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Riescher-Tuczkiewicz A, Rautou PE. Prediction and prevention of post-procedural bleedings in patients with cirrhosis. Clin Mol Hepatol 2025; 31:S205-S227. [PMID: 39962975 PMCID: PMC11925446 DOI: 10.3350/cmh.2024.0928] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2024] [Accepted: 02/17/2025] [Indexed: 03/20/2025] Open
Abstract
Although post-procedural bleedings are infrequent in patients with cirrhosis, they are associated with significant morbidity and mortality. Therefore, predicting and preventing such bleedings is important. Established predictors of post-procedural bleeding include high-bleeding risk procedure, severe cirrhosis and high body mass index; prognostic value of anemia, acute kidney injury and bacterial infection is more uncertain. While prothrombin time and international normalized ratio do not predict post-procedural bleeding, some evidence suggests that platelet count, whole blood thrombin generation assay and viscoelastic tests may be helpful in this context. Prevention of postprocedural bleeding involves careful management of antithrombotic drugs during the periprocedural period. Patients with cirrhosis present unique challenges due to altered pharmacokinetics and pharmacodynamics of antithrombotic drugs, but there is a lack of dedicated studies specifically focused on this patient population. Guidelines for periprocedural management of antithrombotic drugs developed for patients without liver disease are thus applied to those with cirrhosis. Some technical aspects may decrease the risk of post-procedural bleeding, namely ultrasoundguidance, opting for transjugular route rather than percutaneous route, and the level of expertise of the operator. The effectiveness of platelet transfusions or thrombopoietin-receptor agonists remains uncertain. Transfusion of fresh-frozen plasma, of fibrinogen, and administration of tranexamic acid are not recommended for reducing post-procedural bleeding in patients with cirrhosis. In conclusion, prediction of post-procedural requires a global approach taking into account the patients characteristics, the risk of the procedure, and the platelet count. There is little data to support prophylactic correction of hemostasis, and dedicated studies are needed.
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Affiliation(s)
| | - Pierre-Emmanuel Rautou
- Paris City University, Inserm, Inflammatory Research Center, UMR 1149, Paris, France
- AP-HP, Beaujon Hospital, Hepatology Department, DMU DIGEST, Reference Center for Vascular Diseases of the Liver, FILFOIE, ERN RARE-LIVER, Clichy, France
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El-Azab G. Proton Pump Inhibitors in Patients with Cirrhosis: Pharmacokinetics, Benefits and Drawbacks. Curr Gastroenterol Rep 2024; 26:323-334. [PMID: 39167119 DOI: 10.1007/s11894-024-00943-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/01/2024] [Indexed: 08/23/2024]
Abstract
PURPOSE OF REVIEW This review explores the pharmacokinetics, benefits, and risks of proton pump inhibitors (PPIs) in cirrhotic patients, focusing on the appropriateness of their use and potential adverse effects. RECENT FINDINGS Recent studies highlight significant pharmacokinetic alterations in PPIs among cirrhotic patients, with marked increases in lansoprazole and pantoprazole exposure and relatively stable levels of esomeprazole. While effective for managing acid-related disorders and post-band ulcer rebleeding, evidence supporting PPI use for portal hypertension-related bleeding is lacking. Emerging research suggests potential adverse effects such as hepatic decompensation, spontaneous bacterial peritonitis, hepatic encephalopathy, and increased mortality, possibly linked to dysbiosis and bacterial translocation. PPI use in cirrhotic patients alters pharmacokinetics significantly, with esomeprazole potentially safer in advanced cirrhosis. The review advises caution in routine PPI use beyond acid-related conditions due to limited evidence and substantial risks. It underscores the need for careful risk-benefit assessments and exploration of alternative therapies. Future research should aim to identify safer management strategies for portal hypertension complications and to develop evidence-based guidelines for PPI use in patients with cirrhosis.
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Affiliation(s)
- Gasser El-Azab
- Hepatology and Gastroenterology Department, National Liver Institute, Menoufia University, Shebin El-Kom, Menoufia, Egypt.
