Katrine H Thorhauge
- Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark OPEN, Odense Patient data Exploratory Network, Odense University Hospital, Odense, Denmark
| | - Katrine P Lindvig
- Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark OPEN, Odense Patient data Exploratory Network, Odense University Hospital, Odense, Denmark
| | - Wim Laleman
- Department of Liver and Biliopancreatic Disorders, University Hospitals Leuven, KU Leuven, Belgium
| | - Paolo Angeli
- Unit of Hepatic Emergencies and Liver Transplantation, Department of Medicine (DIMED), University of Padova, Padova, Italy
| | - Shivaram P Singh
- Department of Gastroenterology, Medical College, Cuttack, Odisha, India
| | - Aleksander Krag
- Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark OPEN, Odense Patient data Exploratory Network, Odense University Hospital, Odense, Denmark
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16
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Jansen C, Bogs C, Verlinden W, Thiele M, Möller P, Görtzen J, Lehmann J, Praktiknjo M, Chang J, Krag A, Strassburg CP, Francque S, Trebicka J. Algorithm to rule out clinically significant portal hypertension combining Shear-wave elastography of liver and spleen: a prospective multicentre study. Gut 2016; 65:1057-8. [PMID: 26896458 DOI: 10.1136/gutjnl-2016-311536] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2016] [Accepted: 02/01/2016] [Indexed: 12/12/2022]
Affiliation(s)
- Christian Jansen
- Department of Internal Medicine I, University of Bonn, Bonn, Germany
| | - Christopher Bogs
- Department of Internal Medicine I, University of Bonn, Bonn, Germany
| | - Wim Verlinden
- Department of Gastroenterology and Hepatology, University Hospital Antwerp, Edegem, Belgium
| | - Maja Thiele
- Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark
| | - Philipp Möller
- Department of Internal Medicine I, University of Bonn, Bonn, Germany
| | - Jan Görtzen
- Department of Internal Medicine I, University of Bonn, Bonn, Germany
| | - Jennifer Lehmann
- Department of Internal Medicine I, University of Bonn, Bonn, Germany
| | | | - Johannes Chang
- Department of Internal Medicine I, University of Bonn, Bonn, Germany
| | - Aleksander Krag
- Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark
| | | | - Sven Francque
- Department of Gastroenterology and Hepatology, University Hospital Antwerp, Edegem, Belgium
| | - Jonel Trebicka
- Department of Internal Medicine I, University of Bonn, Bonn, Germany Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark
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Takuma Y, Nouso K, Morimoto Y, Tomokuni J, Sahara A, Takabatake H, Doi A, Matsueda K, Yamamoto H. Prediction of oesophageal variceal bleeding by measuring spleen stiffness in patients with liver cirrhosis. Gut 2016; 65:354-5. [PMID: 26006115 DOI: 10.1136/gutjnl-2015-309741] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2015] [Accepted: 05/01/2015] [Indexed: 12/15/2022]
Affiliation(s)
- Yoshitaka Takuma
- Department of Internal Medicine, Hiroshima City Hospital, Hiroshima, Japan Department of Gastroenterology, Kurashiki Central Hospital, Okayama, Japan
| | - Kazuhiro Nouso
- Department of Gastroenterology and Hepatology, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan
| | - Youichi Morimoto
- Department of Gastroenterology, Kurashiki Central Hospital, Okayama, Japan
| | - Junko Tomokuni
- Department of Laboratory Medicine, Kurashiki Central Hospital, Okayama, Japan
| | - Akiko Sahara
- Department of Laboratory Medicine, Kurashiki Central Hospital, Okayama, Japan
| | | | - Akira Doi
- Department of Gastroenterology, Kurashiki Central Hospital, Okayama, Japan
| | - Kazuhiro Matsueda
- Department of Gastroenterology, Kurashiki Central Hospital, Okayama, Japan
| | - Hiroshi Yamamoto
- Department of Gastroenterology, Kurashiki Central Hospital, Okayama, Japan
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18
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Abstract
Upper gastrointestinal (GI) haemorrhage is a common cause for admission to hospital and is associated with a mortality of around 10%. Prompt assessment and resuscitation are vital, as are risk stratification of the severity of bleeding, early involvement of the multidisciplinary team and timely access to endoscopy, preferably within 24 h. The majority of bleeds are due to peptic ulcers for which Helicobacter pylori and non-steroidal anti-inflammatory agents are the main risk factors. Although proton pump inhibitors (PPIs) are widely used before endoscopy, this is controversial. Pre-endoscopic risk stratification with the Glasgow Blatchford score is recommended as is the use of the Rockall score postendoscopy. Endoscopic therapy, with at least two haemostatic modalities, remains the mainstay of treating high-risk lesions and reduces rebleeding rates and mortality. High-dose PPI therapy after endoscopic haemostasis also reduces rebleeding rates and mortality. Variceal oesophageal haemorrhage is associated with a higher rebleeding rate and risk of death. Antibiotics and vasopressin analogues are advised in suspected variceal bleeding; however, endoscopic variceal band ligation remains the haemostatic treatment of choice. Balloon tamponade remains useful in the presence of torrential variceal haemorrhage or when endoscopy fails to secure haemostasis, and can be a bridge to further endoscopic attempts or placement of a transjugular intrahepatic portosystemic shunt. This review aims to provide an update on the latest evidence-based recommendations for the management of acute upper GI haemorrhage.
