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Aggeletopoulou I, Triantos C. Endoscopic Management of Variceal Bleeding. GASTROINTESTINAL AND PANCREATICO-BILIARY DISEASES: ADVANCED DIAGNOSTIC AND THERAPEUTIC ENDOSCOPY 2022:1059-1092. [DOI: 10.1007/978-3-030-56993-8_63] [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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de Mattos ÂZ, Terra C, Farias AQ, Bittencourt PL. Primary prophylaxis of variceal bleeding in patients with cirrhosis: A comparison of different strategies. World J Gastrointest Endosc 2021; 13:628-637. [PMID: 35070024 PMCID: PMC8716979 DOI: 10.4253/wjge.v13.i12.628] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2021] [Revised: 08/07/2021] [Accepted: 11/21/2021] [Indexed: 02/06/2023] Open
Abstract
Patients with cirrhosis and esophageal varices bleed at a yearly rate of 5%-15%, and, when variceal hemorrhage develops, mortality reaches 20%. Patients are deemed at high risk of bleeding when they present with medium or large-sized varices, when they have red signs on varices of any size and when they are classified as Child-Pugh C and have varices of any size. In order to avoid variceal bleeding and death, individuals with cirrhosis at high risk of bleeding must undergo primary prophylaxis, for which currently recommended strategies are the use of traditional non-selective beta-blockers (NSBBs) (i.e., propranolol or nadolol), carvedilol (a NSBB with additional alpha-adrenergic blocking effect) or endoscopic variceal ligation (EVL). The superiority of one of these alternatives over the others is controversial. While EVL might be superior to pharmacological therapy regarding the prevention of the first bleeding episode, either traditional NSBBs or carvedilol seem to play a more prominent role in mortality reduction, probably due to their capacity of preventing other complications of cirrhosis through the decrease in portal hypertension. A sequential strategy, in which patients unresponsive to pharmacological therapy would be submitted to endoscopic treatment, or the combination of pharmacological and endoscopic strategies might be beneficial and deserve further investigation.
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Affiliation(s)
- Ângelo Zambam de Mattos
- Graduate Program in Medicine: Hepatology, Federal University of Health Sciences of Porto Alegre, Porto Alegre 90050-170, Brazil
| | - Carlos Terra
- Department of Internal Medicine, Universidade do Estado do Rio de Janeiro, Rio de Janeiro 20950000, Brazil
| | - Alberto Queiroz Farias
- Department of Gastroenterology, University of São Paulo School of Medicine, São Paulo 05403-000, Brazil
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Roccarina D, Best LM, Freeman SC, Roberts D, Cooper NJ, Sutton AJ, Benmassaoud A, Plaz Torres MC, Iogna Prat L, Csenar M, Arunan S, Begum T, Milne EJ, Tapp M, Pavlov CS, Davidson BR, Tsochatzis E, Williams NR, Gurusamy KS. Primary prevention of variceal bleeding in people with oesophageal varices due to liver cirrhosis: a network meta-analysis. Cochrane Database Syst Rev 2021; 4:CD013121. [PMID: 33822357 PMCID: PMC8092414 DOI: 10.1002/14651858.cd013121.pub2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [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. There are several different treatments to prevent bleeding, including: beta-blockers, endoscopic sclerotherapy, and variceal band ligation. However, there is uncertainty surrounding their individual and relative benefits and harms. OBJECTIVES To compare the benefits and harms of different treatments for prevention of first variceal bleeding from oesophageal varices in adults with liver cirrhosis through a network meta-analysis and to generate rankings of the different treatments for prevention of first variceal bleeding from oesophageal varices 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 to December 2019 to identify randomised clinical trials in people with cirrhosis and oesophageal varices with no history of bleeding. SELECTION CRITERIA We included only randomised clinical trials (irrespective of language, blinding, or status) in adults with cirrhosis and oesophageal varices with no history of bleeding. We excluded randomised clinical trials in which participants had previous bleeding from oesophageal varices and those who had previously undergone liver transplantation or previously received prophylactic treatment for oesophageal varices. 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 for Health and Care Excellence Decision Support Unit guidance. We performed the direct comparisons from randomised clinical trials using the same codes and the same technical details. MAIN RESULTS We included 66 randomised clinical trials (6653 participants) in the review. Sixty trials (6212 participants) provided data for one or more comparisons in the review. The trials that provided the information included people with cirrhosis due to varied aetiologies and those at high risk of bleeding from oesophageal varices. The follow-up in the trials that reported outcomes ranged from 6 months to 60 months. All but one of the trials were at high risk of bias. The interventions compared included beta-blockers, no active intervention, variceal band ligation, sclerotherapy, beta-blockers plus variceal band ligation, beta-blockers plus nitrates, nitrates, beta-blockers plus sclerotherapy, and portocaval shunt. Overall, 21.2% of participants who received non-selective beta-blockers ('beta-blockers') - the reference treatment (chosen because this was the most common treatment compared in the trials) - died during 8-month to 60-month follow-up. Based on low-certainty evidence, beta-blockers, variceal band ligation, sclerotherapy, and beta-blockers plus nitrates all had lower mortality versus no active intervention (beta-blockers: HR 0.49, 95% CrI 0.36 to 0.67; direct comparison HR: 0.59, 95% CrI 0.42 to 0.83; 10 trials, 1200 participants; variceal band ligation: HR 0.51, 95% CrI 0.35 to 0.74; direct comparison HR 0.49, 95% CrI 0.12 to 2.14; 3 trials, 355 participants; sclerotherapy: HR 0.66, 95% CrI 0.51 to 0.85; direct comparison HR 0.61, 95% CrI 0.41 to 0.90; 18 trials, 1666 participants; beta-blockers plus nitrates: HR 0.41, 95% CrI 0.20 to 0.85; no direct comparison). No trials reported health-related quality of life. Based on low-certainty evidence, variceal band ligation had a higher number of serious adverse events (number of events) than beta-blockers (rate ratio 10.49, 95% CrI 2.83 to 60.64; 1 trial, 168 participants). Based on low-certainty evidence, beta-blockers plus nitrates had a higher number of 'any adverse events (number of participants)' than beta-blockers alone (OR 3.41, 95% CrI 1.11 to 11.28; 1 trial, 57 participants). Based on low-certainty evidence, adverse events (number of events) were higher in sclerotherapy than in beta-blockers (rate ratio 2.49, 95% CrI 1.53 to 4.22; direct comparison rate ratio 2.47, 95% CrI 1.27 to 5.06; 2 trials, 90 participants), and in beta-blockers plus variceal band ligation than in beta-blockers (direct comparison rate ratio 1.72, 95% CrI 1.08 to 2.76; 1 trial, 140 participants). Based on low-certainty evidence, any variceal bleed was lower in beta-blockers plus variceal band ligation than in beta-blockers (direct comparison HR 0.21, 95% CrI 0.04 to 0.71; 1 trial, 173 participants). Based on low-certainty evidence, any variceal bleed was higher in nitrates than beta-blockers (direct comparison HR 6.40, 95% CrI 1.58 to 47.42; 1 trial, 52 participants). The evidence indicates considerable uncertainty about the effect of the interventions in the remaining comparisons. AUTHORS' CONCLUSIONS Based on low-certainty evidence, beta-blockers, variceal band ligation, sclerotherapy, and beta-blockers plus nitrates may decrease mortality compared to no intervention in people with high-risk oesophageal varices in people with cirrhosis and no previous history of bleeding. Based on low-certainty evidence, variceal band ligation may result in a higher number of serious adverse events than beta-blockers. The evidence indicates considerable uncertainty about the effect of beta-blockers versus variceal band ligation on variceal bleeding. The evidence also indicates considerable uncertainty about the effect of the interventions in most of the remaining comparisons.
