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Piccolo Serafim L, Simonetto DA. Primary Prophylaxis of Variceal Bleeding in Liver Cirrhosis. VARICEAL BLEEDING IN LIVER CIRRHOSIS 2021:67-75. [DOI: 10.1007/978-981-15-7249-4_6] [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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Garbuzenko DV, Arefyev NO. Primary prevention of bleeding from esophageal varices in patients with liver cirrhosis: An update and review of the literature. J Evid Based Med 2020; 13:313-324. [PMID: 33037792 DOI: 10.1111/jebm.12407] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Accepted: 06/19/2020] [Indexed: 12/12/2022]
Abstract
All patients with liver cirrhosis and portal hypertension should be stratified by risk groups to individualize different therapeutic strategies to increase the effectiveness of treatment. In this regard, the development of primary prophylaxis of variceal bleeding and its management according to the severity of portal hypertension may be promising. This paper is to describe the modern principles of primary prophylaxis of esophageal variceal bleeding in patients with liver cirrhosis. The PubMed and EMbase databases, Web of Science, Google Scholar, and the Cochrane Database of Systematic Reviews were used to search for relevant publications from 1999 to 2019. The results suggested that depending on the severity of portal hypertension, patients with cirrhosis should be divided into those who need preprimary prophylaxis, which aims to prevent the formation of esophageal varices, and those who require measures that aim to prevent esophageal variceal bleeding. In subclinical portal hypertension, therapy should be etiological and pathogenetic. Cirrhosis with clinically significant portal hypertension should receive nonselective β-blockers if they have small esophageal varices and risk factors for variceal bleeding. Nonselective β-blockers are the first-line drugs for the primary prevention of bleeding from medium to large-sized esophageal varices. Endoscopic band ligation is indicated for the patients who are intolerant to nonselective β-blockers or in the case of contraindications to pharmacological therapy. In summary, the stratification of cirrhotic patients by the severity of portal hypertension and an individual approach to the choice of treatment may increase the effectiveness of therapy as well as improve survival rate of these patients.
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Affiliation(s)
| | - Nikolay Olegovich Arefyev
- Department of Pathological Anatomy and Forensic Medicine, South Ural State Medical University, Chelyabinsk, Russia
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Kim BH, Chung JW, Lee CS, Jang ES, Jeong SH, Kim N, Kim JW. Liver volume index predicts the risk of esophageal variceal hemorrhage in cirrhotic patients on propranolol prophylaxis. Korean J Intern Med 2019; 34:1233-1243. [PMID: 30759966 PMCID: PMC6823564 DOI: 10.3904/kjim.2018.120] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2018] [Accepted: 05/21/2018] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND/AIMS Non-selective β-blockers (NSBBs) are used for primary prevention of esophageal variceal hemorrhage (VH) in patients with portal hypertension, but a significant number of patients develop VH while on NSBB therapy. In this study, we sought to determine whether liver volume can predict the risk of primary prophylaxis failure in cirrhotic patients on NSBB therapy. METHODS A retrospective cohort of 309 patients on prophylactic propranolol was analyzed. Liver volume was measured in portal venous phase images of multidetector computed tomography. Predictors of VH were assessed using a Cox proportional hazards model with competing-risks analysis. A nomogram was developed for estimation of the risk of primary prophylaxis failure. RESULTS During a median follow-up of 36 months, 37 patients on propranolol developed VH. Liver volume index, the ratio of measured-to-expected liver volume, was an independent predictor of VH (adjusted hazard ratio [HR], 2.70; 95% confidence interval [CI], 1.37 to 5.33; p = 0.004) as were the presence of large varices and the absence of ascites. A nomogram-based volume score of > 0.6 was predictive of prophylaxis failure (HR, 7.54; 95% CI, 2.88 to 19.73; p < 0.001). Time-dependent receiver operating characteristic curve analysis revealed that a nomogram-based risk score had significantly better discriminatory power than the North Italian Endoscopy Club index in predicting prophylaxis failure at 6 and 8 years. CONCLUSION Liver volume index is an independent predictor of first VH and a nomogram-based volume score stratifies the VH risk in cirrhotic patients on propranolol prophylaxis.
