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Shafiq M, Khan MA, Khan S. Clinical Outcomes of Transjugular Intrahepatic Portosystemic Shunt Among Cirrhosis Patients With Recurrent Esophageal Variceal Bleeding. Cureus 2024; 16:e73101. [PMID: 39651005 PMCID: PMC11621572 DOI: 10.7759/cureus.73101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/05/2024] [Indexed: 12/11/2024] Open
Abstract
Background Transjugular intrahepatic portosystemic shunt (TIPS) has been shown to reduce the risk of rebleeding among patients with recurrent esophageal variceal bleeding. However, the impact of TIPS on survival remains uncertain. This study took on this challenge to determine if TIPS has any impact on all-cause inpatient mortality during the hospitalization in which it is performed and if it impacts all-cause 30-day readmission rates when compared to patients who only undergo esophageal variceal banding (EVB) for recurrent esophageal variceal bleeding. Methods This was a retrospective cohort study using the Healthcare Cost and Utilization Project - National Readmission Database 2019. All adult patients who had a diagnosis of cirrhosis, were hospitalized once for esophageal variceal bleeding requiring EVB in 2019, and then were hospitalized again later in the year for recurrent esophageal variceal bleeding requiring either TIPS or EVB were included. This second hospitalization in which patients either received TIPS or EVB only was considered as the index hospitalization. Patients with missing data and patients who were discharged in December were excluded. The primary outcome was all-cause 30-day readmission rates among patients who either received TIPS or EVB only. The secondary outcomes included: (i) incidence of all-cause inpatient mortality; and (ii) length of hospital stay during index hospitalization. Patients who underwent TIPS were matched with patients who underwent EVB only on age, sex, and baseline comorbidities. After propensity score matching, survival analysis was performed to compare the all-cause 30-day readmission rates after the index hospitalization, between patients who either received TIPS or EVB only during the index hospitalization. χ2 test was used to compare the inpatient mortality. As the data did not have a normal distribution, the Wilcoxon signed-rank test was used to compare the length of index hospitalization between patients who either received TIPS or EVB only. The alpha criterion was set at 0.05 for all statistical tests. Results This study found no difference in all-cause 30-day readmission rates between patients who underwent either TIPS or EVB only for recurrent esophageal variceal bleeding (hazard ratio: 1.24, 95%CI: 0.73-2.12, P = 0.4). In the exploratory analysis, it was noted that the rate of recurrent esophageal variceal bleeding, among patients who were readmitted within 30 days was lower in the TIPS group (13.3%) when compared to the EVB group (50%) with a risk ratio of 0.27 (95%CI: 0.10-0.72, P = 0.003). Although it was not statistically significant, the inpatient mortality rate during the index hospitalization appeared to be lower in the TIPS group when compared to the EVB group (4.2% vs 10.08%, respectively). Patients who underwent TIPS were hospitalized three days longer than patients who underwent EVB only. Conclusion TIPS does not reduce all-cause 30-day readmission rates but is associated with reduced 30-day readmission rates secondary to recurrent esophageal variceal bleeding. TIPS shows a modest survival advantage during index hospitalization when compared to EVB only.
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Affiliation(s)
- Muhammad Shafiq
- Internal Medicine, University of Kansas Medical Center, Kansas City, USA
| | | | - Shahryar Khan
- Internal Medicine, University of Kansas Medical Center, Kansas City, USA
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Kaplan DE, Ripoll C, Thiele M, Fortune BE, Simonetto DA, Garcia-Tsao G, Bosch J. AASLD Practice Guidance on risk stratification and management of portal hypertension and varices in cirrhosis. Hepatology 2024; 79:1180-1211. [PMID: 37870298 DOI: 10.1097/hep.0000000000000647] [Citation(s) in RCA: 103] [Impact Index Per Article: 103.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Accepted: 10/16/2023] [Indexed: 10/24/2023]
Affiliation(s)
- David E Kaplan
- Department of Medicine, Division of Gastroenterology and Hepatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Gastroenterology Section, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA USA
| | - Cristina Ripoll
- Internal Medicine IV, Jena University Hospital, Friedrich Schiller University, Jena, Germany
| | - Maja Thiele
- Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark; Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Brett E Fortune
- Department of Gastroenterology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Douglas A Simonetto
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | | | - Jaime Bosch
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Switzerland
- Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS) and CIBERehd, University of Barcelona, Spain
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Fujisaki H, Fukami Y, Arikawa T, Saito T, Osawa T, Komatsu S, Kaneko K, Kurokawa T, Nonami T, Sano T. Long-term results of laparoscopic Hassab's procedure for esophagogastric varices with portal hypertension. Asian J Endosc Surg 2022; 15:505-512. [PMID: 35132809 DOI: 10.1111/ases.13038] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2021] [Revised: 12/29/2021] [Accepted: 01/22/2022] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Recent reports have shown laparoscopic gastric devascularization and splenectomy (Hassab's procedure) to be a safe and effective treatment for esophagogastric varices with portal hypertension. However, the long-term postoperative results remain unclear. METHODS Between 2009 and 2015, 17 patients with portal hypertension and esophagogastric varices underwent laparoscopic Hassab's procedure at our institution. Two patients were lost to long-term follow-up (at least 2 years) and excluded. The remaining 15 patients' data and endoscopic findings were retrospectively reviewed. RESULTS The median postoperative follow-up period was 56 months. The median spleen volume, operation time, blood loss, and length of postoperative hospital stay were 651 (320-1,265) mL, 305 (275-547) minutes, 347 (24-1,131) mL, and 20 (8-41) days, respectively. According to the endoscopic findings 1 year after surgery, the esophagogastric varices disappeared in three patients and improved in 12 patients. The median platelet count was significantly higher 1 year after surgery (19.7 × 104 /dL) than before surgery (5.5 × 104 /dL) (P < .001) and remained stable 2 years after surgery. Two patients died of liver disease. The remaining 13 patients, with a median postoperative follow-up of 57 months, were alive without bleeding from esophagogastric varices. CONCLUSION Laparoscopic Hassab's procedure is a feasible treatment for esophagogastric varices with portal hypertension in terms of both short- and long-term results.
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Affiliation(s)
- Hiroyuki Fujisaki
- Division of Gastroenterological Surgery, Department of Surgery, Aichi Medical University, Nagakute, Japan
| | - Yasuyuki Fukami
- Division of Gastroenterological Surgery, Department of Surgery, Aichi Medical University, Nagakute, Japan
| | - Takashi Arikawa
- Division of Gastroenterological Surgery, Department of Surgery, Aichi Medical University, Nagakute, Japan
| | - Takuya Saito
- Division of Gastroenterological Surgery, Department of Surgery, Aichi Medical University, Nagakute, Japan
| | - Takaaki Osawa
- Division of Gastroenterological Surgery, Department of Surgery, Aichi Medical University, Nagakute, Japan
| | - Shunichiro Komatsu
- Division of Gastroenterological Surgery, Department of Surgery, Aichi Medical University, Nagakute, Japan
| | - Kenitiro Kaneko
- Division of Gastroenterological Surgery, Department of Surgery, Aichi Medical University, Nagakute, Japan
| | - Tsuyoshi Kurokawa
- Division of Gastroenterological Surgery, Department of Surgery, Aichi Medical University, Nagakute, Japan
| | - Toshiaki Nonami
- Division of Gastroenterological Surgery, Department of Surgery, Aichi Medical University, Nagakute, Japan
| | - Tsuyoshi Sano
- Division of Gastroenterological Surgery, Department of Surgery, Aichi Medical University, Nagakute, Japan
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Abstract
Despite advances in the management of complications of portal hypertension, variceal bleeding continues to be associated with significant morbidity and mortality. While endoscopic variceal band ligation remains first line therapy for treating bleeding and high-risk non-bleeding esophageal varices, alternate therapies have been explored, particularly in cases of refractory bleeding. The therapies being explored include stent placement, hemostatic powder use, over-the-scope clips and others. For gastric variceal bleeding, endoscopic ultrasound-guided therapies have recently emerged as promising interventions for hemostasis. The aim of this article is to highlight these alternative therapies and their potential role in the management of gastric and esophageal variceal bleeding.
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Jung JH, Jo JH, Kim SE, Bang CS, Seo SI, Park CH, Park SW. Minimal and Maximal Extent of Band Ligation for Acute Variceal Bleeding during the First Endoscopic Session. Gut Liver 2022; 16:101-110. [PMID: 34446612 PMCID: PMC8761925 DOI: 10.5009/gnl20375] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Revised: 03/15/2021] [Accepted: 03/15/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND/AIMS The appropriate number of band ligations during the first endoscopic session for acute variceal bleeding is debatable. We aimed to compare the technical aspects of endoscopic variceal ligation (EVL) in patients with variceal bleeding according to the number of bands placed per session. METHODS We retrospectively reviewed multicenter data from patients who underwent EVL for acute variceal bleeding. Patients were classified into minimal EVL (targeting only the foci with active bleeding or stigmata of recent bleeding) and maximal EVL (targeting potential bleeding sources in addition to the aforementioned targets) groups. The primary endpoint was 5-day treatment failure. The secondary endpoints were 30-day rebleeding, 30-day mortality, and intraprocedural adverse events. RESULTS Minimal EVL was associated with lower rates of hypoxia and shock during EVL than maximal EVL (hypoxia, 0.9% vs 2.9%; shock, 1.3% vs 3.4%). However, treatment failure was higher in the minimal EVL group than in the maximal EVL group (odds ratio, 1.60; 95% confidence interval, 1.06 to 2.41). Age ≥60 years, Model for End-Stage Liver Disease score ≥15, Child-Turcotte-Pugh classification C, presence of hepatocellular carcinoma, and systolic blood pressure <90 mm Hg at initial presentation were also associated with treatment failure. In contrast, 30-day rebleeding and 30-day mortality did not differ between the minimal and maximal EVL groups. CONCLUSIONS Given that minimal EVL was associated with a high risk of treatment failure, maximal EVL may be a better option for variceal bleeding. However, the minimal EVL strategy should be considered in select patients because it does not affect 30-day rebleeding and mortality.