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Affiliation(s)
- Davide Roccarina
- Sheila Sherlock Liver Centre, Royal Free Hospital and the UCL Institute of Liver and Digestive Health, 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
| | - 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
| | - 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
| | - 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
| | - Norman R Williams
- Surgical & Interventional Trials Unit (SITU), UCL Division of Surgery & Interventional Science, 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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Duah A, Nkrumah KN, Tachi K. Non-invasive markers as predictors of oesophageal varices in cirrhotic patient in a teaching hospital in Ghana. Ghana Med J 2019; 53:142-149. [PMID: 31481810 PMCID: PMC6697776 DOI: 10.4314/gmj.v53i2.9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Introduction Oesophageal variceal (OV) bleeding is a potentially fatal consequence of portal hypertension in patients with liver cirrhosis. Upper GI endoscopy is recommended for screening for varices in cirrhotics for early detection and treatment, however, this is invasive. The purpose of this study was to assess the predictive values of the noninvasive tests in detecting the presence of OV. Methods A cross-sectional hospital-based study involving 149 patients with liver cirrhosis was carried out at the Korle-Bu Teaching Hospital from 1st November 2015 to 25th November 2016. Relevant clinical parameters assessed included Child-Pugh class, ascites and splenomegaly. Full blood count and liver function tests, abdominal ultrasound and gastroscopy were done for all the participants. Receiver operating characteristic curve was generated to determine the cut-off values for the best sensitivity, specificity, negative and positive predictive values of the variables (serum albumin, platelet count (PC), aspartate aminotransferase (AST)/alanine aminotransferase (ALT), PC/Spleen diameter( SD)) with regard to the presence of OV. Results On gastroscopy, 135 (90.60%) had OV and 14 patients (9.40%) had no OV. One hundred and eleven of the varices (82.22%) were large varices and the rest (17.78%) small varices. The overall mean of serum albumin, PC and PC/SD were not significant predictors of the presence of OV. However, the overall mean of AST/ALT significantly predicted the presence of OV. A PC/SD cut off value of ≤833.3 had 72.62% diagnostic accuracy for diagnosing all OV. Conclusion PC/SD cut-off could be used to screen cirrhotics for OV and treatment initiated in geographical areas lacking endoscopy facilities Funding None declared
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Affiliation(s)
- Amoako Duah
- Department of Medicine, St. Dominic Hospital, Akwatia, Ghana
| | - Kofi N Nkrumah
- Department of Medicine and Therapeutics, School of Medicine and Dentistry, College of Health Science, University of Ghana
| | - Kenneth Tachi
- Department of Medicine and Therapeutics, School of Medicine and Dentistry, College of Health Science, University of Ghana
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Cucchiarelli S, Santopaolo F, Lamazza A, Lionetti R, Lenci I, Manzia TM, Angelico M, Milana M, Baiocchi L. Pitfalls in the reporting of upper endoscopy features in cirrhotic patients. Dig Liver Dis 2019; 51:382-385. [PMID: 30219669 DOI: 10.1016/j.dld.2018.08.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Revised: 08/08/2018] [Accepted: 08/10/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND Upper endoscopy is the main tool for the accurate assessment of the risk of bleeding in cirrhotic patients. AIM To evaluate the diagnostic accuracy of upper endoscopy, in cirrhotic subjects, during common clinical practice. METHODS 120 endoscopic reports produced in different hospitals in our region were retrospectively and randomly selected. After a general evaluation, aimed at assessing the description of various endoscopic features, reports were evaluated by four expert endoscopists and four expert hepatologists. Experts were asked to fill in a questionnaire for each single endoscopic procedure, regarding the diagnostic accuracy of the report. RESULTS Endoscopic reports lacked descriptions of the size of esophageal varices and red signs in 14% and 29% of cases respectively. Presence (or absence) of gastric varices or portal hypertensive gastropathy were not reported in 62% and 34% of cases respectively. According to expert endoscopists 41% of the reports were incomplete, while, according to hepatologists, reports were incomplete and inadequate for clinical purposes in 36% of cases. CONCLUSION Our study clearly evidenced a significant lack of information in reports on upper endoscopy in cirrhotic patients, and supports the prompt adoption of corrective strategies.
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Affiliation(s)
| | | | | | - Raffaella Lionetti
- Infectious disease and Hepatology Unit, Lazzaro Spallanzani Hospital, Rome, Italy
| | - Ilaria Lenci
- Hepatology Unit, Tor Vergata University Hospital, Rome, Italy
| | | | - Mario Angelico
- Hepatology Unit, Tor Vergata University Hospital, Rome, Italy
| | - Martina Milana
- Hepatology Unit, Tor Vergata University Hospital, Rome, Italy
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Schulman AR, Popov V, Thompson CC. Randomized sham-controlled trials in endoscopy: a systematic review and meta-analysis of adverse events. Gastrointest Endosc 2017; 86:972-985.e3. [PMID: 28802556 PMCID: PMC5693737 DOI: 10.1016/j.gie.2017.07.046] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2017] [Accepted: 07/30/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Sham procedures in endoscopy are used with the intention of controlling for placebo response, potentially allowing more precise evaluation of treatment effect. Nevertheless, this type of study may impose significant risk without potential benefit for those in the sham group. The aim of the current study was to systematically review and analyze the endoscopic literature to assess the safety of sham controls. METHODS MEDLINE and Embase databases were searched for endoscopic sham procedures for all dates to July 2017. Only randomized controlled trials comparing an endoscopic therapy with a sham were included. Primary outcome was adverse events (AEs) categorized as mild, moderate, or severe. Results were combined using a random-effects model. Heterogeneity was assessed with the I2 statistic, and publication bias was assessed with the Egger test and funnel plots. RESULTS Data were extracted from 34 publications (1987-2017; 100% full text), with a total of 2492 procedures (1355 treatment/1137 sham). Sham procedures involved upper endoscopy (31 studies) and ERCP (3 studies). Treatment arms included procedures with the following indications: weight loss (38.2%), GI bleeding (26.5%), GERD (20.6%), sphincter of Oddi dysfunction (8.8%), and dysphagia (6.2%). Overall percentage of severe adverse events (SAEs) in the sham group was 1.7% (19/1137). Of these, the most common SAEs in the sham groups were need for surgery/intensive care unit stay (35.3%), post-ERCP pancreatitis (23.5%), and perforation (11.8%). There was no significant difference in the odds of developing an SAE between the treatment group and the sham group (odds ratio, 1.3; 95% confidence interval [CI], 0.7-2.3). The pooled additional risk incurred from being initially randomized to the sham arm and then receiving a cross-over intervention was significant (RR, 1.33; 95% CI, 1.14-1.56; P < .001), compared with patients initially randomized to the study intervention. CONCLUSION The frequency of AEs in endoscopic sham procedures is substantial, and patients are subjected to considerable morbidity. These results raise a serious ethical dilemma regarding the use of sham-controlled trials.
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Affiliation(s)
- Allison R. Schulman
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women’s Hospital, Boston, Massachusetts, USA,Harvard Medical School, Boston, Massachusetts, USA
| | | | - Christopher C. Thompson
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women’s Hospital, Boston, Massachusetts, USA,Harvard Medical School, Boston, Massachusetts, USA
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Abstract
Acute esophageal variceal hemorrhage is a dreaded complication of portal hypertension. Its management has evolved rapidly in recent years. Endoscopic therapy is often employed to arrest bleeding varices as well as to prevent early rebleeding. The combination of vasoconstrictor and endoscopic therapy is superior to vasoconstrictor or endoscopic therapy alone for control of acute esophageal variceal hemorrhage. After control of acute variceal bleeding, combination of banding ligation and beta-blockers is generally recommended to prevent variceal rebleeding. To prevent the catastrophic event of acute variceal bleeding, endoscopic banding ligation is an important tool in the prophylaxis of first bleeding. Endoscopic obturation with cyanoacrylate is usually utilized to arrest acute gastric variceal hemorrhage as well as to prevent rebleeding. It can be concluded that endoscopic therapies play a pivotal role in management of portal hypertensive bleeding.