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Affiliation(s)
- Beom Hee Kim
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Jung Wha Chung
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Chung Seop Lee
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Eun Sun Jang
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Sook-Hyang Jeong
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Nayoung Kim
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Jin-Wook Kim
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
- Correspondence to Jin-Wook Kim, M.D. Department of Internal Medicine, Seoul National University Bundang Hospital, 82 Gumi-ro 173beon-gil, Bundang-gu, Seongnam 13620, Korea Tel: +82-31-787-7013 Fax: +82-31-787-4051 E-mail:
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Kozieł S, Kobryń K, Paluszkiewicz R, Krawczyk M, Wróblewski T. Endoscopic treatment of gastric varices bleeding with the use of n-butyl-2 cyanoacrylate. PRZEGLAD GASTROENTEROLOGICZNY 2015; 10:239-43. [PMID: 26759632 PMCID: PMC4697040 DOI: 10.5114/pg.2015.56112] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/16/2015] [Revised: 11/17/2015] [Accepted: 11/19/2015] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Oesophageal varices and gastric varices are naturally-formed, pathological portosystemic shunts that occur in patients with portal hypertension. Gastric varices are responsible for about 10% of variceal bleeding; however, they are also the cause of massive haemorrhage, often with dramatic progress. AIM To assess the results of endoscopic treatment of gastrointestinal bleeding from oesophageal and gastric varices using tissue glue Histoacryl. MATERIAL AND METHODS From January 2013 to May 2015 170 patients underwent a total of 244 obliterations with the administration of tissue glue due to gastroesophageal varices. We analysed 35 patients who received urgent endoscopic intervention due to life-threatening gastric variceal bleeding. RESULTS Thirty-five patients underwent 47 endoscopic procedures of haemorrhage management. Immediate haemostasis was achieved in 32 (91.4%) patients. In 3 (8.6%) cases endoscopy failed. In 2 patients a Linton tube was applied before secondary endoscopy. A single trans jugular portosystemic shunt (TIPS) was performed. Permanent haemostasis during the first endoscopy was achieved in 26 (74%) patients. Six (17%) patients presented recurrent bleeding 1-4 days following the initial treatment. Three patients had a splenic artery embolisation performed. One of the embolised patients required surgery, and a splenectomy was carried out. CONCLUSIONS If this kind of therapy is unavailable at the time, it is advised that one of the conventional methods of controlling bleeding is used, introducing basic life support and transporting the patient to a specialist centre with adequate endoscopic facilities, radiological possibilities of endovascular intervention, and surgical treatment of liver transplantation.
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Affiliation(s)
- Sławomir Kozieł
- Department of General, Transplant and Liver Surgery, Medical University of Warsaw, Warsaw, Poland
| | - Konrad Kobryń
- Department of General, Transplant and Liver Surgery, Medical University of Warsaw, Warsaw, Poland
| | - Rafał Paluszkiewicz
- Department of General, Transplant and Liver Surgery, Medical University of Warsaw, Warsaw, Poland
| | - Marek Krawczyk
- Department of General, Transplant and Liver Surgery, Medical University of Warsaw, Warsaw, Poland
| | - Tadeusz Wróblewski
- Department of General, Transplant and Liver Surgery, Medical University of Warsaw, Warsaw, Poland
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Triantos C, Kalafateli M. Endoscopic treatment of esophageal varices in patients with liver cirrhosis. World J Gastroenterol 2014; 20:13015-13026. [PMID: 25278695 PMCID: PMC4177480 DOI: 10.3748/wjg.v20.i36.13015] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2013] [Revised: 01/15/2014] [Accepted: 05/26/2014] [Indexed: 02/06/2023] Open
Abstract
Variceal bleeding is a life-threatening complication of portal hypertension with a six-week mortality rate of approximately 20%. Patients with medium- or large-sized varices can be treated for primary prophylaxis of variceal bleeding using two strategies: non-selective beta-blockers (NSBBs) or endoscopic variceal ligation (EVL). Both treatments are equally effective. Patients with acute variceal bleeding are critically ill patients. The available data suggest that vasoactive drugs, combined with endoscopic therapy and antibiotics, are the best treatment strategy with EVL being the endoscopic procedure of choice. In cases of uncontrolled bleeding, transjugular intrahepatic portosystemic shunt (TIPS) with polytetrafluoroethylene (PTFE)-covered stents are recommended. Approximately 60% of the patients experience rebleeding, with a mortality rate of 30%. Secondary prophylaxis should start on day six following the initial bleeding episode. The combination of NSBBs and EVL is the recommended management, whereas TIPS with PTFE-covered stents are the preferred option in patients who fail endoscopic and pharmacologic treatment. Apart from injection sclerotherapy and EVL, other endoscopic procedures, including tissue adhesives, endoloops, endoscopic clipping and argon plasma coagulation, have been used in the management of esophageal varices. However, their efficacy and safety, compared to standard endoscopic treatment, remain to be further elucidated. There are safety issues accompanying endoscopic techniques with aspiration pneumonia occurring at a rate of approximately 2.5%. In conclusion, future research is needed to improve treatment strategies, including novel endoscopic techniques with better efficacy, lower cost, and fewer adverse events.