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Affiliation(s)
- Jang Han Jung
- Division of Gastroenterology, Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Hwaseong, Korea
| | - Jung Hyun Jo
- Division of Gastroenterology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Sung Eun Kim
- Division of Gastroenterology, Department of Internal Medicine, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Korea
| | - Chang Seok Bang
- Division of Gastroenterology, Department of Internal Medicine, Hallym University Chuncheon Sacred Heart Hospital, Hallym University College of Medicine, Chuncheon, Korea
| | - Seung In Seo
- Division of Gastroenterology, Department of Internal Medicine, Gangdong Sacred Heart Hospital, Seoul, Korea
| | - Chan Hyuk Park
- Department of Internal Medicine, Hanyang University Guri Hospital, Hanyang University College of Medicine, Guri, Korea
| | - Se Woo Park
- Division of Gastroenterology, Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Hwaseong, Korea
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Efficacy of Endoscopic Band Ligation in the Treatment of Acute Esophageal Varicose Bleeding. JOURNAL OF CONTEMPORARY MEDICINE 2022. [DOI: 10.16899/jcm.1015238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Su J, Zhang H, Ren M, Xing Y, Yin Y, Liu L. Efficacy and Safety of Ligation Combined With Sclerotherapy for Patients With Acute Esophageal Variceal Bleeding in Cirrhosis: A Meta-Analysis. Front Surg 2021; 8:664454. [PMID: 34179067 PMCID: PMC8219859 DOI: 10.3389/fsurg.2021.664454] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Accepted: 03/22/2021] [Indexed: 01/30/2023] Open
Abstract
Objective: To evaluate the efficacy and safety of endoscopic variceal ligation + endoscopic injection sclerotherapy (EVL+EIS) to control acute variceal bleeding (AVB). Methods: Online databases, including Web of Science, PubMed, the Cochrane Library, Chinese National Knowledge Infrastructure (CNKI), China Biology Medicine (CBM) disc, VIP, and Wanfang, were searched to identify the studies comparing the differences between EVB+EIS and EVB, EIS from the inception of the databases up to December 30, 2020. STATA 13.0 was used for the meta-analysis. Results: A total of eight studies involving 595 patients (317 patients in the EVL group and 278 patients in the EVL+EIS group) were included. The results of the meta-analysis did not reveal any statistically significant differences in the efficacy of acute bleeding control (P = 0.981), overall rebleeding (P = 0.415), variceal eradication (P = 0.960), and overall mortality (P = 0.314), but a significant difference was noted in the overall complications (P = 0.01). Conclusion: EVL is superior to the combination of EVL and EIS in safety, while no statistically significant differences were detected in efficacy. Further studies should be designed with a large sample size, multiple centers, and randomized controlled trials to assess both clinical interventions.
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Affiliation(s)
- Juan Su
- Department of Gastrology Ward III, Xi'an International Medical Center Hospital, Xi'an, China
| | - Huilin Zhang
- Department of Digestive Endoscopy and Treatment Center, Xi'an International Medical Center Hospital, Xi'an, China
| | - Maifang Ren
- Department of Gastrology Ward I, Xi'an International Medical Center Hospital, Xi'an, China
| | - Yanan Xing
- Department of Gastrology Ward III, Xi'an International Medical Center Hospital, Xi'an, China
| | - Yuefei Yin
- Department of Gastrology Ward I, Xi'an International Medical Center Hospital, Xi'an, China
| | - Lihua Liu
- Department of Gastrology Ward III, Xi'an International Medical Center Hospital, Xi'an, China
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Ni JB, Xiang XX, Wu W, Chen SY, Zhang F, Zhang M, Peng CY, Xiao JQ, Zhuge YZ, Zhang CQ. Transjugular intrahepatic portosystemic shunt in patients treated with a balloon tamponade for variceal hemorrhage without response to high doses of vasoactive drugs: A real-world multicenter retrospective study. J Dig Dis 2021; 22:236-245. [PMID: 33634958 DOI: 10.1111/1751-2980.12978] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Accepted: 02/23/2021] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To evaluate the efficacy of transjugular intrahepatic portosystemic shunt (TIPS) and non-TIPS therapy (endoscopy and/or nonselective beta-blockers [NSBB]) in patients with cirrhosis and active variceal hemorrhage who did not respond to high-dose vasoactive drugs and required balloon tamponade for hemostasis. METHODS Medical records of cirrhotic patients who did not respond to high-dose vasoactive drugs and required balloon tamponade for hemostasis at five university hospitals in China between January 2011 and December 2018 were reviewed. Treatment outcomes were compared between the TIPS and the non-TIPS groups. RESULTS Treatment failure of variceal hemorrhage within 5 days was reported in six patients of the non-TIPS group (N = 70) and none of the TIPS group (N = 66) (P = .028). The TIPS group had a higher 1-year variceal rebleeding-free rate compared with the non-TIPS group (95.5% vs 60.0%, P < .001). One patient treated with TIPS and nine with non-TIPS therapy experienced rebleeding within 5 days and 6 weeks after the intervention (P = .009). The cumulative 1-year survival rate was higher in the TIPS group than in the non-TIPS group (93.9% vs 78.6%, P = .01). The TIPS group had a higher incidence of hepatic encephalopathy within one year compared with the non-TIPS group (18.2% vs 4.3%, P = .026). CONCLUSION For patients with cirrhosis and active variceal bleeding who do not respond to high-dose vasoactive agents and require a balloon tamponade for hemostasis, TIPS may be an appropriate treatment choice.
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Affiliation(s)
- Jing Bin Ni
- Department of Gastroenterology, Nanjing Medical University Drum Tower Clinical Medical School, Nanjing, Jiangsu Province, China
- Department of Gastroenterology, Affiliated Wuxi No. 2 People's Hospital of Nanjing Medical University, Wuxi, Jiangsu Province, China
| | - Xiao Xing Xiang
- Department of Gastroenterology, Northern Jiangsu People's Hospital, Yangzhou, Jiangsu Province, China
| | - Wei Wu
- Department of Gastroenterology, First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang Province, China
| | - Shi Yao Chen
- Department of Gastroenterology, Zhongshan Hospital Fudan University, Shanghai, China
| | - Feng Zhang
- Department of Gastroenterology, Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, Jiangsu Province, China
| | - Ming Zhang
- Department of Gastroenterology, Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, Jiangsu Province, China
| | - Chun Yan Peng
- Department of Gastroenterology, Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, Jiangsu Province, China
| | - Jiang Qiang Xiao
- Department of Gastroenterology, Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, Jiangsu Province, China
| | - Yu Zheng Zhuge
- Department of Gastroenterology, Nanjing Medical University Drum Tower Clinical Medical School, Nanjing, Jiangsu Province, China
| | - Chun Qing Zhang
- Department of Gastroenterology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong Province, China
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Roberts D, Best LM, Freeman SC, Sutton AJ, Cooper NJ, Arunan S, Begum T, Williams NR, Walshaw D, Milne EJ, Tapp M, Csenar M, Pavlov CS, Davidson BR, Tsochatzis E, Gurusamy KS. Treatment for bleeding oesophageal varices in people with decompensated liver cirrhosis: a network meta-analysis. Cochrane Database Syst Rev 2021; 4:CD013155. [PMID: 33837526 PMCID: PMC8094233 DOI: 10.1002/14651858.cd013155.pub2] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
BACKGROUND Approximately 40% to 95% of people with liver cirrhosis have oesophageal varices. About 15% to 20% of oesophageal varices bleed within about one to three years after diagnosis. Several different treatments are available, including, among others, endoscopic sclerotherapy, variceal band ligation, somatostatin analogues, vasopressin analogues, and balloon tamponade. However, there is uncertainty surrounding the individual and relative benefits and harms of these treatments. OBJECTIVES To compare the benefits and harms of different initial treatments for variceal bleeding from oesophageal varices in adults with decompensated liver cirrhosis, through a network meta-analysis; and to generate rankings of the different treatments for acute bleeding oesophageal varices, according to their benefits and harms. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, Science Citation Index Expanded, World Health Organization International Clinical Trials Registry Platform, and trials registers until 17 December 2019, to identify randomised clinical trials (RCTs) in people with cirrhosis and acute bleeding from oesophageal varices. SELECTION CRITERIA We included only RCTs (irrespective of language, blinding, or status) in adults with cirrhosis and acutely bleeding oesophageal varices. We excluded RCTs in which participants had bleeding only from gastric varices, those who failed previous treatment (refractory bleeding), those in whom initial haemostasis was achieved before inclusion into the trial, and those who had previously undergone liver transplantation. DATA COLLECTION AND ANALYSIS We performed a network meta-analysis with OpenBUGS software, using Bayesian methods, and calculated the differences in treatments using odds ratios (OR) and rate ratios with 95% credible intervals (CrI) based on an available-case analysis, according to National Institute of Health and Care Excellence Decision Support Unit guidance. We performed also the direct comparisons from RCTs using the same codes and the same technical details. MAIN RESULTS We included a total of 52 RCTs (4580 participants) in the review. Forty-eight trials (4042 participants) were included in one or more comparisons in the review. The trials that provided the information included people with cirrhosis due to varied aetiologies and those with and without a previous history of bleeding. We included outcomes assessed up to six weeks. All trials were at high risk of bias. A total of 19 interventions were compared in the trials (sclerotherapy, somatostatin analogues, vasopressin analogues, sclerotherapy plus somatostatin analogues, variceal band ligation, balloon tamponade, somatostatin analogues plus variceal band ligation, nitrates plus vasopressin analogues, no active intervention, sclerotherapy plus variceal band ligation, balloon tamponade plus sclerotherapy, balloon tamponade plus somatostatin analogues, balloon tamponade plus vasopressin analogues, variceal band ligation plus vasopressin analogues, balloon tamponade plus nitrates plus vasopressin analogues, balloon tamponade plus variceal band ligation, portocaval shunt, sclerotherapy plus transjugular intrahepatic portosystemic shunt (TIPS), and sclerotherapy plus vasopressin analogues). We have reported the effect estimates for the primary and secondary outcomes when there was evidence of differences between the interventions against the reference treatment of sclerotherapy, but reported the other results of the primary and secondary outcomes versus the reference treatment of sclerotherapy without the effect estimates when there was no evidence of differences in order to provide a concise summary of the results. Overall, 15.8% of the trial participants who received the reference treatment of sclerotherapy (chosen because this was the commonest treatment compared in the trials) died during the follow-up periods, which ranged from three days to six weeks. Based on moderate-certainty evidence, somatostatin analogues alone had higher mortality than sclerotherapy (OR 1.57, 95% CrI 1.04 to 2.41; network estimate; direct comparison: 4 trials; 353 participants) and vasopressin analogues alone had higher mortality than sclerotherapy (OR 1.70, 95% CrI 1.13 to 2.62; network estimate; direct comparison: 2 trials; 438 participants). None of the trials reported health-related quality of life. Based on low-certainty evidence, a higher proportion of people receiving balloon tamponade plus sclerotherapy had more serious adverse events than those receiving only sclerotherapy (OR 4.23, 95% CrI 1.22 to 17.80; direct estimate; 1 RCT; 60 participants). Based on moderate-certainty evidence, people receiving vasopressin analogues alone and those receiving variceal band ligation had fewer adverse events than those receiving only sclerotherapy (rate ratio 0.59, 95% CrI 0.35 to 0.96; network estimate; direct comparison: 1 RCT; 219 participants; and rate ratio 0.40, 95% CrI 0.21 to 0.74; network estimate; direct comparison: 1 RCT; 77 participants; respectively). Based on low-certainty evidence, the proportion of people who developed symptomatic rebleed was smaller in people who received sclerotherapy plus somatostatin analogues than those receiving only sclerotherapy (OR 0.21, 95% CrI 0.03 to 0.94; direct estimate; 1 RCT; 105 participants). The evidence suggests considerable uncertainty about the effect of the interventions in the remaining comparisons where sclerotherapy was the control intervention. AUTHORS' CONCLUSIONS Based on moderate-certainty evidence, somatostatin analogues alone and vasopressin analogues alone (with supportive therapy) probably result in increased mortality, compared to endoscopic sclerotherapy. Based on moderate-certainty evidence, vasopressin analogues alone and band ligation alone probably result in fewer adverse events compared to endoscopic sclerotherapy. Based on low-certainty evidence, balloon tamponade plus sclerotherapy may result in large increases in serious adverse events compared to sclerotherapy. Based on low-certainty evidence, sclerotherapy plus somatostatin analogues may result in large decreases in symptomatic rebleed compared to sclerotherapy. In the remaining comparisons, the evidence indicates considerable uncertainty about the effects of the interventions, compared to sclerotherapy.