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Affiliation(s)
- Gin-Ho Lo
- Department of Medical Research, E-Da Hospital, Kaohsiung, School of Medicine for International Students, I-Shou University, 1, Yi-Da Road, Kaohsiung, 824, Taiwan.
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Parbhu SK, Adler DG. Endoscopic management of acute esophageal variceal bleeding. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2017. [DOI: 10.1016/j.tgie.2017.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Abby Philips C, Sahney A. Oesophageal and gastric varices: historical aspects, classification and grading: everything in one place. Gastroenterol Rep (Oxf) 2016; 4:186-95. [PMID: 27324725 PMCID: PMC4976684 DOI: 10.1093/gastro/gow018] [Citation(s) in RCA: 67] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2016] [Revised: 03/31/2016] [Accepted: 04/14/2016] [Indexed: 12/14/2022] Open
Abstract
Variceal disease and its management are of the utmost importance in the treatment of portal hypertension. Current guidelines are universal for management of variceal disease in portal hypertension. Classification and grading systems are numerous and differ according to geographical location. In this exhaustive review, the historical aspects of variceal disease, its classification and the grading systems in use are discussed, with self-explanatory tables and timelines. A better and clear understanding of the evolution of portal hypertension and variceal disease is provided.
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Affiliation(s)
- Cyriac Abby Philips
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, Delhi, India
| | - Amrish Sahney
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, Delhi, India
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Bozic MA, Puri K, Molleston JP. Screening and Prophylaxis for Varices in Children with Liver Disease. Curr Gastroenterol Rep 2015; 17:27. [PMID: 26122248 DOI: 10.1007/s11894-015-0450-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
Esophageal varices in children with portal hypertension are quite common. Bleeding from these varices frequently occurs. Prophylactic measures to prevent such bleeding can be undertaken either before ("primary," prompted by a screening endoscopy) or after ("secondary") an initial variceal bleed. There are no clear pediatric guidelines for primary or secondary prophylaxis of esophageal varices. Adult studies clearly support the use of pharmacologic (beta blockers) and endoscopic (endoscopic band ligation, EBL) management for both primary and secondary prophylaxis of esophageal varices in patients with portal hypertension. Pediatric studies are limited. There are inadequate data to recommend use of beta blockers to prevent variceal bleeding or rebleeding in children with portal hypertension. There is very limited support for EBL for primary prophylaxis in children and more compelling support for EBL for secondary prophylaxis. Further randomized controlled studies are needed but are difficult to implement in this vulnerable population.
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Affiliation(s)
- Molly A Bozic
- Department of Pediatrics, Section of Pediatric Gastroenterology, Hepatology, and Nutrition, Indiana University School of Medicine, 705 Riley Hospital Drive, ROC 4210, Indianapolis, IN, 46202, USA
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Sato T. Treatment of ectopic varices with portal hypertension. World J Hepatol 2015; 7:1601-1605. [PMID: 26140080 PMCID: PMC4483542 DOI: 10.4254/wjh.v7.i12.1601] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2015] [Revised: 02/21/2015] [Accepted: 04/14/2015] [Indexed: 02/06/2023] Open
Abstract
Ectopic varices are unusual with portal hypertension and can involve any site along the digestive tract outside the gastroesophageal region. Hemorrhage from ectopic varices generally are massive and life threatening. Diagnosis of ectopic varices is difficult and subsequent treatment is also difficult; the optimal treatment has not been established. Recently, interventional radiology and endoscopic treatments have been carried out successfully for hemorrhage from ectopic varices.
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Surgical Resection for Hepatocellular Carcinoma with Concomitant Esophageal Varices. World J Surg 2015; 39:2510-8. [DOI: 10.1007/s00268-015-3110-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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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: 16] [Impact Index Per Article: 1.5] [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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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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de Franchis R, Dell’Era A. Pre-primary and Primary Prophylaxis of Variceal Hemorrhage. VARICEAL HEMORRHAGE 2014. [PMCID: PMC7121476 DOI: 10.1007/978-1-4939-0002-2_7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Variceal hemorrhage is a life-threatening complication of portal hypertension. Thus, prevention of variceal formation (pre-primary prophylaxis) or at least prevention of variceal bleeding are important goals to improve life quality and—if possible—survival of patients with liver cirrhosis. Interruption of the underlying cause of liver disease is the most successful approach, which, however, often fails. For this situation interruption or modulation of different pathophysiological mechanisms leading to fibrosis, hyperdynamic circulation and portal hypertension have been shown effective in animal models. But few could be translated to humans. By contrast, different steps to prevent first bleeding from varices have proven successful in many clinical trials. These applied mainly drugs to lower portal pressure, such as nonselective β-blockers, or endoscopic obliteration of varices, while prophylactic shunt procedures are not advised.
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Affiliation(s)
| | - Alessandra Dell’Era
- Ospedale Universitario Luigi Sacco, Universitá degli Studi di Milano, UOC Gastroenterologia, Milano, Italy
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18
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Pal S, Mangla V, Radhakrishna P, Sahni P, Pande GK, Acharya SK, Chattopadhyay TK, Nundy S. Surgery as primary prophylaxis from variceal bleeding in patients with extrahepatic portal venous obstruction. J Gastroenterol Hepatol 2013; 28:1010-4. [PMID: 23301629 DOI: 10.1111/jgh.12123] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/02/2013] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIM In patients with extrahepatic portal venous obstruction (EHO), death is usually due to variceal bleeding. This is more so in developing countries where there is a lack of tertiary health-care facilities and blood banks. Prophylactic operations in cirrhotics have been found to be deleterious. In contrast, patients with EHO have well-preserved liver function, and we therefore investigated the role of prophylactic surgery to prevent variceal bleeding. METHODS Between 1976 and 2010, we operated on selected patients with EHO, who had no history of variceal bleeding but had "high-risk" esophagogastric varices or severe portal hypertensive gastropathy and/or hypersplenism, and came from remote areas with poor access to tertiary health care. Following surgery, these patients were prospectively followed up with regard to mortality, variceal bleeding, encephalopathy, and liver function. RESULTS A total of 114 patients (67 males; mean age 19 years) underwent prophylactic operations (proximal splenorenal shunts 98 [86%]; esophagogastric devascularization 16). Postoperative mortality was 0.9%. Among 89(79%) patients who were followed up (mean 60 months), hypersplenism was cured, and six (6.7%) developed variceal bleeding. The latter were managed successfully by endoscopic sclerotherapy. No patient developed overwhelming post-splenectomy sepsis or encephalopathy, and 90% were free of symptoms. CONCLUSION In patients with EHO, prophylactic surgery is fairly safe and prevents variceal bleeding in ∼ 94% of patients with no occurrence of portosystemic encephalopathy. Patients with EHO who have not bled but have high-risk varices and/or hypersplenism, and poor access to medical facilities should be offered prophylactic operations.
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Affiliation(s)
- Sujoy Pal
- Department of GI Surgery and Liver Transplantation, All India Institute of Medical Sciences, India.
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Abstract
Variceal hemorrhage is a common and devastating complication of portal hypertension and is a leading cause of death in patients with cirrhosis. The management of gastroesophageal varices has evolved over the last decade resulting in improved mortality and morbidity rates. Regarding the primary prevention of variceal hemorrhaging, nonselective β -blockers should be the first-line therapy in all patients with medium to large varices and in patients with small varices associated with high-risk features such as red wale marks and/or advanced cirrhosis. EVL should be offered in cases of intolerance or side effects to β -blockers, or for patients at high-risk for variceal bleeding who have medium or large varices with red wale marks or advanced liver cirrhosis. In acute bleeding, vasoactive agents should be initiated along with antibiotics followed by EVL or endoscopic sclerotherapy (if EVL is technically difficult) within the first 12 hours of presentation. Where available, terlipressin is the preferred agent because of its safety profile and it represents the only drug with a proven efficacy in improving survival. All patients surviving an episode of bleeding should undergo further prophylaxis to prevent rebleeding with EVL and nonselective β -blockers.