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Wang W, Ju H, Zhang W, Ma C, He C. Relationship between platelet-to-lymphocyte ratio and early rebleeding after endoscopic variceal ligation: a bicenter retrospective study. Ann Med 2024; 56:2400315. [PMID: 39239880 PMCID: PMC11382711 DOI: 10.1080/07853890.2024.2400315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2024] [Revised: 08/27/2024] [Accepted: 08/28/2024] [Indexed: 09/07/2024] Open
Abstract
BACKGROUND Endoscopic variceal ligation (EVL) is the primary treatment for esophageal variceal bleeding in patients with liver cirrhosis (LC). Postoperative rebleeding is a complication of EVL, contributing to over 20% of bleeding-related deaths. This study aims to examine the association between platelet-to-lymphocyte ratio (PLR) and rebleeding within 6 weeks after EVL in patients with LC. METHODS The study included 145 eligible patients who underwent their first EVL procedure at Yijishan Hospital of Wannan Medical College between January 2016 and August 2022 (YJS cohort). An external validation cohort comprising 338 eligible patients from NO.2 People's Hospital of Fuyang City (FY cohort) between July 2018 and August 2022 was also utilized. RESULTS In the YJS cohort, Multivariate logistic analysis indicated that high PLR is independently associated with early rebleeding after EVL. The restricted cubic spline analysis demonstrated that the risk of rebleeding increases with rising PLR, stabilizing at PLR values greater than 150. Similar findings were validated in the FY cohort. CONCLUSIONS Our results have the potential to aid in the identification of high-risk patients for early rebleeding after EVL, thereby enabling improved clinical management and outcomes for these individuals.
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Affiliation(s)
- Wei Wang
- Department of Gastroenterology, Yijishan Hospital of Wannan Medical College, Wuhu, China
| | - Honglei Ju
- Department of Gastroenterology, Yijishan Hospital of Wannan Medical College, Wuhu, China
| | - Wei Zhang
- Department of Gastroenterology, Fuyang Second People’s Hospital, Fuyang, China
| | - Chao Ma
- Department of Gastroenterology, Fuyang Second People’s Hospital, Fuyang, China
| | - Chiyi He
- Department of Gastroenterology, Yijishan Hospital of Wannan Medical College, Wuhu, China
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Crăciun R, Grapă C, Mocan T, Tefas C, Nenu I, Buliarcă A, Ștefănescu H, Nemes A, Procopeț B, Spârchez Z. The Bleeding Edge: Managing Coagulation and Bleeding Risk in Patients with Cirrhosis Undergoing Interventional Procedures. Diagnostics (Basel) 2024; 14:2602. [PMID: 39594268 PMCID: PMC11593119 DOI: 10.3390/diagnostics14222602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2024] [Revised: 11/17/2024] [Accepted: 11/18/2024] [Indexed: 11/28/2024] Open
Abstract
This review addresses the peri-procedural bleeding risks in patients with cirrhosis, emphasizing the need for careful coagulation assessment and targeted correction strategies. Liver disease presents a unique hemostatic challenge, where traditional coagulation tests may not accurately predict bleeding risk, complicating the management of procedures like paracentesis, endoscopic therapy, and various interventional procedures. As such, this paper aims to provide a comprehensive analysis of current data, guidelines, and practices for managing coagulation in cirrhotic patients, with a focus on minimizing bleeding risk while avoiding unnecessary correction with blood products. The objectives of this review are threefold: first, to outline the existing evidence on bleeding risks associated with common invasive procedures in cirrhotic patients; second, to evaluate the efficacy and limitations of standard and advanced coagulation tests in predicting procedural bleeding; and third, to examine the role of blood product transfusions and other hemostatic interventions, considering potential risks and benefits in this delicate population. In doing so, this review highlights patient-specific and procedure-specific factors that influence bleeding risk and informs best practices to optimize patient outcomes. This review progresses through key procedures often performed in cirrhotic patients. The discussion begins with paracentesis, a low-risk procedure, followed by endoscopic therapy for varices, and concludes with high-risk interventions requiring advanced hemostatic considerations. Each chapter addresses procedural techniques, bleeding risk assessment, and evidence-based correction approaches. This comprehensive structure aims to guide clinicians in making informed, evidence-backed decisions in managing coagulation in cirrhosis, ultimately reducing procedural complications and improving care quality for this high-risk population.