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Affiliation(s)
- Danielle Roberts
- Division of Surgery and Interventional Science, University College London, London, UK
| | - Lawrence Mj Best
- Division of Surgery and Interventional Science, University College London, London, UK
- Department of Therapy, I.M. Sechenov First Moscow State Medical University, Moscow, Russian Federation
| | - Suzanne C Freeman
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Alex J Sutton
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Nicola J Cooper
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Sivapatham Arunan
- General and Colorectal Surgery, Ealing Hospital and Imperial College, London, Northwood, UK
| | | | - Norman R Williams
- Surgical & Interventional Trials Unit (SITU), UCL Division of Surgery & Interventional Science, London, UK
| | - Dana Walshaw
- Acute Medicine, Barts and The London NHS Trust, London, UK
| | | | | | - Mario Csenar
- Division of Surgery and Interventional Science, University College London, London, UK
| | - Chavdar S Pavlov
- Department of Therapy, I.M. Sechenov First Moscow State Medical University, Moscow, Russian Federation
| | - Brian R Davidson
- Division of Surgery and Interventional Science, University College London, London, UK
| | - Emmanuel Tsochatzis
- Sheila Sherlock Liver Centre, Royal Free Hospital and the UCL Institute of Liver and Digestive Health, London, UK
| | - Kurinchi Selvan Gurusamy
- Division of Surgery and Interventional Science, University College London, London, UK
- Department of Therapy, I.M. Sechenov First Moscow State Medical University, Moscow, Russian Federation
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Plaz Torres MC, Best LM, Freeman SC, Roberts D, Cooper NJ, Sutton AJ, Roccarina D, Benmassaoud A, Iogna Prat L, Williams NR, Csenar M, Fritche D, Begum T, Arunan S, Tapp M, Milne EJ, Pavlov CS, Davidson BR, Tsochatzis E, Gurusamy KS. Secondary prevention of variceal bleeding in adults with previous oesophageal variceal bleeding due to decompensated liver cirrhosis: a network meta-analysis. Cochrane Database Syst Rev 2021; 3:CD013122. [PMID: 33784794 PMCID: PMC8094621 DOI: 10.1002/14651858.cd013122.pub2] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
BACKGROUND Approximately 40% to 95% of people with cirrhosis have oesophageal varices. About 15% to 20% of oesophageal varices bleed in about one to three years of diagnosis. Several different treatments are available, which include endoscopic sclerotherapy, variceal band ligation, beta-blockers, transjugular intrahepatic portosystemic shunt (TIPS), and surgical portocaval shunts, among others. However, there is uncertainty surrounding their individual and relative benefits and harms. OBJECTIVES To compare the benefits and harms of different initial treatments for secondary prevention of variceal bleeding in adults with previous oesophageal variceal bleeding due to decompensated liver cirrhosis through a network meta-analysis and to generate rankings of the different treatments for secondary prevention according to their safety and efficacy. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, Science Citation Index Expanded, World Health Organization International Clinical Trials Registry Platform, and trials registers until December 2019 to identify randomised clinical trials in people with cirrhosis and a previous history of bleeding from oesophageal varices. SELECTION CRITERIA We included only randomised clinical trials (irrespective of language, blinding, or status) in adults with cirrhosis and previous history of bleeding from oesophageal varices. We excluded randomised clinical trials in which participants had no previous history of bleeding from oesophageal varices, previous history of bleeding only from gastric varices, those who failed previous treatment (refractory bleeding), those who had acute bleeding at the time of treatment, and those who had previously undergone liver transplantation. DATA COLLECTION AND ANALYSIS We performed a network meta-analysis with OpenBUGS using Bayesian methods and calculated the differences in treatments using hazard ratios (HR), odds ratios (OR) and rate ratios with 95% credible intervals (CrI) based on an available-case analysis, according to National Institute of Health and Care Excellence Decision Support Unit guidance. MAIN RESULTS We included a total of 48 randomised clinical trials (3526 participants) in the review. Forty-six trials (3442 participants) were included in one or more comparisons. The trials that provided the information included people with cirrhosis due to varied aetiologies. The follow-up ranged from two months to 61 months. All the trials were at high risk of bias. A total of 12 interventions were compared in these trials (sclerotherapy, beta-blockers, variceal band ligation, beta-blockers plus sclerotherapy, no active intervention, TIPS (transjugular intrahepatic portosystemic shunt), beta-blockers plus nitrates, portocaval shunt, sclerotherapy plus variceal band ligation, beta-blockers plus nitrates plus variceal band ligation, beta-blockers plus variceal band ligation, sclerotherapy plus nitrates). Overall, 22.5% of the trial participants who received the reference treatment (chosen because this was the commonest treatment compared in the trials) of sclerotherapy died during the follow-up period ranging from two months to 61 months. There was considerable uncertainty in the effects of interventions on mortality. Accordingly, none of the interventions showed superiority over another. None of the trials reported health-related quality of life. Based on low-certainty evidence, variceal band ligation may result in fewer serious adverse events (number of people) than sclerotherapy (OR 0.19; 95% CrI 0.06 to 0.54; 1 trial; 100 participants). Based on low or very low-certainty evidence, the adverse events (number of participants) and adverse events (number of events) may be different across many comparisons; however, these differences are due to very small trials at high risk of bias showing large differences in some comparisons leading to many differences despite absence of direct evidence. Based on low-certainty evidence, TIPS may result in large decrease in symptomatic rebleed than variceal band ligation (HR 0.12; 95% CrI 0.03 to 0.41; 1 trial; 58 participants). Based on moderate-certainty evidence, any variceal rebleed was probably lower in sclerotherapy than in no active intervention (HR 0.62; 95% CrI 0.35 to 0.99, direct comparison HR 0.66; 95% CrI 0.11 to 3.13; 3 trials; 296 participants), beta-blockers plus sclerotherapy than sclerotherapy alone (HR 0.60; 95% CrI 0.37 to 0.95; direct comparison HR 0.50; 95% CrI 0.07 to 2.96; 4 trials; 231 participants); TIPS than sclerotherapy (HR 0.18; 95% CrI 0.08 to 0.38; direct comparison HR 0.22; 95% CrI 0.01 to 7.51; 2 trials; 109 participants), and in portocaval shunt than sclerotherapy (HR 0.21; 95% CrI 0.05 to 0.77; no direct comparison) groups. Based on low-certainty evidence, beta-blockers alone and TIPS might result in more, other compensation, events than sclerotherapy (rate ratio 2.37; 95% CrI 1.35 to 4.67; 1 trial; 65 participants and rate ratio 2.30; 95% CrI 1.20 to 4.65; 2 trials; 109 participants; low-certainty evidence). The evidence indicates considerable uncertainty about the effect of the interventions including those related to beta-blockers plus variceal band ligation in the remaining comparisons. AUTHORS' CONCLUSIONS The evidence indicates considerable uncertainty about the effect of the interventions on mortality. Variceal band ligation might result in fewer serious adverse events than sclerotherapy. TIPS might result in a large decrease in symptomatic rebleed than variceal band ligation. Sclerotherapy probably results in fewer 'any' variceal rebleeding than no active intervention. Beta-blockers plus sclerotherapy and TIPS probably result in fewer 'any' variceal rebleeding than sclerotherapy. Beta-blockers alone and TIPS might result in more other compensation events than sclerotherapy. The evidence indicates considerable uncertainty about the effect of the interventions in the remaining comparisons. Accordingly, high-quality randomised comparative clinical trials are needed.
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Affiliation(s)
| | - Lawrence Mj Best
- Division of Surgery and Interventional Science, University College London, London, UK
- Department of Therapy, I.M. Sechenov First Moscow State Medical University, Moscow, Russian Federation
| | - Suzanne C Freeman
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Danielle Roberts
- Division of Surgery and Interventional Science, University College London, London, UK
| | - Nicola J Cooper
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Alex J Sutton
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Davide Roccarina
- Sheila Sherlock Liver Centre, Royal Free Hospital and the UCL Institute of Liver and Digestive Health, London, UK
| | - Amine Benmassaoud
- Sheila Sherlock Liver Centre, Royal Free Hospital and the UCL Institute of Liver and Digestive Health, London, UK
| | - Laura Iogna Prat
- Sheila Sherlock Liver Centre, Royal Free Hospital and the UCL Institute of Liver and Digestive Health, London, UK
| | - Norman R Williams
- Surgical & Interventional Trials Unit (SITU), UCL Division of Surgery & Interventional Science, London, UK
| | - Mario Csenar
- Division of Surgery and Interventional Science, University College London, London, UK
| | | | | | - Sivapatham Arunan
- General and Colorectal Surgery, Ealing Hospital and Imperial College, London, Northwood, UK
| | | | | | - Chavdar S Pavlov
- Department of Therapy, I.M. Sechenov First Moscow State Medical University, Moscow, Russian Federation
| | - Brian R Davidson
- Division of Surgery and Interventional Science, University College London, London, UK
| | - Emmanuel Tsochatzis
- Sheila Sherlock Liver Centre, Royal Free Hospital and the UCL Institute of Liver and Digestive Health, London, UK
| | - Kurinchi Selvan Gurusamy
- Division of Surgery and Interventional Science, University College London, London, UK
- Department of Therapy, I.M. Sechenov First Moscow State Medical University, Moscow, Russian Federation
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11
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Esophageal Variceal Ligation Monotherapy versus Combined Ligation and Sclerotherapy for the Treatment of Esophageal Varices. Can J Gastroenterol Hepatol 2021; 2021:8856048. [PMID: 33859966 PMCID: PMC8024074 DOI: 10.1155/2021/8856048] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Revised: 02/25/2021] [Accepted: 03/01/2021] [Indexed: 11/27/2022] Open
Abstract
Currently, endoscopic variceal ligation (EVL) monotherapy is the standard therapy for managing esophageal variceal hemorrhage. Patients generally need several sessions of endoscopy to achieve optimal variceal ablation, and the varices can recur afterward. Endoscopic injection sclerotherapy (EIS) is an older technique, associated with certain complications. This study aimed to evaluate the clinical efficacy of EVL alone versus combined EVL and EIS in the treatment of esophageal varices. This retrospective study included 84 patients, of which 40 patients were treated with EVL monotherapy and 44 patients were treated with combined EVL + EIS. The main outcomes were rebleeding rates, recurrence at six months, number of treatment sessions, length of hospital stay, cost of hospitalization, and procedural complications. At six months, the rebleeding rate and recurrence were significantly lower in the EVL + EIS group compared to the EVL group (2.3% versus 15.0%; and 9.1% versus 27.5%, respectively). The number of treatment sessions, length of hospital stay, and cost of hospitalization were significantly lower in the EVL + EIS group compared to those in the EVL group (2.3 ± 0.6 versus 3.2 ± 0.8 times; 14.5 ± 3.4 versus 23.5 ± 5.9 days; and 23918.6 ± 4220.4 versus 26165.2 ± 4765.1 renminbi, respectively). Chest pain was significantly lower in the EVL + EIS group compared to that in the EVL group (15.9% versus 45.0%). There were no statistically significant differences in the presence of fever or esophageal stricture in both groups. In conclusion, combined EVL + EIS showed less rebleeding rates and recurrence at six months and less chest pain and was more cost effective compared to EVL alone in the treatment of gastroesophageal varices.