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20
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Endoscopic color Doppler ultrasonography for esophagogastric varices. DIAGNOSTIC AND THERAPEUTIC ENDOSCOPY 2012; 2012:859213. [PMID: 23213271 PMCID: PMC3507078 DOI: 10.1155/2012/859213] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/22/2012] [Revised: 10/05/2012] [Accepted: 10/20/2012] [Indexed: 02/06/2023]
Abstract
Esophagogastric varices are considered to be the most common complication in patients with portal hypertension. Endoscopic ultrasonography not only visualizes the surface of the varices but also provides detailed information about their internal structure. The direction of blood flow can be determined and its velocity measured only via endoscopic color Doppler ultrasonography (ECDUS). This can show graphically esophageal varices, paraesophageal veins, and passageways in esophageal variceal patients and gastric varices, perigastric collateral veins in gastric variceal patients. It is important to evaluate the hemodynamics of the portal venous system when treating the esophago-gastric varices. ECDUS is a useful modality for the evaluation of the detailed hemodynamics and the therapeutic effects of esophago-gastric varices.
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Persson EC, Quraishi SM, Welzel TM, Carreon JD, Gridley G, Graubard BI, McGlynn KA. Risk of liver cancer among US male veterans with cirrhosis, 1969-1996. Br J Cancer 2012; 107:195-200. [PMID: 22588556 PMCID: PMC3389404 DOI: 10.1038/bjc.2012.193] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Background: Liver cancer incidence rates in the United States have increased for several decades for reasons that are not entirely clear. Regardless of aetiology, cirrhosis is a strong risk factor for liver cancer. As mortality from cirrhosis has been declining in recent decades, it is possible that the risk of liver cancer among persons with cirrhosis has been affected. Methods: Data from the US Veterans Affairs medical records database were analysed after adjustment for attained age, race, number of hospital visits, obesity, diabetes, and chronic obstructive pulmonary disease. Hazard ratio (HR) and 95% confidence interval (95% CI) were calculated using Cox proportional hazards modelling. Survival analyses were conducted using age as the time metric and incidence of cirrhosis as a time-dependent covariate. Results: Among 103 257 men with incident cirrhosis, 788 liver cancers developed. The HR of liver cancer was highest among men with viral-related cirrhosis (HR=37.59, 95% CI: 22.57–62.61), lowest among men with alcohol-related cirrhosis (HR=8.20, 95% CI: 7.55–8.91) and intermediate among men with idiopathic cirrhosis (HR=10.45, 95% CI: 8.52–12.81), when compared with those without cirrhosis. Regardless of cirrhosis type, white men had higher HRs than black men. The HR of developing liver cancer increased from 6.40 (95% CI: 4.40–9.33) in 1969–1973 to 34.71 (95% CI: 23.10–52.16) in 1992–1996 for those with cirrhosis compared with those without. Conclusion: In conclusion, the significantly increased HR of developing liver cancer among men with cirrhosis compared with men without cirrhosis in the United States may be contributing to the increasing incidence of liver cancer.
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Affiliation(s)
- E C Persson
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Department of Health and Human Services, Bethesda, MD 20852-7234 USA.
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Krystallis C, Masterton GS, Hayes PC, Plevris JN. Update of endoscopy in liver disease: More than just treating varices. World J Gastroenterol 2012; 18:401-11. [PMID: 22346246 PMCID: PMC3272639 DOI: 10.3748/wjg.v18.i5.401] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2011] [Revised: 06/02/2011] [Accepted: 06/09/2011] [Indexed: 02/06/2023] Open
Abstract
The management of complications in liver disease is often complex and challenging. Endoscopy has undergone a period of rapid expansion with numerous novel and specialized endoscopic modalities that are of increasing value in the investigation and management of the patient with liver disease. In this review, relevant literature search and expert opinions have been used to provide a brief overview and update of the current endoscopic management of patients with liver disease and portal hypertension. The main areas covered are safety of endoscopy in patients with liver disease, the use of standard endoscopy for the treatment of varices and the role of new endoscopic modalities such as endoscopic ultrasound, esophageal capsule, argon plasma coagulation, spyglass and endomicroscopy in the investigation and treatment of liver-related gastrointestinal and biliary pathology. It is clear that the role of the endoscopy in liver disease is well beyond that of just treating varices. As the technology in endoscopy expands, so does the role of the endoscopist in liver disease.
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23
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Pal S. Current role of surgery in portal hypertension. Indian J Surg 2011; 74:55-66. [PMID: 23372308 DOI: 10.1007/s12262-011-0381-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2011] [Accepted: 11/17/2011] [Indexed: 12/12/2022] Open
Abstract
Treatment for portal hypertension (PHT) has evolved from surgery being the only option during the 1970s to the wide range of options currently available. Surgery has not vanished from the therapeutic armamentarium, but its role has changed and is constantly evolving. The present review primarily focuses on the role of surgery in tackling patients with PHT and varices with regard to the Indian scenario and also looks at its relevance, given the availability of a host of other therapeutic options.
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Affiliation(s)
- Sujoy Pal
- Department of GI surgery and Liver Transplantation, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029 India
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Detection and grading of esophageal varices on liver CT: comparison of standard and thin-section multiplanar reconstructions in diagnostic accuracy. AJR Am J Roentgenol 2011; 197:643-9. [PMID: 21862806 DOI: 10.2214/ajr.10.5458] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE The objective of our study was to evaluate the performance of liver CT in the diagnosis of esophageal varices in patients with cirrhosis and to determine whether thin-section multiplanar reconstructions (MPRs) improve accuracy. MATERIALS AND METHODS We identified 109 patients with cirrhosis who underwent endoscopy within 10 weeks after dual-phase liver MDCT supplemented with thin-section axial and coronal portal venous phase reconstructions. Two blinded radiologists independently evaluated each CT examination for the presence and sizes of varices using standard 5-mm axial versus 1- to 3-mm multiplanar images in separate sessions. Sensitivity, specificity, and predictive value calculations and receiver operating characteristic analysis were performed using endoscopy as the reference standard. Interobserver variability and correlation of CT size to variceal grade were assessed. RESULTS Twenty-six cases of high-risk esophageal varices were identified; all except two were detected on CT by one of the readers on standard 5-mm images. For both readers, sensitivity and negative predictive value (NPV) for the discrimination of high-risk varices using a criterion of 2 mm or greater were nearly the same for the standard 5-mm images versus the 1- to 3-mm multiplanar images (sensitivity and NPV: reader 1, 96% and 98% vs 96% and 99%; reader 2, and 89% and 95% vs 89% and 96%, respectively). Standard 5-mm images yielded a lower specificity for high-risk esophageal varices than the thin-section multiplanar images, and this difference was statistically significant for reader 2. Substantial interobserver agreement was noted for both esophageal varices detection and size measurements. CONCLUSION Standard liver CT is sensitive for the detection of high-risk varices and deserves further investigation as a potential cost-effective screening tool for the evaluation of patients with cirrhosis. The addition of 1- to 3-mm MPRs may increase specificity for risk stratification based on size measurements.
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Thalheimer U, Triantos C, Goulis J, Burroughs AK. Management of varices in cirrhosis. Expert Opin Pharmacother 2011; 12:721-35. [PMID: 21269241 DOI: 10.1517/14656566.2011.537258] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
INTRODUCTION Acute variceal bleeding is a medical emergency and one of the main causes of mortality in patients with cirrhosis. Timely and effective treatment of the acute bleeding episode results in increased survival, and appropriate prophylactic treatment can prevent bleeding or rebleeding from varices. AREAS COVERED We discuss the prevention of development and growth of varices, the primary and secondary prophylaxis of bleeding, the treatment of acute bleeding, and the management of gastric varices. We systematically reviewed studies, without time limits, identified through Medline and searches of reference lists, and provide an overview of the evidence underlying the -treatment options in the management of varices in cirrhosis. EXPERT OPINION The management of variceal hemorrhage relies on nonspecific interventions (e.g., adequate fluid resuscitation, airway protection) and on specific interventions. These are routine prophylactic antibiotics, vasoactive drugs and endoscopic treatment. Procedures such as the placement of a Sengstaken-Blakemore tube or a transjugular intrahepatic portosystemic shunt (TIPS) can be lifesaving. The primary and secondary prophylaxis of bleeding is based on nonselective beta-blockers and endoscopy, even though TIPS or, less frequently, surgery have a role in selected cases.