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Affiliation(s)
- Rareș Crăciun
- Department of Internal Medicine, “Iuliu Hațieganu” University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania; (R.C.); (C.G.); (A.B.); (B.P.); (Z.S.)
- Gastoenterology Clinic, “Prof. Dr. O. Fodor” Regional Institute of Gastroenterology and Hepatology, 400162 Cluj-Napoca, Romania;
| | - Cristiana Grapă
- Department of Internal Medicine, “Iuliu Hațieganu” University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania; (R.C.); (C.G.); (A.B.); (B.P.); (Z.S.)
- Gastoenterology Clinic, “Prof. Dr. O. Fodor” Regional Institute of Gastroenterology and Hepatology, 400162 Cluj-Napoca, Romania;
| | - Tudor Mocan
- Gastoenterology Clinic, “Prof. Dr. O. Fodor” Regional Institute of Gastroenterology and Hepatology, 400162 Cluj-Napoca, Romania;
- UBBmed Department, Babeș-Bolyai University, 400084 Cluj-Napoca, Romania
| | - Cristian Tefas
- Department of Internal Medicine, “Iuliu Hațieganu” University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania; (R.C.); (C.G.); (A.B.); (B.P.); (Z.S.)
- Gastoenterology Clinic, “Prof. Dr. O. Fodor” Regional Institute of Gastroenterology and Hepatology, 400162 Cluj-Napoca, Romania;
| | - Iuliana Nenu
- Department of Physiology, “Iuliu Hațieganu” University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania;
| | - Alina Buliarcă
- Department of Internal Medicine, “Iuliu Hațieganu” University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania; (R.C.); (C.G.); (A.B.); (B.P.); (Z.S.)
| | - Horia Ștefănescu
- Gastoenterology Clinic, “Prof. Dr. O. Fodor” Regional Institute of Gastroenterology and Hepatology, 400162 Cluj-Napoca, Romania;
| | - Andrada Nemes
- 2nd Department of Anesthesia and Intensive Care, “Iuliu Hațieganu” University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania;
- Intensive Care Unit, Cluj-Napoca Municipal Hospital, 400139 Cluj-Napoca, Romania
| | - Bogdan Procopeț
- Department of Internal Medicine, “Iuliu Hațieganu” University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania; (R.C.); (C.G.); (A.B.); (B.P.); (Z.S.)
- Gastoenterology Clinic, “Prof. Dr. O. Fodor” Regional Institute of Gastroenterology and Hepatology, 400162 Cluj-Napoca, Romania;
| | - Zeno Spârchez
- Department of Internal Medicine, “Iuliu Hațieganu” University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania; (R.C.); (C.G.); (A.B.); (B.P.); (Z.S.)
- Gastoenterology Clinic, “Prof. Dr. O. Fodor” Regional Institute of Gastroenterology and Hepatology, 400162 Cluj-Napoca, Romania;
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Yokoyama S, Honda T, Ishizu Y, Imai N, Ito T, Yamamoto K, Mizuno K, Nakamura M, Kawashima H. Predicting early rebleeding and mortality after endoscopic hemostasis of esophagogastric varices: Diagnostic performance of aspartate aminotransferase-to-platelet ratio index and model for end-stage liver disease-Na score. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2024; 31:830-839. [PMID: 39022894 DOI: 10.1002/jhbp.12057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/20/2024]
Abstract
BACKGROUND Endoscopic variceal ligation and sclerotherapy are recommended for esophagogastric variceal bleeding (EGVB) in cirrhosis but can be complicated by early rebleeding and death. This study aimed to identify noninvasive markers accurately predicting early rebleeding and mortality after endoscopic hemostasis for EGVB. METHODS Among 116 patients with endoscopically confirmed EGVB and endoscopic hemostasis, various noninvasive markers were calculated, and their predictive accuracy was compared by receiver-operating characteristic curve analysis. Endpoints included 5-day rebleeding, 5-day mortality, 6-week rebleeding, and 6-week mortality. RESULTS The median age was 63 years. Child-Pugh class B and C patients accounted for 40.5% and 34.5%, respectively. Only the aspartate aminotransferase-to-platelet ratio index (APRI) significantly predicted 5-day rebleeding, with an area under the curve (AUC) of 0.777 (95% confidence interval [CI]: 0.537-1). The model for end-stage liver disease-Na (MELD-Na) score showed good predictive accuracy for 5-day mortality (AUC: 0.839, 95% CI: 0.681-0.997), 6-week rebleeding (AUC: 0.797, 95% CI: 0.663-0.932), and 6-week mortality (AUC: 0.888, 95% CI: 0.797-0.979). CONCLUSIONS Patients with cirrhosis with a high APRI and MELD-Na score were at high risk of early rebleeding and death after EGVB. Allocating appropriate monitoring and care for those patients is necessary.