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12
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Kovalic AJ, Satapathy SK. Secondary Prophylaxis of Variceal Bleeding in Liver Cirrhosis. VARICEAL BLEEDING IN LIVER CIRRHOSIS 2021:77-121. [DOI: 10.1007/978-981-15-7249-4_7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2025]
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13
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Ibrahim M, Roshdy N. Management of Acute Variceal Bleeding in Liver Cirrhosis. VARICEAL BLEEDING IN LIVER CIRRHOSIS 2021:53-65. [DOI: 10.1007/978-981-15-7249-4_5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2025]
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14
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Lau LHS, Sung JJY. Treatment of upper gastrointestinal bleeding in 2020: New techniques and outcomes. Dig Endosc 2021; 33:83-94. [PMID: 32216134 DOI: 10.1111/den.13674] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Revised: 03/15/2020] [Accepted: 03/19/2020] [Indexed: 02/08/2023]
Abstract
The clinical outcome of upper gastrointestinal bleeding has improved due to advances in endoscopic therapy and standardized peri-endoscopy care. Apart from validating clinical scores, artificial intelligence-assisted machine learning models may play an important role in risk stratification. While standard endoscopic treatments remain irreplaceable, novel endoscopic modalities have changed the landscape of management. Over-the-scope clips have high success rates as rescue or even first-line treatments in difficult-to-treat cases. Hemostatic powder is safe and easy to use, which can be useful as temporary control with its high immediate hemostatic ability. After endoscopic hemostasis, Doppler endoscopic probe can offer an objective measure to guide the treatment endpoint. In refractory bleeding, angiographic embolization should be considered before salvage surgery. In variceal hemorrhage, banding ligation and glue injection are first-line treatment options. Endoscopic ultrasound-guided therapy is gaining popularity due to its capability of precise localization for treatment targets. A self-expandable metal stent may be considered as an alternative option to balloon tamponade in refractory bleeding. Transjugular intrahepatic portosystemic shunting should be reserved as salvage therapy. In this article, we aim to provide an evidence-based comprehensive review of the major advancements in endoscopic hemostatic techniques and clinical outcomes.
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Affiliation(s)
- Louis H S Lau
- Institute of Digestive Disease, The Chinese University of Hong Kong, Shatin New Territories, Hong Kong.,Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Shatin New Territories, Hong Kong
| | - Joseph J Y Sung
- Institute of Digestive Disease, The Chinese University of Hong Kong, Shatin New Territories, Hong Kong.,Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Shatin New Territories, Hong Kong
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15
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Krige J, Jonas E, Kotze U, Kloppers C, Gandhi K, Allam H, Bernon M, Burmeister S, Setshedi M. Defining the advantages and exposing the limitations of endoscopic variceal ligation in controlling acute bleeding and achieving complete variceal eradication. World J Gastrointest Endosc 2020; 12:365-377. [PMID: 33133373 PMCID: PMC7579524 DOI: 10.4253/wjge.v12.i10.365] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 06/29/2020] [Accepted: 09/11/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Bleeding esophageal varices (BEV) is a potentially life-threatening complication in patients with portal hypertension with mortality rates as high as 25% within six weeks of the index variceal bleed. After control of the initial bleeding episode patients should enter a long-term surveillance program with endoscopic intervention combined with non-selective β-blockers to prevent further bleeding and eradicate EV.
AIM To assess the efficacy of endoscopic variceal ligation (EVL) in controlling acute variceal bleeding, preventing variceal recurrence and rebleeding and achieving complete eradication of esophageal varices (EV) in patients who present with BEV.
METHODS A prospectively documented single-center database was used to retrospectively identify all patients with BEV who were treated with EVL between 2000 and 2018. Control of acute bleeding, variceal recurrence, rebleeding, eradication and survival were analyzed using Baveno assessment criteria.
RESULTS One hundred and forty patients (100 men, 40 women; mean age 50 years; range, 21–84 years; Child-Pugh grade A = 32; B = 48; C = 60) underwent 160 emergency and 298 elective EVL interventions during a total of 928 endoscopy sessions. One hundred and fourteen (81%) of the 140 patients had variceal bleeding that was effectively controlled during the index banding procedure and never bled again from EV, while 26 (19%) patients had complicated and refractory variceal bleeding. EVL controlled the acute sentinel variceal bleed during the first endoscopic intervention in 134 of 140 patients (95.7%). Six patients required balloon tamponade for control and 4 other patients rebled in hospital. Overall 5-d endoscopic failure to control variceal bleeding was 7.1% (n = 10) and four patients required a salvage transjugular intrahepatic portosystemic shunt. Index admission mortality was 14.2% (n = 20). EV were completely eradicated in 50 of 111 patients (45%) who survived > 3 mo of whom 31 recurred and 3 rebled. Sixteen (13.3%) of 120 surviving patients subsequently had 21 EV rebleeding episodes and 10 patients bled from other sources after discharge from hospital. Overall rebleeding from all sources after 2 years was 21.7% (n = 26). Sixty-nine (49.3%) of the 140 patients died, mainly due to liver failure (n = 46) during follow-up. Cumulative survival for the 140 patients was 71.4% at 1 year, 65% at 3 years, 60% at 5 years and 52.1% at 10 years.
CONCLUSION EVL was highly effective in controlling the sentinel variceal bleed with an overall 5-day failure to control bleeding of 7.1%. Although repeated EVL achieved complete variceal eradication in less than half of patients with BEV, of whom 62% recurred, there was a significant reduction in subsequent rebleeding.
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Affiliation(s)
- Jake Krige
- Departments of Surgery and Medicine, University of Cape Town Health Sciences Faculty, Cape Town 7925, South Africa
- Department of Surgery, University of Cape Town Health Sciences Faculty, Cape Town 7925, South Africa
| | - Eduard Jonas
- Departments of Surgery and Medicine, University of Cape Town Health Sciences Faculty, Cape Town 7925, South Africa
| | - Urda Kotze
- Departments of Surgery and Medicine, University of Cape Town Health Sciences Faculty, Cape Town 7925, South Africa
| | - Christo Kloppers
- Departments of Surgery and Medicine, University of Cape Town Health Sciences Faculty, Cape Town 7925, South Africa
| | - Karan Gandhi
- Departments of Surgery and Medicine, University of Cape Town Health Sciences Faculty, Cape Town 7925, South Africa
| | - Hisham Allam
- Departments of Surgery and Medicine, University of Cape Town Health Sciences Faculty, Cape Town 7925, South Africa
| | - Marc Bernon
- Departments of Surgery and Medicine, University of Cape Town Health Sciences Faculty, Cape Town 7925, South Africa
| | - Sean Burmeister
- Departments of Surgery and Medicine, University of Cape Town Health Sciences Faculty, Cape Town 7925, South Africa
| | - Mashiko Setshedi
- Departments of Surgery and Medicine, University of Cape Town Health Sciences Faculty, Cape Town 7925, South Africa
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16
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Sterpetti AV, Kappes SK. Cirrhosis and Bleeding Esophageal Varices: Historic Perspectives. J Gastrointest Surg 2020; 24:1929-1936. [PMID: 32500417 DOI: 10.1007/s11605-020-04674-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Accepted: 05/25/2020] [Indexed: 01/31/2023]
Abstract
The paper describes the fundamental discoveries in the definition and treatment of patients with bleeding esophageal varices and cirrhosis.
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Affiliation(s)
- Antonio V Sterpetti
- University of Rome Sapienza, Rome, Italy. .,Policlinico Umberto I, Viale del Policlinico, 00167, Rome, Italy.
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17
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Onofrio FDQ, Pereira-Lima JC, Valença FM, Azeredo-da-Silva ALF, Tetelbom Stein A. Efficacy of endoscopic treatments for acute esophageal variceal bleeding in cirrhotic patients: systematic review and meta-analysis. Endosc Int Open 2019; 7:E1503-E1514. [PMID: 31673624 PMCID: PMC6811355 DOI: 10.1055/a-0901-7146] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Accepted: 04/04/2019] [Indexed: 01/14/2023] Open
Abstract
Background and aim Guidelines recommend use of ligation and vasoactive drugs as first-line therapy and as grade A evidence for acute variceal bleeding (AVB), although Western studies about this issue are lacking. Methods We performed a systematic review and meta-analysis of randomized controlled trials (RCT) to evaluate the efficacy of endoscopic treatments for AVB in patients with cirrhosis. Trials that included patients with hepatocellular carcinoma, use of portocaval shunts or esophageal resection, balloon tamponade as first bleeding control measure, or that received placebo or elective treatment in one study arm were excluded. Results A total of 8382 publications were searched, of which 36 RCTs with 3593 patients were included. Ligation was associated with a significant improvement in bleeding control (relative risk [RR] 1.08; 95 % confidence interval [CI] 1.02 - 1.15) when compared to sclerotherapy. Sclerotherapy combined with vasoactive drugs showed higher efficacy in active bleeding control compared to sclerotherapy alone (RR 1.17; 95 % CI 1.10 - 1.25). The combination of ligation and vasoactive drugs was not superior to ligation alone in terms of overall rebleeding (RR 2.21; 95 %CI 0.55 - 8.92) and in-hospital mortality (RR 1.97; 95 %CI 0.78 - 4.97). Other treatments did not generate meta-analysis. Conclusions This study showed that ligation is superior to sclerotherapy, although with moderate heterogeneity. The combination of sclerotherapy and vasoactive drugs was more effective than sclerotherapy alone. Although current guidelines recommend combined use of ligation with vasoactive drugs in treatment of esophageal variceal bleeding, this study failed to demonstrate the superiority of this combined treatment.