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Affiliation(s)
- Ulrich Thalheimer
- The Royal Free Sheila Sherlock Liver Centre, University Department of Surgery, Royal Free Hospital, Pond Street, NW3 2QG, London, UK.
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Hsu YC, Chung CS, Wang HP. Application of endoscopy in improving survival of cirrhotic patients with acute variceal hemorrhage. Int J Hepatol 2011; 2011:893973. [PMID: 21994875 PMCID: PMC3170849 DOI: 10.4061/2011/893973] [Citation(s) in RCA: 11] [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: 03/15/2011] [Accepted: 05/12/2011] [Indexed: 12/21/2022] Open
Abstract
Playing a central role in the modern multidisciplinary management of acute gastroesophageal variceal hemorrhage, endoscopy is essential to stratify patient at risk, control active hemorrhage, and prevent first as well as recurrent bleeding. Before endoscopic procedure, antibiotic prophylaxis along with vasoactive medication is now routine practice. Intravenous erythromycin effectively cleanses stomach and may improve the quality of endoscopy. The timing of endoscopy should be on an urgent basis as delay for more than 15 hours after presentation is associated with mortality. Active variceal bleeding on endoscopy in a patient with hepatic decompensation heralds poor prognosis and mandates consideration of aggressive strategy with early portosystemic shunting. Band ligation has become the preferred modality to control and prevent bleeding from esophageal varices, although occasionally sclerotherapy may still be used to achieve hemostasis. Addition of pharmacotherapy with nonselective beta blockade to endoscopic ligation has become the current standard of care in the setting of secondary prophylaxis but remains controversial with inconsistent data for the purpose of primary prophylaxis. Gastric varices extending from esophagus may be treated like esophageal varices, whereas variceal obliteration by tissue glue is the endoscopic therapy of choice to control and prevent bleeding from fundic and isolated gastric varices.
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Affiliation(s)
- Yao-Chun Hsu
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, E-Da Hospital/I-Shou University, Kaohsiung 824, Taiwan
| | - Chen-Shuan Chung
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Far Eastern Memorial Hospital, New Taipei 220, Taiwan
| | - Hsiu-Po Wang
- Department of Internal Medicine, National Taiwan University College of Medicine, National Taiwan University Hospital, Taipei 100, Taiwan,Department of Internal Medicine, National Taiwan University Hospital, 7, Chung-Shan South Road, Taipei 100, Taiwan,*Hsiu-Po Wang:
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28
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Sato T, Akaike J, Toyota J, Karino Y, Ohmura T. Clinicopathological features and treatment of ectopic varices with portal hypertension. Int J Hepatol 2011; 2011:960720. [PMID: 21994879 PMCID: PMC3170857 DOI: 10.4061/2011/960720] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2011] [Accepted: 05/12/2011] [Indexed: 12/12/2022] Open
Abstract
Bleeding from ectopic varices, which is rare in patients with portal hypertension, is generally massive and life-threatening. Forty-three patients were hospitalized in our ward for gastrointestinal bleeding from ectopic varices. The frequency of ectopic varices was 43/1218 (3.5%) among portal hypertensive patients in our ward. The locations of the ectopic varices were rectal in thirty-two, duodenal in three, intestinal in two, vesical in three, stomal in one, and colonic in two patients. Endoscopic or interventional radiologic treatment was performed successfully for ectopic varices. Hemorrhage from ectopic varices should be kept in mind in patients with portal hypertension presenting with lower gastrointestinal bleeding.
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Affiliation(s)
- Takahiro Sato
- Department of Gastroenterology, Sapporo Kosei General Hospital, Kita 3 Higashi 8, Chuo-ku, Sapporo 060-0033, Japan,*Takahiro Sato:
| | - Jun Akaike
- Department of Gastroenterology, Sapporo Kosei General Hospital, Kita 3 Higashi 8, Chuo-ku, Sapporo 060-0033, Japan
| | - Jouji Toyota
- Department of Gastroenterology, Sapporo Kosei General Hospital, Kita 3 Higashi 8, Chuo-ku, Sapporo 060-0033, Japan
| | - Yoshiyasu Karino
- Department of Gastroenterology, Sapporo Kosei General Hospital, Kita 3 Higashi 8, Chuo-ku, Sapporo 060-0033, Japan
| | - Takumi Ohmura
- Department of Gastroenterology, Sapporo Kosei General Hospital, Kita 3 Higashi 8, Chuo-ku, Sapporo 060-0033, Japan
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29
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Zhang C, Thabut D, Kamath PS, Shah VH. Oesophageal varices in cirrhotic patients: from variceal screening to primary prophylaxis of the first oesophageal variceal bleeding. Liver Int 2011; 31:108-19. [PMID: 20946450 DOI: 10.1111/j.1478-3231.2010.02351.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Bleeding from oesophageal varices is still a lethal complication in cirrhotic patients with portal hypertension. Approximately 5-10% of patients with cirrhosis will develop oesophageal varices per year, and about 25-30% of cirrhotic patients with oesophageal varices and without previous variceal haemorrhage will bleed from ruptured varices. To date, data on preventing the formation/growth of oesophageal varices (preprimary prophylaxis) are conflicting, with insufficient evidence to use β-blockers. There is evidence for the need for primary prophylaxis, and both β-blockers and endoscopic variceal ligation have shown the same efficacy in preventing first bleeding, but which one to prefer is still controversial. The present article reviews the established and potential therapeutic strategies for preventing the development and rupture of oesophageal varices.
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Affiliation(s)
- Chunqing Zhang
- Department of Gastroenterology, Provincial Hospital Affiliated to Shandong University, Jinan Shandong, China
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Bittencourt PL, Farias AQ, Strauss E, Mattos AAD. Variceal bleeding: consensus meeting report from the Brazilian Society of Hepatology. ARQUIVOS DE GASTROENTEROLOGIA 2010; 47:202-16. [PMID: 20721469 DOI: 10.1590/s0004-28032010000200017] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/01/2009] [Accepted: 08/17/2009] [Indexed: 02/06/2023]
Abstract
In the last decades, several improvements in the management of variceal bleeding have resulted in a significant decrease in morbidity and mortality of patients with cirrhosis and bleeding varices. Progress in the multidisciplinary approach to these patients has led to a better management of this disease by critical care physicians, hepatologists, gastroenterologists, endoscopists, radiologists and surgeons. In this respect, the Brazilian Society of Hepatology has, recently, sponsored a consensus meeting in order to draw evidence-based recommendations on the management of these difficult-to-treat subjects. An organizing committee comprised of four people was elected by the Governing Board and was responsible to invite 27 researchers from distinct regions of the country to make a systematic review of the subject and to present topics related to variceal bleeding, including prevention, diagnosis, management and treatment, according to evidence-based medicine. After the meeting, all participants met together for discussion of the topics and the elaboration of the aforementioned recommendations. The organizing committee was responsible for writing the final document. The meeting was held at Salvador, May 6th, 2009 and the present manuscript is the summary of the systematic review that was presented during the meeting, organized in topics, followed by the recommendations of the Brazilian Society of Hepatology.