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Affiliation(s)
- Shinya Yokoyama
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Takashi Honda
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Yoji Ishizu
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Norihiro Imai
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Takanori Ito
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Kenta Yamamoto
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Kazuyuki Mizuno
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Masanao Nakamura
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Hiroki Kawashima
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
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Cao C, Jin J, Cai R, Chu Y, Wu K, Wang Z, Xiao T, Zhang H, Huang H, Liu H, Zhang Q, Mei X, Kong D. Correlation between diameter of esophageal varices and early rebleeding following endoscopic variceal ligation: a multicenter retrospective study based on artificial intelligence-based endoscopic virtual rule. Front Med (Lausanne) 2024; 11:1406108. [PMID: 38933116 PMCID: PMC11199532 DOI: 10.3389/fmed.2024.1406108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2024] [Accepted: 05/29/2024] [Indexed: 06/28/2024] Open
Abstract
Background and objective Bleeding following endoscopic variceal ligation (EVL) may occur as a result of numerous factors, including a diameter of esophageal varices (EV) that is too large to be completely ligated. The present study aimed to develop an artificial intelligence-based endoscopic virtual ruler (EVR) to measure the diameter of EV with a view to finding more suitable cases for EVL. Methods The present study was a multicenter retrospective study that included a total of 1,062 EVLs in 727 patients with liver cirrhosis with EV, who underwent EVL from April 2016 to March 2023. Patients were divided into early rebleeding (n = 80) and non-rebleeding groups (n = 982) according to whether postoperative bleeding occurred at 6 weeks. The characteristics of patient baseline data, the status of rebleeding at 6 weeks after surgery and the survival status at 6 weeks after rebleeding were analyzed. Results The early rebleeding rate following 1,062 EVL procedures was 7.5%, and the mortality rate at 6 weeks after bleeding was 16.5%. Results of the one-way binary logistic regression analysis demonstrated that the risk factors for early rebleeding following EVL included: high TB (P = 0.009), low Alb (P = 0.001), high PT (P = 0.004), PVT (P = 0.026), HCC (P = 0.018), high Child-Pugh score (P < 0.001), Child-Pugh grade C(P < 0.001), high MELD score(P = 0.004), Japanese variceal grade F3 (P < 0.001), diameter of EV (P < 0.001), and number of ligature rings (P = 0.029). Results of the multifactorial binary logistic regression analysis demonstrated that Child-Pugh grade C (P = 0.007), Japanese variceal grade F3 (P = 0.009), and diameter of EV (P < 0.001) may exhibit potential in predicting early rebleeding following EVL. ROC analysis demonstrated that the area under curve (AUC) for EV diameter was 0.848, and the AUC for Japanese variceal grade was 0.635, which was statistically significant (P < 0.001). Thus, results of the present study demonstrated that EV diameter was more optimal in predicting early rebleeding following EVL than Japanese variceal grade criteria. The cut-off value of EV diameter was calculated to be 1.35 cm (sensitivity, 70.0%; specificity, 89.2%). Conclusion If the diameter of EV is ≥1.4 cm, there may be a high risk of early rebleeding following EVL surgery; thus, we recommend caution with EVL.