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Affiliation(s)
- Fernanda de Quadros Onofrio
- Department of Gastroenterology and Hepatology, Santa Casa Hospital, Federal University of Health Sciences of Porto Alegre (UFCSPA), Porto Alegre, Brazil
| | - Julio Carlos Pereira-Lima
- Department of Gastroenterology and Hepatology, Santa Casa Hospital, Federal University of Health Sciences of Porto Alegre (UFCSPA), Porto Alegre, Brazil
| | - Felipe Marquezi Valença
- Department of Gastroenterology and Hepatology, Santa Casa Hospital, Federal University of Health Sciences of Porto Alegre (UFCSPA), Porto Alegre, Brazil
| | | | - Airton Tetelbom Stein
- Department of Public Health, Federal University of Health Sciences of Porto Alegre (UFCSPA), Porto Alegre, Brazil
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18
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Then EO, Are VS, Lopez-Luciano M, Bijjam R, Ofosu A, Culliford A, Gaduputi V. Elevated International Normalized Ratio: A Risk Factor for Portal Vein Thrombosis in Cirrhotic Patients. Gastroenterology Res 2019; 12:135-140. [PMID: 31236154 PMCID: PMC6575138 DOI: 10.14740/gr1179] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Accepted: 04/17/2019] [Indexed: 12/11/2022] Open
Abstract
Background Portal vein thrombosis (PVT) is a complication that is commonly seen in patients with cirrhosis and an entity that leads to increased mortality in patients who undergo liver transplantation. This study aims to establish a link between an elevated international normalized ratio (INR) and the presence of PVT in a cohort of cirrhotic patients. Methods We retrospectively reviewed the electronic medical records of all patients diagnosed with cirrhosis in SBH Health System from 2013 to 2018. Among these patients we extracted baseline demographic data, laboratory results, co-morbidities and the presence of PVT. Results In total there were 268 patients who met our inclusion criteria. Twenty-two patients had PVT, while 246 patients did not. Of the 22 patients with PVT there was a statistically significant increase in INR when compared to patients without PVT. There was also a statistically significant increase in total bilirubin, alkaline phosphatase and platelet count. Conclusions Elevated INR levels are associated with the presence of PVT in patients with cirrhosis. These findings suggest a hypercoagulable state and could assist clinicians in risk-stratifying patients when making the decision to initiate anti-coagulation therapy.
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Affiliation(s)
- Eric Omar Then
- Division of Gastroenterology and Hepatology, SBH Health System, 4422 Third Ave, Bronx, NY 10457, USA
| | - Vijay Shailendra Are
- Department of Internal Medicine, Stormont Vail Health, 1500 SW 10th Ave Topeka, KS 66604, USA
| | - Michell Lopez-Luciano
- Division of Gastroenterology and Hepatology, SBH Health System, 4422 Third Ave, Bronx, NY 10457, USA
| | - Rani Bijjam
- Division of Gastroenterology and Hepatology, SBH Health System, 4422 Third Ave, Bronx, NY 10457, USA
| | - Andrew Ofosu
- Division of Gastroenterology and Hepatology, The Brooklyn Hospital Center, Clinical Affiliate of The Mount Sinai Hospital, 121 Dekalb Ave, Brooklyn, NY 11201, USA
| | - Andrea Culliford
- Division of Gastroenterology and Hepatology, SBH Health System, 4422 Third Ave, Bronx, NY 10457, USA
| | - Vinaya Gaduputi
- Division of Gastroenterology and Hepatology, SBH Health System, 4422 Third Ave, Bronx, NY 10457, USA
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Aggeletopoulou I, Konstantakis C, Manolakopoulos S, Triantos C. Role of band ligation for secondary prophylaxis of variceal bleeding. World J Gastroenterol 2018; 24:2902-2914. [PMID: 30018485 PMCID: PMC6048424 DOI: 10.3748/wjg.v24.i26.2902] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Revised: 06/05/2018] [Accepted: 06/25/2018] [Indexed: 02/06/2023] Open
Abstract
AIM To summarize and critically examine the role of band ligation in secondary prophylaxis of variceal bleeding in patients with cirrhosis.
METHODS A literature review was performed using the MEDLINE and PubMed databases. The search terms consisted of the words “endoscopic band ligation” OR “variceal band ligation” OR “ligation” AND “secondary prophylaxis” OR “secondary prevention” AND “variceal bleeding” OR “variceal hemorrhage” AND “liver cirrhosis”. The data collected from relevant meta-analyses and from the most recent randomized studies that were not included in these meta-analyses were used to evaluate the role of endoscopic band ligation in an effort to demonstrate the most recent advances in the treatment of esophageal varices.
RESULTS This study included 11 meta-analyses published from 2002 to 2017 and 10 randomized trials published from 2010 to 2017 that evaluated the efficacy of band ligation in the secondary prophylaxis of variceal bleeding. Overall, the results proved that band ligation was superior to endoscopic sclerotherapy. Moreover, the use of β-blockers in combination with band ligation increased the treatment effectiveness, supporting the current recommendations for secondary prophylaxis of variceal bleeding. The use of transjugular intrahepatic portosystemic shunt was superior to combination therapy regarding rebleeding prophylaxis, with no difference in the survival rates; however, the results concerning the hepatic encephalopathy incidence were conflicting. Recent advances in the management of secondary prophylaxis of variceal bleeding have targeted a decrease in portal pressure based on the pathophysiological mechanisms of portal hypertension.
CONCLUSION This review suggests that future research should be conducted to enhance current interventions and/or to develop innovative treatment options with improved clinical endpoints.
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Affiliation(s)
| | | | - Spilios Manolakopoulos
- 2nd Department of Internal Medicine, Hippokration General Hospital of Athens, Athens 11527, Greece
| | - Christos Triantos
- Department of Gastroenterology, University Hospital of Patras, Patras 26504, Greece
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20
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Zhu J, Qi X, Yu H, Su C, Guo X. Acid suppression in patients treated with endoscopic therapy for the management of gastroesophageal varices: a systematic review and meta-analysis. Expert Rev Gastroenterol Hepatol 2018; 12:617-624. [PMID: 29564926 DOI: 10.1080/17474124.2018.1456918] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2017] [Accepted: 03/21/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIM Endoscopic therapy is the cornerstone choice for the management of varices and variceal hemorrhage. The aim of the present systematic review and meta-analysis was to evaluate the efficacy of acid suppression in patients treated with endoscopic therapy for gastroesophageal varices. METHODS All eligible studies were searched via the PubMed, EMBASE, and Cochrane Library databases. Incidence of bleeding, mortality, ulcers, chest pain, and dysphagia after endoscopic therapy and length of stay were analyzed. Subgroup analyses were performed according to the types and major indications of endoscopic treatments. Odds ratios (ORs) with 95% confidence intervals (95%CIs) were calculated. RESULTS Nine studies with 1470 patients were included. Acid suppression could significantly decrease the incidence of bleeding (OR = 0.39, 95%CI: 0.19-0.81, P = 0.01) and diminish the ulcer size (OR = 0.78, 95%CI: 0.38-1.57, P = 0.48) after endoscopic therapy. The subgroup analyses showed that acid suppression could significantly decrease the incidence of bleeding in patients undergoing prophylactic EVL, rather than in patients undergoing therapeutic EVL. There was no significant difference in the incidence of mortality, ulcers, chest pain, and dysphagia and length of stay between patients treated with and without acid suppression. CONCLUSION Acid suppression might be considered in patients undergoing prophylactic EVL for gastroesophageal varices.
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Affiliation(s)
- Jia Zhu
- a Liver Cirrhosis Study Group, Department of Gastroenterology , General Hospital of Shenyang Military Area , Shenyang , China
- b Postgraduate College , Shenyang Pharmaceutical University , Shenyang , China
| | - Xingshun Qi
- a Liver Cirrhosis Study Group, Department of Gastroenterology , General Hospital of Shenyang Military Area , Shenyang , China
| | - Haonan Yu
- b Postgraduate College , Shenyang Pharmaceutical University , Shenyang , China
| | - Chunping Su
- c Library of Fourth Military Medical University , Xi'an , China
| | - Xiaozhong Guo
- a Liver Cirrhosis Study Group, Department of Gastroenterology , General Hospital of Shenyang Military Area , Shenyang , China
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21
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Ibrahim M, Mostafa I, Devière J. New Developments in Managing Variceal Bleeding. Gastroenterology 2018; 154:1964-1969. [PMID: 29481777 DOI: 10.1053/j.gastro.2018.02.023] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2017] [Revised: 02/13/2018] [Accepted: 02/15/2018] [Indexed: 12/14/2022]
Abstract
Liver cirrhosis is the end stage of chronic liver disease, independent of etiology, and is characterized by accumulation of fibrotic tissue and conversion of the normal liver parenchyma into abnormal regenerative nodules. Complications include portal hypertension (PH) with gastroesophageal varices, ascites, hepatorenal syndrome, hepatic encephalopathy, bacteremia, and hypersplenism. The most life-threatening complication of liver cirrhosis is acute variceal bleeding (AVB) which is associated with increased mortality that, despite recent progress in management, is still around 20% at 6 weeks. Combined treatment with vasoactive drugs, prophylactic antibiotics, and endoscopic techniques is the recommended standard of care for patients with acute variceal bleeding. There are many promising new modalities including the combination of coil and glue injection for management of bleeding or non-bleeding gastric varices and hemostatic powder application, that requires minimal expertise, when performed early after admission of a cirrhotic patient with AVB and overt hematemesis acting as a bridge therapy till definitive endoscopic therapy can be performed in hemodynamically stable conditions and without acute bleeding.
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Affiliation(s)
- Mostafa Ibrahim
- Department of Gastroenterology, Hepatopancreatology and Digestive Oncology, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium; Department of Gastroenterology and Hepatology, Theodor Bilharz Research Institute, Cairo, Egypt.
| | - Ibrahim Mostafa
- Department of Gastroenterology and Hepatology, Theodor Bilharz Research Institute, Cairo, Egypt
| | - Jacques Devière
- Department of Gastroenterology, Hepatopancreatology and Digestive Oncology, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
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Mansour L, El-Kalla F, El-Bassat H, Abd-Elsalam S, El-Bedewy M, Kobtan A, Badawi R, Elhendawy M. Randomized controlled trial of scleroligation versus band ligation alone for eradication of gastroesophageal varices. Gastrointest Endosc 2017; 86:307-315. [PMID: 28082116 DOI: 10.1016/j.gie.2016.12.026] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2016] [Accepted: 12/27/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS Gastric varices develop in 5% to 33% of patients with portal hypertension. Their most common form is concomitant gastroesophageal varices. Scleroligation (combined sclerotherapy and band ligation) has been used successfully in management of esophageal varices but has not been evaluated previously in the management of gastroesophageal varices. The aim of this work was evaluation of a new scleroligation technique for management of bleeding gastroesophageal varices regarding efficacy, adverse events, variceal recurrence, and survival. METHODS This study was conducted on 120 cirrhotic patients with bleeding gastroesophageal varices, whom we divided randomly into 2 groups of 60 patients each-a band ligation group and a scleroligation group. RESULTS The mean number of sessions was lower in the scleroligation group than in the band ligation group (2.22 ± 0.92 and 3.43 ± 0.67, respectively) (P < .001), as were the duration of treatment and total number of bands used. Cost and survival were comparable in the 2 groups. There was no significant difference between the 2 maneuvers regarding adverse events, recurrence rates, or rebleeding rates after obliteration. Recurrence was significantly higher in patients with larger varices, ulceration, and postprocedure pyrexia. Rebleeding was significantly higher among those who experienced postprocedure pyrexia and developed or had worsening of gastric antral vascular ectasia. CONCLUSIONS Scleroligation appears to achieve a faster rate of eradication with fewer treatment sessions and total number of bands deployed to achieve variceal obliteration than band ligation and is comparable in cost and in adverse event and recurrence rates. (Clinical trial registration number: NCT02646202.).