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Lee CH. [Prevention of esophageal variceal bleeding]. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2010; 56:155-67. [PMID: 20847606 DOI: 10.4166/kjg.2010.56.3.155] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Esophageal varices(EV) are present in 40% and 60% of Child-Pugh A and C patients, respectively when cirrhosis is diagnosed. EV bleeding is a life-threatening complication of liver cirrhosis with a high probability of recurrence. Treatment to prevent first EV bleeding or rebleeding is mandatory. In small EV with high risk of bleeding, nonselective β-blockers should be used for the prevention of first variceal bleeding. For medium to large EV, nonselective β-blockers or endoscopic variceal ligation (EVL) may be recommended to high risk varices. But, nonselective β-blockers are the first treatment option to non-high risk varices and EVL is an alternative when nonselective β-blockers are contraindicated or not tolerated. For the prevention of rebleeding, a combination of nonselective β-blockers and EVL may be the best option. 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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Affiliation(s)
- Chang Hyeong Lee
- Department of Internal Medicine, Catholic University of Daegu College of Medicine, Daegu, Korea.
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Tripathi D. Overview of the methods and therapies for the primary prevention of variceal bleeding. Expert Rev Gastroenterol Hepatol 2010; 4:399-407. [PMID: 20678013 DOI: 10.1586/egh.10.35] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Patients with cirrhosis develop varices at a rate of 5% per year, and a third of patients with high-risk varices will bleed. The mortality associated with variceal haemorrhage is typically 20%, and still exceeds that of myocardial infarction. Current options to prevent the first variceal bleed include noncardioselective beta-blockers or variceal band ligation. In patients with medium-to-large esophageal varices, both therapies reduce the risk of bleeding by 50% or more. The choice of therapy should take into account patient choice and local availability; although for most patients drug therapy is the preferred first-line treatment. There has been recent interest in carvedilol, with promising initial data. Further studies are necessary before universal recommendation. There is no role for drug therapy in patients without varices, and the use of beta-blockers for patients with small varices is controversial.
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Affiliation(s)
- Dhiraj Tripathi
- Liver Unit, Queen Elizabeth Hospital, Edgbaston, Birmingham B152TH, UK.
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Transabdominal color Doppler ultrasonography for the diagnosis of small intestinal and vesical varices in a patient successfully treated with percutaneous transhepatic obliteration. Clin J Gastroenterol 2010; 3:214-8. [DOI: 10.1007/s12328-010-0164-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2010] [Accepted: 06/30/2010] [Indexed: 02/06/2023]
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Albillos A, Peñas B, Zamora J. Role of endoscopy in primary prophylaxis for esophageal variceal bleeding. Clin Liver Dis 2010; 14:231-50. [PMID: 20682232 DOI: 10.1016/j.cld.2010.03.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Cirrhosis is the leading cause of portal hypertension in the Western world. From a clinical standpoint, the most significant consequence of portal hypertension is the development of esophageal varices. Despite the many advances in the management of variceal bleeding, it remains a life-threatening complication of portal hypertension. Primary prophylaxis to prevent the first bleeding episode in patients with cirrhosis and esophageal varices is therefore critically important in the management of patients with cirrhosis.
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Affiliation(s)
- Agustín Albillos
- Hospital Universitario Ramón y Cajal, Universidad de Alcalá, Madrid, Spain.
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Abstract
Portal hypertension is a progressively debilitating complication of cirrhosis and a principal cause of mortality in patients who have hepatic decompensation. This article describes the classification system and pathophysiology of portal hypertension. It also discusses a practical approach to prevention of first variceal hemorrhage, general management of the acute bleeding episode, and secondary prophylaxis to prevent rebleeding. Pharmacologic, endoscopic, radiologic, and surgical modalities are all described in detail.
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Affiliation(s)
- David A Sass
- Division of Gastroenterology and Hepatology, Drexel University College of Medicine, 216 N. Broad Street, Feinstein Building, Suite 504, MS 1001, Philadelphia, PA 19102, USA.
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Garcia-Tsao G, Lim JK. Management and treatment of patients with cirrhosis and portal hypertension: recommendations from the Department of Veterans Affairs Hepatitis C Resource Center Program and the National Hepatitis C Program. Am J Gastroenterol 2009; 104:1802-29. [PMID: 19455106 DOI: 10.1038/ajg.2009.191] [Citation(s) in RCA: 170] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Cirrhosis represents the end stage of any chronic liver disease. Hepatitis C and alcohol are currently the main causes of cirrhosis in the United States. Although initially cirrhosis is compensated, it eventually becomes decompensated, as defined by the presence of ascites, variceal hemorrhage, encephalopathy, and/or jaundice. These management recommendations are divided according to the status, compensated or decompensated, of the cirrhotic patient, with a separate section for the screening, diagnosis, and management of hepatocellular carcinoma (HCC), as this applies to patients with both compensated and decompensated cirrhosis. In the compensated patient, the main objective is to prevent variceal hemorrhage and any practice that could lead to decompensation. In the decompensated patient, acute variceal hemorrhage and spontaneous bacterial peritonitis are severe complications that require hospitalization. Hepatorenal syndrome is also a severe complication of cirrhosis but one that usually occurs in patients who are already in the hospital and, as it represents an extreme of the hemodynamic alterations that lead to ascites formation, it is placed under treatment of ascites. Recent advances in the pathophysiology of the complications of cirrhosis have allowed for a more rational management of cirrhosis and also for the stratification of patients into different risk groups that require different management. These recommendations are based on evidence in the literature, mainly from randomized clinical trials and meta-analyses of these trials. When few or no data exist from well-designed prospective trials, emphasis is given to results from large series and consensus conferences with involvement of recognized experts. A rational management of cirrhosis will result in improvements in quality of life, treatment adherence, and, ultimately, in outcomes.
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Sato T, Yamazaki K, Toyota J, Karino Y, Ohmura T, Akaike J. Ileal Varices Treated with Balloon-Occluded Retrograde Transvenous Obliteration. Gastroenterology Res 2009; 2:122-125. [PMID: 27956966 PMCID: PMC5139830 DOI: 10.4021/gr2009.04.1286] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/16/2009] [Indexed: 01/21/2023] Open
Abstract
A 55-year-old man with hepatitis B virus antigen-positive liver cirrhosis was admitted to our hospital with anal bleeding. Colonoscopy revealed blood retention in the entire colon, but no bleeding lesion was found. Computed tomography images showed that vessels in the ileum were connected to the right testicular vein, and we suspected ileal varices to be the most probable cause of bleeding. We immediately performed double balloon enteroscopy, but failed to find any site of bleeding owing to the difficulty of fiberscope insertion with sever adhesion. Using a balloon catheter during retrograde transvenous venography, we found ileal varices communicating with the right testicular vein (efferent vein) with the superior mesenteric vein branch as the afferent vein of these varices. We performed balloon occluded retrograde transvenous obliteration by way of the efferent vein of the varices and have detected no further bleeding in this patient one year after treatment.