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Affiliation(s)
- Chuankun Cao
- Department of Gastroenterology, The First Affiliated Hospital of Anhui Medical University, Anhui Provincial Key Laboratory of Digestive Diseases, Hefei, China
- Department of Gastroenterology, Phoenix Hospital of Huainan Oriental Hospital Group, Huainan, China
| | - Jing Jin
- Department of Gastroenterology, The First Affiliated Hospital of Anhui Medical University, Anhui Provincial Key Laboratory of Digestive Diseases, Hefei, China
| | - Rui Cai
- Department of Gastroenterology, Phoenix Hospital of Huainan Oriental Hospital Group, Huainan, China
| | - Yuan Chu
- Department of Gastroenterology, General Hospital of Huainan Oriental Hospital Group, Huainan, China
| | - Kai Wu
- Department of Gastroenterology, General Hospital of Huainan Oriental Hospital Group, Huainan, China
| | - Zuo Wang
- Department of Gastroenterology, General Hospital of Huainan Oriental Hospital Group, Huainan, China
| | - Ting Xiao
- Department of Gastroenterology, Phoenix Hospital of Huainan Oriental Hospital Group, Huainan, China
| | - Heng Zhang
- Department of Gastroenterology, Phoenix Hospital of Huainan Oriental Hospital Group, Huainan, China
| | - Hongfei Huang
- Department of Gastroenterology, Phoenix Hospital of Huainan Oriental Hospital Group, Huainan, China
| | - Heng Liu
- Department of Gastroenterology, The First Affiliated Hospital of Anhui Medical University, Anhui Provincial Key Laboratory of Digestive Diseases, Hefei, China
| | - Qianqian Zhang
- Department of Gastroenterology, The First Affiliated Hospital of Anhui Medical University, Anhui Provincial Key Laboratory of Digestive Diseases, Hefei, China
| | - Xuecan Mei
- Department of Gastroenterology, The First Affiliated Hospital of Anhui Medical University, Anhui Provincial Key Laboratory of Digestive Diseases, Hefei, China
| | - Derun Kong
- Department of Gastroenterology, The First Affiliated Hospital of Anhui Medical University, Anhui Provincial Key Laboratory of Digestive Diseases, Hefei, China
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Ramrakhiani H, Triadafilopoulos G. Banding on the Run: Use of Over-the-Scope Clips (OTSC) for Treatment of Post Banding Ulcer Bleeding (PBUB). Dig Dis Sci 2024; 69:1098-1101. [PMID: 38446310 DOI: 10.1007/s10620-024-08331-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Accepted: 01/30/2024] [Indexed: 03/07/2024]
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Ryu H, Kim TU, Yoon KT, Hong YM. Predicting the risk of early bleeding following endoscopic variceal ligation in cirrhotic patients with computed tomography. BMC Gastroenterol 2023; 23:410. [PMID: 38001426 PMCID: PMC10668468 DOI: 10.1186/s12876-023-03038-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Accepted: 11/07/2023] [Indexed: 11/26/2023] Open
Abstract
BACKGROUND Life-threatening bleeding following endoscopic variceal ligation (EVL) in patients with cirrhosis rarely can occur. The present study aimed to evaluate the performance of computed tomography (CT) in predicting the risk of early bleeding following EVL in cirrhotic patients. METHODS We retrospectively investigated 285 cirrhotic patients who had undergone EVL. EVL was performed for prophylaxis or acute variceal bleeding. The patients were classified into 2 groups: early bleeding (< 14 days after EVL) and non-early bleeding. We compared baseline characteristics including CT findings between the patient groups. RESULTS Among the 285 patients who underwent EVL treatment, 19 patients (6.7%) experienced early bleeding. On average, these bleeding occurred 9.3 ± 3.5 days after the EVL, with a range of 3 to 13 days. Patients who experience early bleeding had a higher six-week bleeding-related mortality rate compared to those in the non-early bleeding group (31.6% vs. 10.2%; p = 0.014). There was a correlation between the grade of esophageal varix observed during endoscopy and the diameter of esophageal varix observed on CT (p < 0.001). The diameter of esophageal varix on CT was identified as the only significant predictive factor for early bleeding (p = 0.005). CONCLUSION A larger esophageal varix diameter observed on CT is associated with an increased risk of early bleeding after EVL treatment. Early identification of this high-risk group can provide a change of treatment strategies to improve patient outcomes.