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Affiliation(s)
- Loai Mansour
- Tropical Medicine and Infectious Diseases Department, Tanta University, Tanta, Egypt
| | - Ferial El-Kalla
- Tropical Medicine and Infectious Diseases Department, Tanta University, Tanta, Egypt
| | - Hanan El-Bassat
- Tropical Medicine and Infectious Diseases Department, Tanta University, Tanta, Egypt
| | - Sherief Abd-Elsalam
- Tropical Medicine and Infectious Diseases Department, Tanta University, Tanta, Egypt
| | | | - Abdelrahman Kobtan
- Tropical Medicine and Infectious Diseases Department, Tanta University, Tanta, Egypt
| | - Rehab Badawi
- Tropical Medicine and Infectious Diseases Department, Tanta University, Tanta, Egypt
| | - Mohamed Elhendawy
- Tropical Medicine and Infectious Diseases Department, Tanta University, Tanta, Egypt
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Tau JA, Qureshi WA. Variceal Upper GI Bleeding. UPPER ENDOSCOPY FOR GI FELLOWS 2017:21-29. [DOI: 10.1007/978-3-319-49041-0_3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/05/2025]
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Branch-Elliman W, Perumalswami P, Factor SH, Sled SM, Flamm SL. Rates of recurrent variceal bleeding are low with modern esophageal banding strategies: a retrospective cohort study. Scand J Gastroenterol 2016; 50:1059-67. [PMID: 25865440 DOI: 10.3109/00365521.2015.1027263] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Variceal bleeding has a high rate of mortality and recurrence. Endoscopic band ligation (EBL) is the established standard of care for secondary prevention of variceal bleeding. OBJECTIVE To determine the long-term re-bleeding rate of an EBL protocol similar to current society guidelines. DESIGN We conducted a retrospective cohort study at a tertiary care center of all patients with a history of a variceal bleed who underwent an aggressive band ligation protocol. INTERVENTIONS At the time of sentinel bleed, all varices, regardless of size, were ligated. EBL was then repeated every 2 weeks until stabilization, and all visible varices were ligated. The interval between banding sessions then increased. MAIN OUTCOME MEASUREMENTS The incidence of re-bleeding was calculated as the time between clinical stabilization after the sentinel event until data censoring, which occurred at time of re-bleed, death, transplant or loss-to-follow up. Gastric variceal bleeding was a secondary endpoint. RESULTS N = 176 patients were treated with aggressive EBL, and followed for a median of 16 months (range, 3 months - 6.9 years). The 6 month incidence of re-bleeding was 2.3%, the 12 month incidence was 3.4%, and the 2 year incidence was 4.6%. Overall, aggressive EBL was well-tolerated. One patient died during follow-up secondary to a gastric variceal bleed. CONCLUSIONS Aggressive EBL yields a low rate of re-bleeding when compared to standard practice. Secondary prophylaxis with aggressive EBL should be a consideration for patients following a sentinel bleeding event.
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Affiliation(s)
- Westyn Branch-Elliman
- Department of Medicine, Division of Infectious Diseases, Eastern Colorado VA Healthcare System and University of Colorado School of Medicine , Denver, CO , USA
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Balducci G, Sterpetti AV, Ventura M. A short history of portal hypertension and of its management. J Gastroenterol Hepatol 2016; 31:541-5. [PMID: 26510487 DOI: 10.1111/jgh.13200] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2015] [Revised: 09/11/2015] [Accepted: 10/07/2015] [Indexed: 12/11/2022]
Abstract
The aim of our study was to review the changing trends in the treatment of complications from portal hypertension. A short history of portal hypertension and of the treatment of its complications is reported, underlying the most important achievements and changes.
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Abstract
BACKGROUND The verbalisation of quality standards and parameters by medical societies are relevant for qualitative improvement but may also be an instrument to demand more resources for health care or be a unique characteristic. Within the health care system 3 different quality levels can be defined: structure, process and result quality. METHODS The current S2k guideline of the German Society for Gastroenterology (quality requirements for gastrointestinal endoscopy) AWMF registry no. 021-022 provides recommendations based on the available evidence for the structure quality (requirements for equipment, human resources) as well as for the process quality (patient preparation, conduct, documentation) and result quality (follow-up of specific endoscopic procedures). RESULTS Based on these recommendations, measurable quality indicators/parameters for the endoscopy have been selected and formulated. General quality parameters for endoscopic examinations are given as well as quality parameters for specific procedures for the preparation, conduct, and follow-up of specific endoscopic interventions. CONCLUSION Only the regular review of processes and courses by means of defined measurement parameters builds up the basis for corrections based on facts. In addition, the implementation of recommended standards may be an instrument in demanding more resources from the health care system and, therefore, should be embedded as routine.
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Affiliation(s)
- Ulrike W. Denzer
- Clinic for Interdisciplinary Endoscopy, University Clinic Hamburg Eppendorf, Hamburg, Germany
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27
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Randomized controlled trial comparing endoscopic ligation with or without sclerotherapy for secondary prophylaxis of variceal bleeding. Eur J Gastroenterol Hepatol 2016; 28:95-100. [PMID: 26517621 DOI: 10.1097/meg.0000000000000499] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECTIVES A recently published network meta-analysis showed that ligation combined with sclerotherapy might be the most efficacious intervention for secondary prophylaxis of variceal bleeding. Most studies excluded patients with concomitant gastric varices; thus, the outcomes in such patients have not yet been reported. The present study aimed to investigate the efficacy of two endoscopic procedures for secondary prophylaxis in cirrhotic patients presenting with both esophageal and gastric varices. MATERIALS AND METHODS A randomized controlled study was carried out in a tertiary care referral center. Patients were randomized into two groups: sclerotherapy- and sclerotherapy+ group. Continued endoscopic ligation was used to treat esophageal varices in the sclerotherapy- group, whereas combined ligation and sclerotherapy with lauromacrogol was performed in the sclerotherapy+ group. A cyanoacrylate injection was used for gastric varices in both groups. All participants were followed up for 6 months. RESULTS Overall, 96 patients were included between 25 March 2012 and 25 June 2013. Three patients were lost during follow-up (one in the sclerotherapy- group and two in the sclerotherapy+ group). The cumulative recurrence rate of bleeding was significantly higher in the sclerotherapy+ group (14.6 vs. 35.4%, P=0.013). The cumulative mortality rate (2.1 vs. 6.3%, P=0.286) and the incidence rate of adverse events were similar between the two groups. CONCLUSION Continued ligation+cyanoacrylate injection was superior to combined ligation and sclerotherapy+cyanoacrylate injection during the first 6 months in terms of rebleeding in cirrhotic patients presenting with both esophageal and gastric varices. Long-term results entail further investigation (http://www.clinicaltrials.gov, NCT01592578).
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Comparison and efficacy of LigaSure and rubber band ligature in closing the inflamed cecal stump in a rat model of acute appendicitis. BIOMED RESEARCH INTERNATIONAL 2015; 2015:260312. [PMID: 25699264 PMCID: PMC4324495 DOI: 10.1155/2015/260312] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/28/2014] [Accepted: 10/17/2014] [Indexed: 02/06/2023]
Abstract
Safety of either LigaSure or rubber band in closing inflamed appendiceal stump in acute appendicitis has been less investigated. In this study, cecal ligation followed by resecting inflamed cecum was performed to mimic appendectomy in a rat model of acute appendicitis. Rats were sacrificed immediately (Group A) and 7 days (Group B) after cecal resection, respectively. The cecal stumps were closed by silk ligature (S), 5 mm LigaSure (L), or rubber band (R). Seven days after cecal resection, the LigaSure (BL) and silk subgroups (BS) had significantly less intra-abdominal adhesion and better laparotomy wound healing than rubber band subgroup (BR). The initial bursting pressure at cecal stump was comparable among the three methods; along with tissue healing process, both BL and BS provided a higher bursting pressure than BR 7 days after appendectomy. BL subgroup had more abundant hydroxyproline deposition than BS and BR subgroup. Furthermore, serum TNF-α in BR group kept persistently increasing along with time after cecal resection. Thus, the finding that LigaSure but not rubber band is safe in sealing off the inflamed cecal stump in rat model of acute appendicitis suggests the possibility of applying LigaSure for appendectomy via single port procedure or natural orifice transluminal endoscopic surgery (NOTES).
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Cremers I, Ribeiro S. Management of variceal and nonvariceal upper gastrointestinal bleeding in patients with cirrhosis. Therap Adv Gastroenterol 2014; 7:206-16. [PMID: 25177367 PMCID: PMC4107701 DOI: 10.1177/1756283x14538688] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Acute upper gastrointestinal haemorrhage remains the most common medical emergency managed by gastroenterologists. Causes of upper gastrointestinal bleeding (UGIB) in patients with liver cirrhosis can be grouped into two categories: the first includes lesions that arise by virtue of portal hypertension, namely gastroesophageal varices and portal hypertensive gastropathy; and the second includes lesions seen in the general population (peptic ulcer, erosive gastritis, reflux esophagitis, Mallory-Weiss syndrome, tumors, etc.). Emergency upper gastrointestinal endoscopy is the standard procedure recommended for both diagnosis and treatment of UGIB. The endoscopic treatment of choice for esophageal variceal bleeding is band ligation of varices. Bleeding from gastric varices is treated by injection with cyanoacrylate. Treatment with vasoactive drugs as well as antibiotic treatment is started before or at the same time as endoscopy. Bleeding from portal hypertensive gastropathy is less frequent, usually chronic and treatment options include β-blocker therapy, injection therapy and interventional radiology. The standard of care of UGIB in patients with cirrhosis includes careful resuscitation, preferably in an intensive care setting, medical and endoscopic therapy, early consideration for placement of transjugular intrahepatic portosystemic shunt and, sometimes, surgical therapy or hepatic transplant.
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Affiliation(s)
- Isabelle Cremers
- Centro Hospitalar de Setúbal, R Camilo Castelo Branco, Setubal 2910-446, Portugal
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Hwang JH, Shergill AK, Acosta RD, Chandrasekhara V, Chathadi KV, Decker GA, Early DS, Evans JA, Fanelli RD, Fisher DA, Foley KQ, Fonkalsrud L, Jue T, Khashab MA, Lightdale JR, Muthusamy VR, Pasha SF, Saltzman JR, Sharaf R, Cash BD. The role of endoscopy in the management of variceal hemorrhage. Gastrointest Endosc 2014; 80:221-7. [PMID: 25034836 DOI: 10.1016/j.gie.2013.07.023] [Citation(s) in RCA: 129] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2013] [Accepted: 07/11/2013] [Indexed: 02/06/2023]
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Nusrat S, Khan MS, Fazili J, Madhoun MF. Cirrhosis and its complications: Evidence based treatment. World J Gastroenterol 2014; 20:5442-5460. [PMID: 24833875 PMCID: PMC4017060 DOI: 10.3748/wjg.v20.i18.5442] [Citation(s) in RCA: 155] [Impact Index Per Article: 14.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2013] [Revised: 01/17/2014] [Accepted: 02/20/2014] [Indexed: 02/06/2023] Open
Abstract
Cirrhosis results from progressive fibrosis and is the final outcome of all chronic liver disease. It is among the ten leading causes of death in United States. Cirrhosis can result in portal hypertension and/or hepatic dysfunction. Both of these either alone or in combination can lead to many complications, including ascites, varices, hepatic encephalopathy, hepatocellular carcinoma, hepatopulmonary syndrome, and coagulation disorders. Cirrhosis and its complications not only impair quality of life but also decrease survival. Managing patients with cirrhosis can be a challenge and requires an organized and systematic approach. Increasing physicians’ knowledge about prevention and treatment of these potential complications is important to improve patient outcomes. A literature search of the published data was performed to provide a comprehensive review regarding the management of cirrhosis and its complications.