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Triantos C, Kalafateli M. Primary prevention of bleeding from esophageal varices in patients with liver cirrhosis. World J Hepatol 2014; 6:363-369. [PMID: 25018847 PMCID: PMC4081611 DOI: 10.4254/wjh.v6.i6.363] [Citation(s) in RCA: 15] [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: 11/24/2013] [Revised: 02/07/2014] [Accepted: 04/11/2014] [Indexed: 02/06/2023] Open
Abstract
Variceal bleeding is a life threatening situation with mortality rates of at least 20%. Prophylactic treatment with non-selective beta blockers (NSBBs) is recommended for patients with small varices that have not bled but with increased risk for bleeding. The recommended treatment strategies on primary prevention of variceal bleeding in patients with medium and large-sized varices are NSBBs or endoscopic band ligation. Nitrates, shunt surgery and sclerotherapy are not recommended in this setting. In this review, the most recent data on prevention of esophageal variceal bleeding are presented. Available data derived from randomized-controlled trials suggest both treatment strategies, and according to Baveno V consensus in portal hypertension “the choice of treatment should be based on local resources and expertise, patient preference and characteristics, side-effects and contra-indications”.
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Abstract
Assessing the presence of clinically significant portal hypertension and esophageal varices is clinically important in cirrhosis. The reference standard techniques to assess the presence of portal hypertension and varices are the measurement of the hepatic vein pressure gradient and esophagogastroduodenoscopy, respectively. Some newer methods have shown a good performance, but none has been proven precise enough to replace hepatic vein pressure gradient measurement or esophagogastroduodenoscopy for the diagnosis of portal hypertension or the presence and grade of esophageal varices.
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Suk KT. Hepatic venous pressure gradient: clinical use in chronic liver disease. Clin Mol Hepatol 2014. [PMID: 24757653 DOI: 10.3350/cmh.2014.] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Portal hypertension is a severe consequence of chronic liver diseases and is responsible for the main clinical complications of liver cirrhosis. Hepatic venous pressure gradient (HVPG) measurement is the best available method to evaluate the presence and severity of portal hypertension. Clinically significant portal hypertension is defined as an increase in HVPG to >10 mmHg. In this condition, the complications of portal hypertension might begin to appear. HVPG measurement is increasingly used in the clinical fields, and the HVPG is a robust surrogate marker in many clinical applications such as diagnosis, risk stratification, identification of patients with hepatocellular carcinoma who are candidates for liver resection, monitoring of the efficacy of medical treatment, and assessment of progression of portal hypertension. Patients who had a reduction in HVPG of ≥ 20% or to ≤ 12 mmHg in response to drug therapy are defined as responders. Responders have a markedly decreased risk of bleeding/rebleeding, ascites, and spontaneous bacterial peritonitis, which results in improved survival. This review provides clinical use of HVPG measurement in the field of liver disease.