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Affiliation(s)
- Hwaseong Ryu
- Department of Radiology, Pusan National University College of Medicine, Pusan National University Yangsan Hospital, Yangsan, Republic of Korea
| | - Tae Un Kim
- Department of Radiology, Pusan National University College of Medicine, Pusan National University Yangsan Hospital, Yangsan, Republic of Korea
| | - Ki Tae Yoon
- Department of Internal Medicine, Pusan National University College of Medicine, Pusan National University Yangsan Hospital, Yangsan, Republic of Korea
| | - Young Mi Hong
- Department of Internal Medicine, Pusan National University College of Medicine, Pusan National University Yangsan Hospital, Yangsan, Republic of Korea.
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Lashen SA, Shamseya MM, Shamseya AM, Hablass FH. Efficacy of Vonoprazan vs. Pantoprazole or Non-acid Suppression in Prevention of Post-variceal Ligation Ulcer Bleeding in Portal Hypertension: A Multi-arm Randomized Controlled Trial. J Clin Exp Hepatol 2023; 13:962-971. [PMID: 37975046 PMCID: PMC10643493 DOI: 10.1016/j.jceh.2023.05.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Accepted: 05/15/2023] [Indexed: 11/19/2023] Open
Abstract
Background Up-to-date data about the role of acid suppression therapy e.g. proton-pump inhibitors; to reduce post-endoscopic variceal ligation (EVL) ulcer-bleeding are conflicting. Vonoprazan; a recently introduced potassium-competitor acid blocker, has not been studied to prevent post-EVL ulcer/bleeding. The aim was to evaluate the efficacy of vonoprazan vs. pantoprazole or non-acid suppression to prevent post-EVL ulcer/bleeding in portal hypertension patients. Material and methods We enrolled 275 portal hypertension patients undergoing EVL in a three-arm randomized, single-blind, controlled study. A clinico-laboratory baseline evaluation was performed. Following EVL, patients were randomly and equally assigned to receive vonoprazan 20mg once daily, pantoprazole 40 mg once daily, or no acid suppression therapy. Post-EVL ulcer bleeding, ulcer dimensions, odynophagia as well as vonoprazan safety were evaluated after 2 weeks of EVL. Results Post-EVL ulcer bleeding occurred among 2.15% of vonoprazan, 8.7% of pantoprazole, and 14.2% of the non-acid suppression groups (P < 0.001). Post-ligation ulcer frequency and dimensions were higher among non-acid suppression and pantoprazole groups vs. vonoprazan (P < 0.05). Chest pain and odynophagia were encountered among 73.6% and 54.9% of the non-acid suppression group vs. 39.6% and 45.1% in pantoprazole, and 17.2% and 21.5% in vonoprazan groups, respectively (P < 0.05). There were no vonoprazan-related adverse events. Non-use of vonoprazan was the strongest independent predictor for post-EVL bleeding. Conclusion Short course of vonoprazan 20 mg/day is safe and superior to pantoprazole 40 mg/day in the reduction of post-EVL ulcer dimensions at 2 weeks post-EVL, and prevention of ulcer-related bleeding. Acid suppression is superior to no acid suppression to prevent post-EVL complications.