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Affiliation(s)
- Takahiro Sato
- Department of Gastroenterology, Sapporo Kosei General Hospital, Kita 3 Higashi 8, Chuo-ku, Sapporo 060-0033, Japan
| | - Katsu Yamazaki
- Department of Gastroenterology, Sapporo Kosei General Hospital, Kita 3 Higashi 8, Chuo-ku, Sapporo 060-0033, Japan
| | - Jouji Toyota
- Department of Gastroenterology, Sapporo Kosei General Hospital, Kita 3 Higashi 8, Chuo-ku, Sapporo 060-0033, Japan
| | - Yoshiyasu Karino
- Department of Gastroenterology, Sapporo Kosei General Hospital, Kita 3 Higashi 8, Chuo-ku, Sapporo 060-0033, Japan
| | - Takumi Ohmura
- Department of Gastroenterology, Sapporo Kosei General Hospital, Kita 3 Higashi 8, Chuo-ku, Sapporo 060-0033, Japan
| | - Jun Akaike
- Department of Gastroenterology, Sapporo Kosei General Hospital, Kita 3 Higashi 8, Chuo-ku, Sapporo 060-0033, Japan
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Sato T, Yamazaki K, Toyota J, Karino Y, Ohmura T, Akaike J. Endoscopic ultrasonographic evaluation of hemodynamics related to variceal relapse in esophageal variceal patients. Hepatol Res 2009; 39:126-33. [PMID: 19208033 DOI: 10.1111/j.1872-034x.2008.00415.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
AIM To evaluate retrospectively the hemodynamics of esophageal varices before and after endoscopic injection sclerotherapy (EIS) using endoscopic color Doppler ultrasonography (ECDUS). METHODS The study included 306 patients whose esophageal varices had been treated with EIS. The underlying pathologies of portal hypertension in these 306 patients included liver cirrhosis (193), cirrhosis associated with hepatocellular carcinoma (102), primary biliary cirrhosis (6), idiopathic portal hypertension (4) and extrahepatic portal vein obstruction (1). ECDUS was used for the examination of all 306 cases before EIS and 3-5 months after EIS. ECDUS was performed to evaluate flow in the left gastric vein, paraesophageal veins, perforating veins and cardiac intramural veins. RESULTS The patients were divided into three groups according to time of esophageal variceal recurrence: early recurrence within one year (Group A, n = 16), no recurrence over three years (Group B, n = 12), and recurrence between one and three years (Group C, n = 278). Before EIS, the frequency of detection of perforating veins and the inflowing type of perforating veins using ECDUS was significantly higher for Group A than Groups B or C. After EIS, the frequency of detection of cardiac intramural veins, perforating veins and the inflowing type of perforating veins using ECDUS was significantly higher in Group A than Groups B or C. CONCLUSION Endoscopic ultrasonographic evaluation of the hemodynamics in esophageal varices before and after EIS enables prediction of early variceal recurrence.
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Affiliation(s)
- Takahiro Sato
- Department of Gastroenterology, Sapporo Kosei General Hospital, Sapporo, Japan
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Lo GH, Chen WC, Lin CK, Tsai WL, Chan HH, Chen TA, Yu HC, Hsu PI, Lai KH. Improved survival in patients receiving medical therapy as compared with banding ligation for the prevention of esophageal variceal rebleeding. Hepatology 2008; 48:580-7. [PMID: 18666235 DOI: 10.1002/hep.22358] [Citation(s) in RCA: 82] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
UNLABELLED Both medical therapy and endoscopic variceal ligation (EVL) have proven to be comparable in the prevention of variceal rebleeding. However, the long-term results are still lacking. Our previous study enrolled 121 patients with history of esophageal variceal bleeding and randomized to receive EVL (EVL group, 60 patients) or drug therapy, nadolol plus isosorbide-5-mononitrate (N+I) (N+I group, 61 patients) to prevent variceal rebleeding. The EVL group received ligation regularly until variceal obliteration. The N+I group received N+I during the study period. Patients were followed for up to 8 years. After a median follow-up of 82 months, recurrent upper gastrointestinal bleeding developed in 28 patients (47%) in the EVL group and 49 patients (80%) in the N+I group (P = 0.001). Recurrent bleeding from esophageal varices occurred in 18 patients (30%) in the EVL group and 39 patients (64%) in the N+I group. The actuarial probability of rebleeding from esophageal varices was lower in the EVL group (P = 0.001). A total of 42 patients of the EVL group and 30 patients of the N+I group died (P = 0.013). The multivariate Cox analysis indicated that age, serum albumin, presence of encephalopathy, and treatment were the factors predictive of mortality. CONCLUSION Our long-term follow-up study showed that combination of N+I therapy was inferior to banding ligation in the reduction of variceal rebleeding, but with enhanced survival.
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Affiliation(s)
- Gin-Ho Lo
- Department of Medical Education and Research, Division of Gastroenterology, National Yang-Ming University, Taipei, Taiwan, Republic of China.
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Sharma S, Gurakar A, Jabbour N. Avoiding pitfalls: what an endoscopist should know in liver transplantation--part 1. Dig Dis Sci 2008; 53:1757-73. [PMID: 17990105 DOI: 10.1007/s10620-007-0079-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2007] [Accepted: 10/14/2007] [Indexed: 02/07/2023]
Abstract
Cirrhosis is associated with global homodynamic changes, but the majority of the complications are usually manifested through the gastrointestinal tract. Therefore, Gastrointestinal Endoscopy has become an important tool in the multidisciplinary approach in the management of these patients. With the ever growing number of cirrhotic patients requiring pre-transplant endoscopic management, it is imperative that the community endoscopists are well aware of the pathologies that can be potentially noted on Gastrointestinal Endoscopy. Their timely management is also considered to have the utmost importance in being able to stabilize the patient until their transfer to a Liver Transplant Center. The aim of this manuscript is to give a comprehensive update and review of various endoscopic findings that a non-transplant endoscopist will encounter in the pre-transplant setting.
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Affiliation(s)
- Sharad Sharma
- Baptist Medical Center, Nazih Zuhdi Transplant Institute, 3300 North West Expressway, Oklahoma City, OK 73112, USA.
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41
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Transverse colonic varices successfully treated with endoscopic procedure. Clin J Gastroenterol 2008; 1:52-55. [PMID: 26193462 DOI: 10.1007/s12328-008-0010-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2008] [Accepted: 03/03/2008] [Indexed: 01/27/2023]
Abstract
A 75-year-old woman with hepatitis C virus antibody-positive liver cirrhosis was admitted to our hospital with anal bleeding. Colonoscopy revealed red color-positive tortuous transverse colonic varices near the splenic flexure. Colonic varices were considered to be the most probable cause of bleeding, although the precise site could not be determined. Endoscopic injection sclerotherapy was performed for colonic varices. Endoscopic clipping was performed for bilateral sites of varices as an additional treatment. Four months after endoscopic treatments, colonoscopy revealed ulcer scars in the transverse colon and shrinkage of the varices.
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Abstract
Portal hypertension, a major hallmark of cirrhosis, is defined as a portal pressure gradient exceeding 5 mm Hg. In portal hypertension, porto-systemic collaterals decompress the portal circulation and give rise to varices. Successful management of portal hypertension and its complications requires knowledge of the underlying pathophysiology, the pertinent anatomy, and the natural history of the collateral circulation, particularly the gastroesophageal varices.
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Affiliation(s)
- Nagib Toubia
- Division of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University School of Medicine, MCV, Box 980341, Richmond, VA 23298-0341, USA
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Hemodynamic evaluation by endoscopic ultrasonography of esophageal varices resistant to injection sclerotherapy. J Med Ultrason (2001) 2008; 35:19-25. [PMID: 27278560 DOI: 10.1007/s10396-007-0165-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2007] [Accepted: 09/27/2007] [Indexed: 10/22/2022]
Abstract
PURPOSE Some esophageal variceal cases are resistant to endoscopic injection sclerotherapy (EIS) using 5% ethanolamine oleate (5% EO). We evaluated the hemodynamics of esophageal varices that were resistant to EIS using 5% EO. METHODS Selected for this study were 290 consecutive patients who underwent hemodynamic evaluation using endoscopic color Doppler ultrasonography (ECDUS) and an ultrasonic microprobe (UMP) before EIS. EIS was performed using 5% EO with iopamidol (5% EOI) under fluoroscopy. We retrospectively evaluated the hemodynamic differences between patients resistant to and not resistant to EIS using 5% EOI. RESULTS Nine patients were resistant to EIS using 5% EOI (group A). Various parameters were compared between the 281 patients who had been given EIS using 5% EOI for esophageal varices (group B) and the 9 patients in group A. The mean number of EIS treatments until shrinkage of esophageal varices was achieved in group A (6.8 ± 3.4) was significantly greater than that in group B (4.4 ± 2.1) (P < 0.01). The mean amount of 5% EOI used in group A (31.1 ± 17.4 ml) was significantly larger than that used in group B (14.9 ± 8.8 ml) (P < 0.001). The mean frequency shift of esophageal varices in group A (452.9 ± 106.6 Hz) was significantly higher than that in group B (313.0 ± 103.2 Hz) (P < 0.001) as determined by ECDUS. The mean diameter of esophageal varices as found by UMP was 8.0 ± 3.5 mm in group A and 4.6 ± 2.4 mm in group B, with the difference being significant (P < 0.01). Perforating veins inflowing from extramural to intramural regions were recognized in 8 (88.9%) of the 9 patients in group A and in 67 (24.1 %) of the 281 patients in group B. The mean diameter of the perforating vein was 3.8 ± 1.9 mm in group A and 2.1 ± 0.5 mm in group B, as shown by UMP, a difference that was statistically significant (P < 0.01). CONCLUSION Hemodynamic evaluation revealed that the esophageal varices were of a higher grade in group A than in group B. By using ECDUS and UMP, this study shed light on the hemodynamics of esophageal variceal cases resistant to EIS using 5% EOI.