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Affiliation(s)
- Ki Tae Suk
- Department of Internal Medicine, Hallym University College of Medicine, Chuncheon, Korea
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Suk KT. Hepatic venous pressure gradient: clinical use in chronic liver disease. Clin Mol Hepatol 2014; 20:6-14. [PMID: 24757653 PMCID: PMC3992331 DOI: 10.3350/cmh.2014.20.1.6] [Citation(s) in RCA: 117] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2014] [Accepted: 02/26/2014] [Indexed: 02/06/2023] Open
Abstract
Portal hypertension is a severe consequence of chronic liver diseases and is responsible for the main clinical complications of liver cirrhosis. Hepatic venous pressure gradient (HVPG) measurement is the best available method to evaluate the presence and severity of portal hypertension. Clinically significant portal hypertension is defined as an increase in HVPG to >10 mmHg. In this condition, the complications of portal hypertension might begin to appear. HVPG measurement is increasingly used in the clinical fields, and the HVPG is a robust surrogate marker in many clinical applications such as diagnosis, risk stratification, identification of patients with hepatocellular carcinoma who are candidates for liver resection, monitoring of the efficacy of medical treatment, and assessment of progression of portal hypertension. Patients who had a reduction in HVPG of ≥ 20% or to ≤ 12 mmHg in response to drug therapy are defined as responders. Responders have a markedly decreased risk of bleeding/rebleeding, ascites, and spontaneous bacterial peritonitis, which results in improved survival. This review provides clinical use of HVPG measurement in the field of liver disease.
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Affiliation(s)
- Ki Tae Suk
- Department of Internal Medicine, Hallym University College of Medicine, Chuncheon, Korea
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Dell'Era A, Iannuzzi F, Fabris FM, Fontana P, Reati R, Grillo P, Aghemo A, de Franchis R, Primignani M. Impact of portal vein thrombosis on the efficacy of endoscopic variceal band ligation. Dig Liver Dis 2014; 46:152-6. [PMID: 24084343 DOI: 10.1016/j.dld.2013.08.138] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2013] [Revised: 08/11/2013] [Accepted: 08/20/2013] [Indexed: 12/11/2022]
Abstract
BACKGROUND Influence of portal vein thrombosis on efficacy of endoscopic variceal banding in patients with cirrhosis or extrahepatic portal vein obstruction has never been evaluated. Aim of the study was to assess influence of thrombosis on rate and time to eradication in cirrhosis and extrahepatic portal vein obstruction undergoing banding, compared to cirrhotic patients without thrombosis. METHODS Retrospective analysis of 235 consecutive patients (192 with cirrhosis without thrombosis, 22 cirrhosis and thrombosis and 21 extrahepatic portal vein obstruction) who underwent banding. Banding was performed every 2-3 weeks until eradication; endoscopic follow-up was performed at 1, 3, 6 months, then annually. RESULTS Eradication was achieved in 233 patients. Median time to eradication in cirrhotic patients with portal vein thrombosis vs. cirrhotic patients without thrombosis was 50.9 days (12-440) vs. 43.4 days (13-489.4); log-rank: 0.04; patients with extrahepatic portal vein obstruction vs. cirrhotic patients without thrombosis 63.9 days (31-321.6) vs. 43.4 days (13.0-489.4); log-rank: 0.008. Thrombosis was shown to be the only risk factor for longer time to eradication. CONCLUSIONS Portal vein thrombosis per se appears to be the cause of a longer time to achieve eradication of varices but, once eradication is achieved, it does not influence their recurrence.
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Affiliation(s)
- Alessandra Dell'Era
- Department of Medical Sciences, Università degli Studi di Milano - IRCCS Fondazione Cà Granda Ospedale Policlinico di Milano, Milan, Italy; Gastroenterology 3 Unit - IRCCS Fondazione Cà Granda Ospedale Policlinico di Milano, Milan, Italy.