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Affiliation(s)
- Sameh A. Lashen
- Department of Internal Medicine (Hepatology & Gastroenterology Division), Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Mohammed M. Shamseya
- Department of Clinical and Experimental Internal Medicine, Medical Research Institute, Alexandria University, Alexandria, Egypt
| | - Ayman M. Shamseya
- Department of Internal Medicine (Hepatology & Gastroenterology Division), Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Fahmy H. Hablass
- Department of Internal Medicine (Hepatology & Gastroenterology Division), Faculty of Medicine, Alexandria University, Alexandria, Egypt
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Dutta AK, Jain A, Jearth V, Mahajan R, Panigrahi MK, Sharma V, Goenka MK, Kochhar R, Makharia G, Reddy DN, Kirubakaran R, Ahuja V, Berry N, Bhat N, Dutta U, Ghoshal UC, Jain A, Jalihal U, Jayanthi V, Kumar A, Nijhawan S, Poddar U, Ramesh GN, Singh SP, Zargar S, Bhatia S. Guidelines on optimizing the use of proton pump inhibitors: PPI stewardship. Indian J Gastroenterol 2023; 42:601-628. [PMID: 37698821 DOI: 10.1007/s12664-023-01428-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Accepted: 07/10/2023] [Indexed: 09/13/2023]
Abstract
Proton pump inhibitors (PPIs) have been available for over three decades and are among the most commonly prescribed medications. They are effective in treating a variety of gastric acid-related disorders. They are freely available and based on current evidence, use of PPIs for inappropriate indications and duration appears to be common. Over the years, concerns have been raised on the safety of PPIs as they have been associated with several adverse effects. Hence, there is a need for PPI stewardship to promote the use of PPIs for appropriate indication and duration. With this objective, the Indian Society of Gastroenterology has formulated guidelines on the rational use of PPIs. The guidelines were developed using a modified Delphi process. This paper presents these guidelines in detail, including the statements, review of literature, level of evidence and recommendations. This would help the clinicians in optimizing the use of PPIs in their practice and promote PPI stewardship.
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Affiliation(s)
- Amit Kumar Dutta
- Department of Gastroenterology, Christian Medical College and Hospital, Vellore, 632 004, India.
| | | | - Vaneet Jearth
- Postgraduate Institute of Medical Education and Research, Chandigarh, 160 012, India
| | - Ramit Mahajan
- Dayanand Medical College and Hospital, Ludhiana, 141 001, India
| | | | - Vishal Sharma
- Postgraduate Institute of Medical Education and Research, Chandigarh, 160 012, India
| | | | | | - Govind Makharia
- All India Institute of Medical Sciences, New Delhi, 110 029, India
| | | | - Richard Kirubakaran
- Center of Biostatistics and Evidence Based Medicine, Vellore, 632 004, India
| | - Vineet Ahuja
- All India Institute of Medical Sciences, New Delhi, 110 029, India
| | - Neha Berry
- BLK Institute of Digestive and Liver Disease, New Delhi, 201 012, India
| | - Naresh Bhat
- Aster CMI Hospital, Bengaluru, 560 092, India
| | - Usha Dutta
- Postgraduate Institute of Medical Education and Research, Chandigarh, 160 012, India
| | - Uday Chand Ghoshal
- Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, 226 014, India
| | - Ajay Jain
- Choithram Hospital and Research Center, Indore, 452 014, India
| | | | - V Jayanthi
- Sri Ramachandra Medical College, Chennai, 600 116, India
| | - Ajay Kumar
- Institute of Digestive and Liver Diseases, BLK - Max Superspeciality Hospital, New Delhi, 201 012, India
| | | | - Ujjal Poddar
- Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, 226 014, India
| | | | - Shivram P Singh
- Kalinga Gastroenterology Foundation, Cuttack, 753 001, India
| | - Showkat Zargar
- Department of Gastroenterology, Sher-i-Kashmir Institute of Medical Sciences, Kashmir, 190 011, India
| | - Shobna Bhatia
- Sir H N Reliance Foundation Hospital, Mumbai, 400 004, India
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11
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Pfisterer N, Schwarz M, Jachs M, Putre F, Ritt L, Mandorfer M, Madl C, Trauner M, Reiberger T. Endoscopic band ligation is safe despite low platelet count and high INR. Hepatol Int 2023; 17:1205-1214. [PMID: 37024710 PMCID: PMC10522720 DOI: 10.1007/s12072-023-10515-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2022] [Accepted: 03/07/2023] [Indexed: 04/08/2023]