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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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45
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SATO T, YAMAZAKI K, TOYOTA J, KARINO Y, OHMURA T, SUGA T. Perforating Veins in Recurrent Esophageal Varices after Endoscopic Therapy Visualized by Endoscopic Color Doppler Ultrasonography. Dig Endosc 2007. [DOI: 10.1111/j.1443-1661.1999.tb00009.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/23/2023]
Affiliation(s)
- Takahiro SATO
- Department of Gastroenterology, Sapporo Kosei General Hospital, Sapporo, Japan
| | - Katsu YAMAZAKI
- Department of Gastroenterology, Sapporo Kosei General Hospital, Sapporo, Japan
| | - Jouji TOYOTA
- Department of Gastroenterology, Sapporo Kosei General Hospital, Sapporo, Japan
| | - Yoshiyasu KARINO
- Department of Gastroenterology, Sapporo Kosei General Hospital, Sapporo, Japan
| | - Takumi OHMURA
- Department of Gastroenterology, Sapporo Kosei General Hospital, Sapporo, Japan
| | - Toshihiro SUGA
- Department of Gastroenterology, Sapporo Kosei General Hospital, Sapporo, Japan
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Affiliation(s)
- Rome JUTABHA
- Department of Medicine, Division of Digestive Diseases, UCLA Center for the Health Sciences, Center for Ulcer Research and Education : Digestive Diseases Research Center (CURE : DDRC); and the West Los Angeles Veterans Administration Medical Center, Los Angeles, California, USA
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47
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SATO T, YAMAZAKI K, TOYOTA J, KARINO Y, OHMURA T, SUGA T. Pulsatile Wave in Esophageal Wall Blood Vessels after Endoscopic Therapy for Esophageal Varices. Dig Endosc 2007. [DOI: 10.1111/j.1443-1661.1998.tb00532.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/23/2023]
Affiliation(s)
- Takahiro SATO
- Department of Gastroenterology, Sapporo Kosei General Hospital, Sapporo, Japan
| | - Katsu YAMAZAKI
- Department of Gastroenterology, Sapporo Kosei General Hospital, Sapporo, Japan
| | - Jouji TOYOTA
- Department of Gastroenterology, Sapporo Kosei General Hospital, Sapporo, Japan
| | - Yoshiyasu KARINO
- Department of Gastroenterology, Sapporo Kosei General Hospital, Sapporo, Japan
| | - Takumi OHMURA
- Department of Gastroenterology, Sapporo Kosei General Hospital, Sapporo, Japan
| | - Toshihiro SUGA
- Department of Gastroenterology, Sapporo Kosei General Hospital, Sapporo, Japan
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48
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Spiegel BMR, Esrailian E, Eisen G. The budget impact of endoscopic screening for esophageal varices in cirrhosis. Gastrointest Endosc 2007; 66:679-92. [PMID: 17905009 DOI: 10.1016/j.gie.2007.02.048] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2006] [Accepted: 02/18/2007] [Indexed: 02/08/2023]
Abstract
BACKGROUND The cost-effectiveness of screening for esophageal varices in cirrhosis remains uncertain. Previous analyses found that screening with upper endoscopy (EGD) may not be cost effective versus empiric beta-blocker (BB) therapy. However, these models were conducted before advances in variceal screening, including capsule endoscopy (CE), and they did not measure the budget impact (vs cost-effectiveness) of variceal screening. OBJECTIVE To compare the managed care budget impact of variceal screening strategies. DESIGN Budget impact model. SETTING Hypothetical managed care organization with 1 million covered lives. PATIENTS Patients with compensated cirrhosis. INTERVENTIONS Compared 5 strategies: (1) empiric BB, (2) screening EGD followed by BB if varices present (EGD --> BB), (3) EGD followed by endoscopic band ligation if varices present (EGD --> EBL), (4) CE followed by BB if varices present (CE --> BB), and (5) CE followed by EBL if varices present (CE --> EBL). MAIN OUTCOME MEASUREMENT Per-member per-month cost. RESULTS BB was the least expensive, and CE --> EBL was the most expensive. Substituting CE --> BB in lieu of BB cost each member an additional $0.20 per month to subsidize. Compared with CE --> BB, both EGD-based strategies were more expensive. However, CE was not viable in managed care organizations capable of reducing the cost of endoscopy below $410, unless the cost of CE was reduced in lockstep. LIMITATIONS Data on CE remain limited. CONCLUSIONS Screening for varices may have an acceptable budget impact but is highly sensitive to local costs of EGD and CE. In managed care organizations willing to subsidize EBL for variceal prophylaxis, it is inefficient to screen with CE compared with EGD.
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Affiliation(s)
- Brennan M R Spiegel
- Greater Los Angeles Healthcare System, David Geffen School of Medicine at UCLA, UCLA/VA Center for Outcomes Research and Education (CORE), 11301 Wilshire Blvd, Bldg 115 Rm 215, Los Angeles, CA 90073, USA
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Norberto L, Polese L, Cillo U, Grigoletto F, Burroughs AK, Neri D, Zanus G, Boccagni P, Burra P, D'Amico DF. A randomized study comparing ligation with propranolol for primary prophylaxis of variceal bleeding in candidates for liver transplantation. Liver Transpl 2007; 13:1272-8. [PMID: 17370331 DOI: 10.1002/lt.21083] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Whether beta-blockers (BB) or banding is the best therapy for primary prophylaxis of variceal bleeding is subject to debate. A randomized comparison between the 2 treatments was performed in candidates for liver transplantation (LT). A total of 62 patients with Child-Turcotte-Pugh B-C cirrhosis and high risk varices received propranolol (31) or variceal banding (31). The primary endpoint was variceal bleeding. There were 2 variceal hemorrhages (6.5%) in the banding group, related to postbanding ulcers, and 3 (9.7%) in the propranolol group (P = not significant [n.s.]). Deaths and bleeding related deaths were 3 and 1 for banding and 3 and 2 for BB, respectively (P = n.s.). A total of 14 patients underwent LT in the banding group and 10 in the propranolol group (P = n.s.). Adverse events were 2 postbanding ulcer bleedings in ligated patients (1 fatal) and 5 were intolerant to propranolol (P = n.s.). Mean costs per patient were higher with banding than with propranolol treatment (4,289 +/- 285 vs. 1,425 +/- 460 U.S. dollars, P < 0.001). In conclusion, propranolol and banding are similarly effective in reducing the incidence of variceal bleeding in candidates for LT, but ligation can be complicated by fatal bleeding and is more expensive. Our results suggest that banding should not be utilized as primary prophylaxis in transplant candidates who can be treated with BB.
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Affiliation(s)
- Lorenzo Norberto
- Department of Surgical and Gastroenterological Sciences, 1st Surgical Clinic, Surgical Endoscopy Unit, University of Padova, Padova, Italy.
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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: 1196] [Impact Index Per Article: 66.4] [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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