| | - Francesca Iannuzzi
- Department of Medical Sciences, Università degli Studi di Milano - IRCCS Fondazione Cà Granda Ospedale Policlinico di Milano, Milan, Italy; Gastroenterology 3 Unit - IRCCS Fondazione Cà Granda Ospedale Policlinico di Milano, Milan, Italy
| | - Federica M Fabris
- Gastroenterology 3 Unit - IRCCS Fondazione Cà Granda Ospedale Policlinico di Milano, Milan, Italy
| | - Paola Fontana
- Department of Medical Sciences, Università degli Studi di Milano - IRCCS Fondazione Cà Granda Ospedale Policlinico di Milano, Milan, Italy; Gastroenterology 3 Unit - IRCCS Fondazione Cà Granda Ospedale Policlinico di Milano, Milan, Italy
| | - Raffaella Reati
- Department of Medical Sciences, Università degli Studi di Milano - IRCCS Fondazione Cà Granda Ospedale Policlinico di Milano, Milan, Italy; Gastroenterology 3 Unit - IRCCS Fondazione Cà Granda Ospedale Policlinico di Milano, Milan, Italy
| | - Paolo Grillo
- Epidemiology Unit - IRCCS Fondazione Cà Granda Ospedale Policlinico di Milano, Milan, Italy
| | - Alessio Aghemo
- Gastroenterology 1 Unit - IRCCS Fondazione Cà Granda Ospedale Policlinico di Milano, Milan, Italy
| | - Roberto de Franchis
- Department of Medical Sciences, Università degli Studi di Milano - IRCCS Fondazione Cà Granda Ospedale Policlinico di Milano, Milan, Italy; Gastroenterology 3 Unit - IRCCS Fondazione Cà Granda Ospedale Policlinico di Milano, Milan, Italy
| | - Massimo Primignani
- Gastroenterology 3 Unit - IRCCS Fondazione Cà Granda Ospedale Policlinico di Milano, Milan, Italy
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Merkel C, Montagnese S, Amodio P. Primary prophylaxis of bleeding from esophageal varices in cirrhosis. J Clin Exp Hepatol 2013; 3:198-203. [PMID: 25755501 PMCID: PMC3940186 DOI: 10.1016/j.jceh.2013.08.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2013] [Accepted: 08/02/2013] [Indexed: 12/12/2022] Open
Abstract
Prophylaxis of the first bleeding from esophageal varices became a clinical option more than 20 years ago, and gained a large diffusion in the following years. It is based on the use of nonselective beta-blockers, which decreases portal pressure, or on the eradication of esophageal varices by endoscopic band ligation of varices. In patients with medium or large varices either of these treatments is indicated. In patients with small varices only medical treatment is feasible, and in patients with medium and large varices with contraindication or side-effects due to beta-blockers, only endoscopic band ligation may be used. In this review the rationale and the results of the prophylaxis of bleeding from esophageal varices are discussed.
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Affiliation(s)
- Carlo Merkel
- Department of Medicine DIMED, University of Padua, Via Giustiniani, 2, I-35126 Padova, Italy
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Lonardo A, Loria P. Potential for statins in the chemoprevention and management of hepatocellular carcinoma. J Gastroenterol Hepatol 2012; 27:1654-1664. [PMID: 22849701 DOI: 10.1111/j.1440-1746.2012.07232.x] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/25/2012] [Indexed: 02/05/2023]
Abstract
Hepatocellular carcinoma (HCC) is a common, treatment-resistant malignancy with a complex molecular pathogenesis. Statins are a widely used class of cholesterol-lowering drugs with potential anticancer activity. We reviewed the evidence for a role of statins in primary and secondary chemoprevention of HCC and slowing the course of otherwise incurable primary or recurrent disease. A literature search (key words: Statins, hepatocellular carcinoma) conducted to this end, retrieved 119 references. Here we summarize the history, mechanism of action and cardiovascular use of statins and highlight that statins can affect several pathways implicated in the development of HCC. In vitro and animal studies provide strong evidence for a favorable effect of statins on HCC. However, evidence in humans is conflicting. We discuss in full detail the methodological strengths and pitfalls of published data including three cohort studies suggesting that the use of statins may protect from the development of HCC and of a single trial reporting increased survival in those with advanced HCC randomized to receive statins. A remarkably hepato-safe class of drugs acting on both hepatocyte and endothelial cells, statins also have potentially beneficial effects in lowering portal hypertension. In conclusion, there is strong experimental evidence that statins are beneficial in chemopreventing and slowing the growth of HCC. However, randomized controlled trials are necessary in order to investigate the role of statins in the chemoprevention of HCC and in slowing the course of otherwise incurable disease in humans.
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Affiliation(s)
- Amedeo Lonardo
- Department of Internal Medicine, Endocrinology, Metabolism and Geriatrics, University of Modena and Reggio Emilia and Nocsae Baggiovara, Modena, Italy.