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Rosołowski M, Hartleb M, Marek T, Milewski J, Linke K, Wallner G, Dąbrowski A, Rydzewska G. Therapeutic and prophylactic management of bleeding from oesophageal and gastric varices - recommendations of the Working Group of the National Consultant for Gastroenterology. PRZEGLAD GASTROENTEROLOGICZNY 2014; 9:63-8. [PMID: 25061484 PMCID: PMC4108746 DOI: 10.5114/pg.2014.42497] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/15/2014] [Revised: 04/16/2014] [Accepted: 04/17/2014] [Indexed: 12/12/2022]
Abstract
Gastroesophageal varices are one of the most serious consequences of portal hypertension. One-third of patients with varices will develop variceal haemorrhage. Despite significant improvements in the outcomes of treatment, mortality due to bleeding from gastro-oesophageal varices still remains very high. These recommendations present optimal management of patients with non-bleeding and bleeding varices.
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Affiliation(s)
- Mariusz Rosołowski
- Department of Gastroenterology and Internal Medicine, Medical University of Bialystok, Poland
| | - Marek Hartleb
- Department of Gastroenterology and Hepatology, Medical University of Silesia, Katowice, Poland
| | - Tomasz Marek
- Department of Gastroenterology and Hepatology, Medical University of Silesia, Katowice, Poland
| | - Janusz Milewski
- Department of Internal Medicine and Gastroenterology, Central Clinical Hospital of Ministry of Internal Affairs, Warsaw, Poland
| | - Krzysztof Linke
- Department of Gastroenterology, Human Nutrition and Internal Diseases, Poznan University of Medical Sciences, Poznan, Poland
| | - Grzegorz Wallner
- Department and Clinic of General Surgery, Gastroenterology and Digestive Tract Neoplasm, Medical University of Lublin, Poland
| | - Andrzej Dąbrowski
- Department of Gastroenterology and Internal Medicine, Medical University of Bialystok, Poland
| | - Grażyna Rydzewska
- Department of Internal Medicine and Gastroenterology, Central Clinical Hospital of Ministry of Internal Affairs, Warsaw, Poland
- Faculty of Sciences, University of Jan Kochanowski, Kielce, Poland
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Lahbabi M, Mellouki I, Aqodad N, Elabkari M, Elyousfi M, Ibrahimi SA, Benajah DA. Esophageal variceal ligation in the secondary prevention of variceal bleeding: Result of long term follow-up. Pan Afr Med J 2013; 15:3. [PMID: 23847700 PMCID: PMC3708329 DOI: 10.11604/pamj.2013.15.3.2098] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2012] [Accepted: 04/16/2013] [Indexed: 01/13/2023] Open
Abstract
Introduction Long-term outcome of patients after band ligation have been poorly defined. Therefore, we conducted a long-term follow-up study to delineate the outcome of ligation in patients with portal hypertension in the Hassan II university hospital, Fes, Morocco. Methods Over 118 months patients treated by endoscopic variceal ligation were received regular follow- up and detailed clinical assessment of at least 24 months. Results One hundred twenty five patients were followed up for a mean of 31 months (range 12-107 months). Obliteration of the varices was achieved in 89.6 % (N = 112) of patients, with 3 +/-1.99 (range 1-8) endoscopy sessions over a period of 14 + /-6.8 weeks (range 3-28). The percentage of variceal recurrence during follow-up after ligation was 20.5 % (N = 23). Recurrence were observed in a mean of 22 months +/- 7.3 (range 3-48). Bleeding rate from recurrent varices was 30.4 % (7/23). Rebleeding from esophageal ulcers occurred in 5.6 % (7/125) of patients. Portal hypertensive gastropathy before and after eradication of varices was 17.6% (N = 22) and 44.6% (N = 50) respectively; p< 0.05. Fundal gastric varices was 30.4% (N = 38) and 35.7% (N = 40) before and after eradication of varices respectively; p> 0.05. The overall mortality was 4 % (N = 5). Conclusion Band ligation was an effective technical approach for variceal obliteration with low rates of variceal recurrence, rebleeding and development of gastric varices. Furthermore, it was associated with frequent development of portal hypertensive gastropathy.
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Affiliation(s)
- Mounia Lahbabi
- Department of Hepato Gastroenterology Hassan II University Hospital Fez, Morocco
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Hamza I, Mahmoud M, Labib S. The initial experience of safety and efficacy of argon plasma coagulation (APC) in the primary prevention of variceal bleeding. Arab J Gastroenterol 2012; 13:125-9. [PMID: 23122453 DOI: 10.1016/j.ajg.2012.08.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2011] [Accepted: 08/12/2012] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND STUDY AIMS The well-known complications of variceal bleeding together with the high mortality rate mandate effective prophylaxis. Because of the intolerance, failure of response and lack of compliance related to B blockers and because of the high incidence of variceal recurrence after endoscopic variceal ligation (EVL), other alternatives should be investigated. As APC provides coagulation at a shallow depth, it has been considered an ideal procedure to promote mucosal fibrosis for oesophageal varices. This study aims to investigate the safety and effectiveness of APC application to the oesophagus post-variceal obliteration in an attempt to decrease variceal recurrence and bleeding, as compared to EVL. PATIENTS AND METHODS This study included 60 patients with chronic liver disease and portal hypertension referred to the Gastrointestinal Endoscopy Unit, Kasr Al-Aini Hospital, Cairo University, during the period from August 2008 till January 2010. Patients had to have large-sized varices (F3), without history of bleeding, portal hypotensive drugs or intervention. Patients were allocated into either group I that included 30 patients for whom EVL was performed and sequentially followed by one session of APC or group II that included 30 patients for whom EVL alone was done. Patients underwent surveillance endoscopy at 3 and 6months to evaluate variceal recurrence (F1 or more). RESULTS Both groups were comparable in terms of the demographic features, hepatic functional reserve and endoscopic findings. Post-APC, fever was reported in 6.7%, dysphagia in 3.3%, procedure-related bleeding in 0% and stricture in 3.3%. At 3 and 6months follow-up, both groups were comparable in terms of variceal recurrence and none of the patients in both groups developed variceal bleeding. CONCLUSION Although, APC application to the oesophageal mucosa is a safe technique, its additive benefit in terms of variceal recurrence and re-bleeding is comparable to EVL alone. This is encountered when only a single session of APC is applied. A more beneficial effect of multiple sessions of APC awaits further studies.
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Affiliation(s)
- I Hamza
- Tropical Medicine Department, Faculty of Medicine, Cairo University, Cairo, Egypt.
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Abbas Z, Rizvi L, Ahmed US, Mumtaz K, Jafri W. Cost saving by reloading the multiband ligator in endoscopic esophageal variceal ligation: a proposal for developing countries. World J Gastroenterol 2008; 14:2222-2225. [PMID: 18407598 PMCID: PMC2703849 DOI: 10.3748/wjg.14.2222] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2007] [Revised: 02/13/2008] [Indexed: 02/06/2023] Open
Abstract
AIM To assess the cost savings of reloading the multiband ligator in endoscopic esophageal variceal ligation (EVL) used on the same patient for subsequent sessions. METHODS This single centre retrospective descriptive study analysed patients undergoing variceal ligation at a tertiary care centre between 1st January, 2003 and 30th June, 2006. The multiband ligator was reloaded with six hemorrhoidal bands using hemorrhoidal ligator for the second and subsequent sessions. Analysis of cost saving was done for the number of follow-up sessions for the variceal eradication. RESULTS A total of 261 patients underwent at least one session of endoscopic esophageal variceal ligation between January 2003 and June 2006. Out of 261, 108 patients (males 67) agreed to follow the eradication program and underwent repeated sessions. A total of 304 sessions was performed with 2.81 sessions per patient on average. Thirty-two patients could not complete the program. In 76 patients (70%), variceal obliteration was achieved. The ratio of the costs for the session with reloaded ligator versus a session with a new ligator was 1:2.37. Among the patients who completed esophageal varices eradication, cost saving with reloaded ligator was 58%. CONCLUSION EVL using reloaded multiband ligators for the follow-up sessions on patients undergoing variceal eradication is a cost saving procedure. Reloading the ligator thus is recommended especially for developing countries where most of the patients are not health insured.
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Park WG, Yeh RW, Triadafilopoulos G. Injection therapies for variceal bleeding disorders of the GI tract. Gastrointest Endosc 2008; 67:313-23. [PMID: 18226695 DOI: 10.1016/j.gie.2007.09.052] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2007] [Accepted: 09/27/2007] [Indexed: 02/07/2023]
Affiliation(s)
- Walter G Park
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, California 94305, USA.
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Affiliation(s)
- J. E. J. KRIGE
- Surgical Gastroenterology, Department of Surgery and M. R. C. Liver Research Centre, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa
| | - J. F. BOTHA
- Surgical Gastroenterology, Department of Surgery and M. R. C. Liver Research Centre, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa
| | - P. C. BORNMAN
- Surgical Gastroenterology, Department of Surgery and M. R. C. Liver Research Centre, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa
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Garcia-Tsao G, Sanyal AJ, Grace ND, Carey W. Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis. Hepatology 2007; 46:922-38. [PMID: 17879356 DOI: 10.1002/hep.21907] [Citation(s) in RCA: 1202] [Impact Index Per Article: 66.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- Guadalupe Garcia-Tsao
- Section of Digestive Diseases, Yale University School of Medicine and VACT Healthcare System, New Haven, CT, USA
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Croffie J, Somogyi L, Chuttani R, DiSario J, Liu J, Mishkin D, Shah RJ, Tierney W, Wong Kee Song LM, Petersen BT. Sclerosing agents for use in GI endoscopy. Gastrointest Endosc 2007; 66:1-6. [PMID: 17591465 DOI: 10.1016/j.gie.2007.02.014] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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Abstract
Bleeding from esophageal varices (EVs) is a catastrophic complication of chronic liver disease. Many years ago, surgical procedures such as esophageal transection or distal splenorenal shunting were the only treatments for EVs. In the 1970s, interventional radiology procedures such as transportal obliteration, left gastric artery embolization, and partial splenic artery embolization were introduced, improving the survival of patients with bleeding EVs. In the 1980s, endoscopic treatment, endoscopic injection sclerotherapy (EIS), and endoscopic variceal ligation (EVL), further contributed to improved survival. We combined IVR with endoscopic treatment or EIS with EVL. Most patients with EVs treated endoscopically required follow-up treatment for recurrent varices. Proper management of recurrent EVs can significantly improve patients’ quality of life. Recently, we have performed EVL at 2-mo (bi-monthly) intervals for the management of EVs. Longer intervals between treatment sessions resulted in a higher rate of total eradication and lower rates of recurrence and additional treatment.