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Affiliation(s)
| | - Anisa Jabeen Nasir Jafar
- Gastroenterology Department, Stockport NHS Foundation Trust, Stockport, UK,Emergency Department, Salford Royal NHS Foundation Trust, Salford, UK
| | - Abhishek Sharma
- Gastroenterology
Department, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, UK
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19
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Tripathi D, Stanley AJ, Hayes PC, Patch D, Millson C, Mehrzad H, Austin A, Ferguson JW, Olliff SP, Hudson M, Christie JM. U.K. guidelines on the management of variceal haemorrhage in cirrhotic patients. Gut 2015; 64:1680-704. [PMID: 25887380 PMCID: PMC4680175 DOI: 10.1136/gutjnl-2015-309262] [Citation(s) in RCA: 351] [Impact Index Per Article: 39.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2015] [Accepted: 03/17/2015] [Indexed: 12/12/2022]
Abstract
These updated guidelines on the management of variceal haemorrhage have been commissioned by the Clinical Services and Standards Committee (CSSC) of the British Society of Gastroenterology (BSG) under the auspices of the liver section of the BSG. The original guidelines which this document supersedes were written in 2000 and have undergone extensive revision by 13 members of the Guidelines Development Group (GDG). The GDG comprises elected members of the BSG liver section, representation from British Association for the Study of the Liver (BASL) and Liver QuEST, a nursing representative and a patient representative. The quality of evidence and grading of recommendations was appraised using the AGREE II tool.The nature of variceal haemorrhage in cirrhotic patients with its complex range of complications makes rigid guidelines inappropriate. These guidelines deal specifically with the management of varices in patients with cirrhosis under the following subheadings: (1) primary prophylaxis; (2) acute variceal haemorrhage; (3) secondary prophylaxis of variceal haemorrhage; and (4) gastric varices. They are not designed to deal with (1) the management of the underlying liver disease; (2) the management of variceal haemorrhage in children; or (3) variceal haemorrhage from other aetiological conditions.
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Affiliation(s)
- Dhiraj Tripathi
- Liver Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | | | - Peter C Hayes
- Liver Unit, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - David Patch
- The Royal Free Sheila Sherlock Liver Centre, Royal Free Hospital and University College London, London, UK
| | - Charles Millson
- Gastrointestinal and Liver Services, York Teaching Hospitals NHS Foundation Trust, York, UK
| | - Homoyon Mehrzad
- Department of Interventional Radiology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Andrew Austin
- Department of Gastroenterology, Derby Hospitals NHS Foundation Trust, Derby, UK
| | - James W Ferguson
- Liver Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Simon P Olliff
- Department of Interventional Radiology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Mark Hudson
- Liver Unit, Freeman Hospital, Newcastle upon Tyne, UK
| | - John M Christie
- Department of Gastroenterology, Royal Devon and Exeter Hospital, Devon, UK
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20
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Maharshi S, Sharma BC, Srivastava S, Jindal A. Randomised controlled trial of lactulose versus rifaximin for prophylaxis of hepatic encephalopathy in patients with acute variceal bleed. Gut 2015; 64:1341-2. [PMID: 25320105 DOI: 10.1136/gutjnl-2014-308521] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2014] [Accepted: 09/29/2014] [Indexed: 12/16/2022]
Affiliation(s)
- Sudhir Maharshi
- Department of Gastroenterology, G.B. Pant Hospital, New Delhi, India
| | | | | | - Amit Jindal
- Department of Gastroenterology, G.B. Pant Hospital, New Delhi, India
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21
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Ramiah R, Wurm P. Provision of an out-of-hours emergency endoscopy service: the Leicester experience. Frontline Gastroenterol 2013; 4:288-295. [PMID: 28840921 PMCID: PMC5369819 DOI: 10.1136/flgastro-2013-100313] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2013] [Revised: 04/21/2013] [Accepted: 04/22/2013] [Indexed: 02/04/2023] Open
Abstract
INTRODUCTION The British Society of Gastroenterology (BSG) Strategy document 'Care of patients with Gastrointestinal (GI) disorders' recommends that all acute hospitals should have arrangements for out-of-hours (OOH) endoscopy staffed with appropriately trained endoscopists. The UK national audit published in 2010 found that only 52% of hospitals across the UK had a formal consultant-led OOH endoscopy on-call rota. The University Hospitals of Leicester (UHL) established a consultant-led rota in 2006, which now provides 24/7 endoscopy cover. To define the workload of a newly established OOH service, we examined procedures performed since the introduction of an OOH service in 2006. METHODS The audit period covered August-January (6 months) for each of five consecutive years. Data were gathered from formal endoscopy reports on Unisoft reporting tool and OOH record books. We examined indication for endoscopy, timing of procedure, findings at index endoscopy, intervention and immediate outcome. RESULTS Across the three UHL sites, data on 982 patients were analysed. Eighty-one percent of procedures performed were gastroscopies. 63% of the procedures were performed for GI bleed indications. Over the five years, there was an overall increase in the number of procedures performed where no pathology was found. Immediate outcomes postendoscopy were good, with over 90% being returned to their base ward. CONCLUSIONS The experience at UHL appears to show a trend towards an increasing number of procedures performed OOH, with fewer positive findings and less need for therapy. A likely contributing factor is the ongoing shortage of medical beds, requiring more routine work to be done OOH in order to expedite discharges. However, early specialist endoscopic input is likely to improve patient management. The impact of an OOH service on other services, however, needs to be carefully considered.
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Affiliation(s)
- Rekha Ramiah
- Department of Gastroenterology, University Hospitals of Leicester, Leicester, UK
| | - Peter Wurm
- Department of Gastroenterology, University Hospitals of Leicester NHS Trust, Leicester, UK
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