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Augustin S, González A, Badia L, Millán L, Gelabert A, Romero A, Segarra A, Martell M, Esteban R, Guardia J, Genescà J. Long-term follow-up of hemodynamic responders to pharmacological therapy after variceal bleeding. Hepatology 2012; 56:706-14. [PMID: 22378235 DOI: 10.1002/hep.25686] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2011] [Accepted: 02/13/2012] [Indexed: 02/06/2023]
Abstract
UNLABELLED Although it is assumed that hemodynamic responders to pharmacological therapy after a variceal hemorrhage are adequately protected from rebleeding, there is no evidence that either this response or its protective effect extend beyond the usual 2-year follow-up featured in available studies. We aimed to assess the maintenance of hemodynamic response and its impact on outcomes in a large cohort of hemodynamic responders during a long follow-up. One hundred three patients with cirrhosis admitted with acute variceal bleeding between 2001 and 2010 were prospectively evaluated. The hepatic venous pressure gradient (HVPG) was determined 5 days after the bleeding and repeated 5-7 days after maximal tolerated doses of nadolol and nitrates. Hemodynamic responders (HVPG ≤ 12 mm Hg or ≥ 20% decrease from baseline) were maintained on drugs and followed up with annual HVPG measurements. Forty-eight patients (47%) were hemodynamic responders. The median follow-up was 48 months (range, 2-108 months). Long-term HVPG evaluations could not be performed in eight patients (four deaths, two rebleedings, two follow-ups <1 year). Among the remaining 40 patients, hemodynamic response was maintained in 26 (65%) and lost in 14 (35%). There were no baseline differences between the two subgroups. However, 100% of alcoholic patients who remained abstinent maintained long-term response, compared with 36% of nonabstinent alcoholics and 50% of patients with viral cirrhosis. Patients with loss of hemodynamic response rebled more during follow-up and showed a higher incidence of death or liver transplantation. CONCLUSIONS After variceal bleeding, long-term maintenance of hemodynamic response to drug therapy is mainly restricted to patients with alcoholic cirrhosis who remain abstinent. The loss of this long-term response carries worse clinical outcomes.
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Affiliation(s)
- Salvador Augustin
- Liver Unit, Department of Internal Medicine, Hospital Universitari Vall d'Hebron, Institut de Recerca, Universitat Autónoma de Barcelona, Barcelona, Spain.
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Adding banding ligation is effective as rescue therapy to prevent variceal rebleeding in haemodynamic non-responders to pharmacological therapy. Dig Liver Dis 2012; 44:55-60. [PMID: 21890439 DOI: 10.1016/j.dld.2011.07.019] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2011] [Revised: 05/20/2011] [Accepted: 07/26/2011] [Indexed: 12/11/2022]
Abstract
BACKGROUND It is unknown which is the best therapy to treat haemodynamic non-responders to pharmacological therapy after variceal bleeding. AIM To evaluate the efficacy of adding banding ligation to drugs to prevent variceal rebleeding in haemodynamic non-responders to drugs. METHODS Fifty-three cirrhotic patients with variceal bleeding underwent a hepatic venous pressure gradient (HVPG) measurement 5 days after the episode. Nadolol and nitrates were then titrated to maximum tolerated doses. A second HVPG was taken 14 days later. Responders (HVPG ≤12 mm Hg or ≥20% decrease from baseline) were maintained on drugs and non-responders had banding ligation added to drugs. RESULTS Mean follow-up was 28 months. In 5 patients the second HVPG could not be performed because of early rebleeding. The remaining 48 patients were classified as responders (n=24) and non-responders (n=24), who had banding added. No baseline differences were observed between groups. Variceal rebleeding occurred in 12% of the 48 patients whose haemodynamic response was assessed. Responders on drug therapy presented a 16% rebleeding rate, whilst non-responders rescued with banding showed an 8% rebleeding rate. Rebleeding-related mortality was not different between groups. CONCLUSION In a HVPG-guided strategy, adding banding ligation to drugs is an effective rescue strategy to prevent rebleeding in haemodynamic non-responders to drug therapy.