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Kuramochi A, Imazu H, Kakutani H, Uchiyama Y, Hino S, Urashima M. Color Doppler endoscopic ultrasonography in identifying groups at a high-risk of recurrence of esophageal varices after endoscopic treatment. J Gastroenterol 2007; 42:219-24. [PMID: 17380280 DOI: 10.1007/s00535-006-1992-x] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2006] [Accepted: 12/04/2006] [Indexed: 02/04/2023]
Abstract
BACKGROUND Our preliminary study indicated that either a high hepatofugal flow velocity in the left gastric vein (LGV) or an anterior branch dominant pattern seen under color Doppler EUS (CD-EUS) were possible contributing risk factors for variceal recurrence after endoscopic treatment. However, the sample size was too small, and in this study we aimed to validate the results of the preliminary study. METHODS Sixty-eight patients treated for moderate or large esophageal varices between 2001 and 2004 at a single university hospital were enrolled in this study. CD-EUS was followed by endoscopic variceal ligation and sclerotherapy. RESULTS Patients were classified into either a high-risk group, which exhibited anterior branch dominance and flow velocity of 12 cm/s or more, or a low-risk group, which included all other patients. Half of the patients in the high-risk group exhibited a recurrence within half a year, whereas it took almost 2 years for half of the patients in the other group to exhibit a recurrence (P=0.0044). Using the Cox proportional hazard model with multivariate analysis, only the features of the high-risk group were significant in triggering recurrence of varices (hazard ratio [HR], 3.00; 95% confidence interval [CI], 1.35-6.65; P<0.001). CONCLUSIONS These results suggest that patients showing anterior branch dominance and rapid hepatofugal flow velocity in the LGV on CD-EUS examination may have a high risk of an early recurrence of esophageal varices.
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Affiliation(s)
- Akira Kuramochi
- Department of Endoscopy, The Jikei University School of Medicine, 3-25-8 Nishishinbashi, Minato-ku, Tokyo, 105-8461, Japan
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Vinel JP. [Rupture of esophageal varices]. GASTROENTEROLOGIE CLINIQUE ET BIOLOGIQUE 2006; 30:875-9. [PMID: 16885872 DOI: 10.1016/s0399-8320(06)73335-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/11/2023]
Affiliation(s)
- Jean-Pierre Vinel
- Hépato-Gastroentérologie, Fédération Digestive, CHU Purpan INSERM U531, 31059 Toulouse.
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Garcia-Pagán JC, Bosch J. Endoscopic band ligation in the treatment of portal hypertension. ACTA ACUST UNITED AC 2005; 2:526-35. [PMID: 16355158 DOI: 10.1038/ncpgasthep0323] [Citation(s) in RCA: 115] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2005] [Accepted: 09/16/2005] [Indexed: 12/13/2022]
Abstract
The evidence that endoscopic band ligation (EBL) has greater efficacy and fewer side effects than endoscopic injection sclerotherapy has renewed interest in endoscopic treatments for portal hypertension. The introduction of multishot band devices, which allow the placement of 5-10 bands at a time, has made the technique much easier to perform, avoiding the use of overtubes and their related complications. EBL sessions are usually repeated at 2 week intervals until varices are obliterated, which is achieved in about 90% of patients after 2-4 sessions. Variceal recurrence is frequent, with 20-75% of patients requiring repeated EBL sessions. According to current evidence, nonselective beta-blockers are the preferred treatment option for prevention of a first variceal bleed, whereas EBL should be reserved for patients with contraindications or intolerance to beta-blockers. Nonselective beta-blockers, probably in association with the vasodilator isosorbide mononitrate, and EBL are good treatment options to prevent recurrent variceal rebleeding. The efficacy of EBL might be increased by combining it with beta-blocker therapy. Patients who are intolerant, have contraindications or bled while receiving primary prophylaxis with beta-blockers must be treated with EBL. In the latter situation, EBL should be added to rather than replace beta-blocker therapy. EBL, in combination with vasoactive drugs, is the recommended form of therapy for acute esophageal variceal bleeding; however, endoscopic injection sclerotherapy can be used in the acute setting if EBL is technically difficult.
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Krige JEJ, Shaw JM, Bornman PC. The Evolving Role of Endoscopic Treatment for Bleeding Esophageal Varices. World J Surg 2005; 29:966-73. [PMID: 15981047 DOI: 10.1007/s00268-005-0138-2] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The treatment of acute and recurrent variceal bleeding is best accomplished by a skilled, knowledgeable, and well-equipped team using a multidisciplinary integrated approach. Optimal management should provide the full spectrum of treatment options including pharmacologic therapy, endoscopic treatment, interventional radiologic procedures, surgical shunts, and liver transplantation. Endoscopic therapy with either band ligation or injection sclerotherapy is an integral component of the management of acute variceal bleeding and of the long-term treatment of patients after a variceal bleed. Variceal eradication with endoscopic ligation requires fewer endoscopic treatment sessions and causes substantially less esophageal complications than does injection sclerotherapy. Although the incidence of early gastrointestinal rebleeding is reduced by endoscopic ligation in most studies, there is no overall survival benefit relative to injection sclerotherapy. Simultaneous combined ligation and sclerotherapy confers no advantage over ligation alone. A sequential staged approach with initial endoscopic ligation followed by sclerotherapy when varices are small may prove to be the optimal method of reducing variceal recurrence. Overall, current data demonstrate clear advantages for using ligation in preference to sclerotherapy. Ligation should therefore be considered the endoscopic treatment of choice in the treatment of esophageal varices.
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Affiliation(s)
- J E J Krige
- Department of Surgery and Medical Research Council, Liver Research Center, University of Cape Town Health Sciences Faculty, Observatory, 7925 Cape Town, South Africa.
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Abstract
Endoscopic therapy for nonvariceal bleeding should only be used if major stigmata of hemorrhage such as active bleeding and nonbleeding visible vessel are present. Treatment of peptic ulcers with adherent clots is currently controversial. Combination of epinephrine injection and coaptive coagulation is most effective in achieving endoscopic hemostasis. Hemoclips may be preferable for very deep ulcers and large visible blood vessels if coaptive coagulation is anticipated to have a high risk of perforation or bleeding. Adrenaline injection or hemoclip application should be used in bleeding Mallory-Weiss tears, as the safety of thermal methods is not well established. Argon plasma coagulation is the mainstay of endoscopic treatment for superficial lesions such as angiodysplasia and gastric antral vascular ectasia. Both sclerotherapy and band ligation are effective in acute hemostasis of bleeding esophageal varices. Variceal band ligation is preferred due to its superior safety profile and shorter procedure time. Due to the early recurrence of varices after banding ligation, there may be a role for metachronous combination therapy of ligation followed by sclerotherapy. Histoacryl glue is the preferred method of endoscopic hemostasis in gastric varices.
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Affiliation(s)
- Aric J Hui
- Department of Medicine and Therapeutics, Prince of Wales Hospital, Shatin, N. T., Hong Kong SAR, China.
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46
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Karsan HA, Morton SC, Shekelle PG, Spiegel BMR, Suttorp MJ, Edelstein MA, Gralnek IM. Combination endoscopic band ligation and sclerotherapy compared with endoscopic band ligation alone for the secondary prophylaxis of esophageal variceal hemorrhage: a meta-analysis. Dig Dis Sci 2005; 50:399-406. [PMID: 15745108 DOI: 10.1007/s10620-005-1618-9] [Citation(s) in RCA: 58] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Endoscopic band ligation (EBL) is the community-accepted standard therapy for the secondary prophylaxis of esophageal variceal hemorrhage. Recent data indicate that combination EBL and sclerotherapy may be a more effective therapy than EBL alone. Yet existing data are conflicting. We therefore performed a meta-analysis to compare the efficacy and safety of EBL and sclerotherapy versus EBL alone for the secondary prophylaxis of esophageal variceal hemorrhage. We performed a systematic review of two computerized databases (MEDLINE and EMBASE) along with manual-searching of published abstracts to identify relevant citations without language restrictions from 1990 to 2002. Eight studies met explicit inclusion criteria. We performed meta-analysis of these studies to pool the relative risk for the following outcomes: esophageal variceal rebleeding, death, number of endoscopic sessions to achieve variceal obliteration, and therapeutic complications. There were no significant differences between EBL and sclerotherapy versus EBL alone in the risk of esophageal variceal rebleeding (RR = 1.05; 95% CI = 0.67-1.64; P = 0.83), death (RR = 0.99; 95% CI = 0.68-1.44; P = 0.96), or number of endoscopic sessions to variceal obliteration (RR = 0.23; 95% CI = 0.055-0.51; P = 0.11). However, the incidence of esophageal stricture formation was significantly higher in the EBL group than in the sclerotherapy group. There is no evidence that the addition of sclerotherapy to endoscopic band ligation changes clinically relevant outcomes (variceal rebleeding, death, time to variceal obliteration) in the secondary prophylaxis of esophageal variceal hemorrhage. Moreover, combination EBL and sclerotherapy had more esophageal stricture formation than EBL alone.
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Affiliation(s)
- Hetal A Karsan
- VA Greater Los Angeles Healthcare System, David Geffen School of Medicine at UCLA, Center for the Health Sciences, Division of Digestive Diseases, Los Angeles, California 90073, USA
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Farooq FT, Wong RC. Injection sclerotherapy for the management of esophageal and gastric varices. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2005; 7:8-17. [DOI: 10.1016/j.tgie.2004.10.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2025]
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Thabut D. [Gastrointestinal hemorrhage. How to prevent rebleeding: role of pharmacological and endoscopic treatments]. ACTA ACUST UNITED AC 2004; 28 Spec No 2:B73-82. [PMID: 15150499 DOI: 10.1016/s0399-8320(04)95242-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Affiliation(s)
- Dominique Thabut
- Service d'Hépato-Gastroentérologie, Hôpital de la Pitié Salpétrière, 47-83 boulevard de l'hôpital, 75013, Paris
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Vinel JP. [Gastrointestinal hemorrhage. Failure of pharmacological and endoscopic treatment: what is to be done?]. GASTROENTEROLOGIE CLINIQUE ET BIOLOGIQUE 2004; 28 Spec No 2:B237-41. [PMID: 15150519 DOI: 10.1016/s0399-8320(04)95262-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/29/2023]
Affiliation(s)
- J-P Vinel
- Service d'Hépato-Gastroentérologie, Fédération Digestive, CHU Purpan, 31059 Toulouse
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50
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Bernard-Chabert B. [Gastrointestinal hemorrhage. How to prevent rebleeding: pharmacological and endoscopic treatments]. GASTROENTEROLOGIE CLINIQUE ET BIOLOGIQUE 2004; 28 Spec No 2:B227-31. [PMID: 15150517 DOI: 10.1016/s0399-8320(04)95260-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/29/2023]
Affiliation(s)
- Brigitte Bernard-Chabert
- Service d'Hépato-Gastroentérologie, Hôpital Robert Debré, Boulevard du général Koenig, 51092 Reims Cedex
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