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Hepatic venous pressure gradient measurement in clinical hepatology. Dig Liver Dis 2011; 43:762-7. [PMID: 21549649 DOI: 10.1016/j.dld.2011.03.002] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2010] [Revised: 01/19/2011] [Accepted: 03/10/2011] [Indexed: 02/06/2023]
Abstract
Portal hypertension is key to the natural history of cirrhosis and the standard way to assess it is the hepatic venous pressure gradient. Hepatic venous pressure gradient is a strong predictor of variceal bleeding/survival and is the only suitable tool to assess the response of portal hypertension to medical treatment. The clinical applications, indications and timing for hepatic venous pressure gradient measurement, together with measurement principles and costs, are reviewed.
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Ouakaa-Kchaou A, Kharrat J, Mir K, Houda B, Abdelli N, Ajmi S, Azzouz M, Ben Abdallah H, Ben Mami N, Bouzaidi S, Chouaib S, Golli L, Melki W, Najjar T, Saffar H, Belhadj N, Ghorbel A. Variceal band ligation in the prevention of variceal bleeding: a multicenter trial. Saudi J Gastroenterol 2011; 17:105-9. [PMID: 21372346 PMCID: PMC3099054 DOI: 10.4103/1319-3767.77238] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2010] [Accepted: 09/02/2010] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND/AIM Variceal bleeding is a life-threatening complication of portal hypertension with a high probability of recurrence. Treatment to prevent first bleeding or rebleeding is mandatory. The study has been aimed at investigating the effectiveness of endoscopic band ligation in preventing upper gastrointestinal bleeding in patients with portal hypertension and to establish the clinical outcome of patients. PATIENTS AND METHODS We analyzed in a multicenter trial, the efficacy and side effects of endoscopic band ligation for the primary and secondary prophylaxis of esophageal variceal bleeding. We assigned 603 patients with portal hypertension who were hospitalized to receive treatment with endoscopic ligation. Sessions of ligation were repeated every two to three weeks until the varices were eradicated. The primary end point was recurrent bleeding. RESULTS The median follow-up period was 32 months. A total of 126 patients had recurrent bleeding. All episodes were related to portal hypertension and 79 to recurrent variceal bleeding. There were major complications in 51 patients (30 had bleeding esophageal ulcers). Seventy-eight patients died, 26 deaths were related to variceal bleeding and 1 to bleeding esophageal ulcers. CONCLUSIONS A great improvement in the prevention of variceal bleeding has emerged over the last years. However, further therapeutic options that combine higher efficacy, better tolerance and fewer side effects are needed.
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Merkel C, Bolognesi M, Berzigotti A, Amodio P, Cavasin L, Casarotto IM, Zoli M, Gatta A. Clinical significance of worsening portal hypertension during long-term medical treatment in patients with cirrhosis who had been classified as early good-responders on haemodynamic criteria. J Hepatol 2010; 52:45-53. [PMID: 19914730 DOI: 10.1016/j.jhep.2009.10.014] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2009] [Revised: 07/23/2009] [Accepted: 07/30/2009] [Indexed: 02/06/2023]
Abstract
BACKGROUND & AIMS It is established that cirrhotic patients who respond to beta-blockers by lowering their hepatic venous pressure gradient (HVPG) to < or =12 mmHg or by > or =20% of the baseline values are protected from bleeding. However, it is not known whether the effect remains unchanged over the treatment period. METHODS A group of 24 patients with cirrhosis and oesophageal varices, treated with beta-blockers+/-nitrates, good-responders on haemodynamic criteria, were followed for up to 76 months with sequential HVPG measurements. Another group of 16 patients was used for validation. RESULTS HVPG worsened in 10 of the 24 patients during follow-up. Changes in HVPG correlated to concomitant changes in liver function parameters. Variceal bleeding occurred in four of the 10 patients whose HVPG had worsened (bleed; 3-21 months after the measured increase in HVPG) and in none of those with stable HVPG (p=0.02). Patients with increased HVPG also had shorter survival (p=0.05). Worsening of HVPG was an independent predictor of death, additive to Child-Pugh or MELD scores, in a time-dependent Cox's regression analysis. This relationship was confirmed in the validation group. CONCLUSIONS Worsening HVPG during follow-up in patients who had initially been good-responders to medical treatment is related to worsening in hepatic function. The maintenance of a good haemodynamic response to medical treatment of portal hypertension is an excellent predictor of outcome in these patients.
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Affiliation(s)
- Carlo Merkel
- Department of Clinical and Experimental Medicine, University of Padua, Italy.
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