Abstract
BACKGROUND Prophylactic endoscopic band ligation (EBL) is used to prevent variceal bleeding in patients with liver cirrhosis. The association of thrombocytopenia, high INR (international normalized ratio) and liver dysfunction with the risk of procedure-related bleeding (PRB) remains debated and recommendations are controversial. METHODS We analyzed real-life data of cirrhotic patients undergoing elective EBL at two large Viennese centers between Q1/2000-Q1/2018. PRB was defined as bleeding occurring within 30 days after EBL. RESULTS We included 617 patients undergoing a total of 1178 prophylactic EBL procedures (median 2 per patient). Sixteen (2.6%) of 617 patients experienced PRB after a median of 12.5 (IQR 17.3) days with no difference in characteristics and laboratory values between the two groups. The proportion of patients with platelets (PLT) < 50 G/L or INR ≥ 1.5 was similar in patients with vs. without PRB. A higher MELD showed a non-significant association with EBL-related bleeding risk (odds ratio, OR 1.07; 95% confidence interval 95% CI 1.00-1.16, p = 0.058). While serum bilirubin was a significant predictor for PRB (OR: 1.10; 95% CI 1.03-1.18), the presence of large varices (OR 0.85 vs. small varices; 95% CI 0.20-3.84), INR (OR 0.50; 95% CI 0.10-3.14), PLT (OR 1.00; 95% CI 1.00-1.01) and the use of non-selective betablockers (OR 1.20; CI 95% 0.38-3.76) were not associated with PRB. CONCLUSION EBL is safe and procedure-related bleedings are rare (2.6%) including in patients with thrombocytopenia < 50 G/L or high INR ≥ 1.5. Only high MELD, and especially high bilirubin seem to be linked to an increased risk of EBL-related bleeding.
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Affiliation(s)
- Nikolaus Pfisterer
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
- Vienna Hepatic Hemodynamic Lab, Medical University of Vienna, Vienna, Austria
- 4. Medizinische Abteilung für Gastroenterologie und Hepatologie, Klinik Landstrasse, Vienna, Austria
| | - Michael Schwarz
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
- Vienna Hepatic Hemodynamic Lab, Medical University of Vienna, Vienna, Austria
- 4. Medizinische Abteilung für Gastroenterologie und Hepatologie, Klinik Ottakring, Vienna, Austria
| | - Mathias Jachs
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
- Vienna Hepatic Hemodynamic Lab, Medical University of Vienna, Vienna, Austria
| | - Florian Putre
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Lukas Ritt
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Mattias Mandorfer
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
- Vienna Hepatic Hemodynamic Lab, Medical University of Vienna, Vienna, Austria
| | - Christian Madl
- 4. Medizinische Abteilung für Gastroenterologie und Hepatologie, Klinik Landstrasse, Vienna, Austria
- Private Medical School, Sigmund Freud University, Vienna, Austria
| | - Michael Trauner
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Thomas Reiberger
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria.
- Vienna Hepatic Hemodynamic Lab, Medical University of Vienna, Vienna, Austria.
- Christian-Doppler Laboratory for Portal Hypertension and Liver Fibrosis, Medical University of Vienna, Vienna, Austria.
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12
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de Brito Nunes M, Knecht M, Wiest R, Bosch J, Berzigotti A. Predictors and management of post-banding ulcer bleeding in cirrhosis: A systematic review and meta-analysis. Liver Int 2023; 43:1644-1653. [PMID: 37222256 DOI: 10.1111/liv.15621] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Revised: 04/24/2023] [Accepted: 05/14/2023] [Indexed: 05/25/2023]
Abstract
BACKGROUND AND AIMS Post-banding ulcer bleeding (PBUB) is an understudied complication of oesophageal varices endoscopic band ligation (EBL). This systematic review with meta-analysis aimed at: (a) evaluating the incidence of PBUB in patients with cirrhosis treated with EBL in primary or secondary prophylaxis or urgent treatment for acute variceal bleeding and (b) identifying predictors of PBUB. METHODS We conducted a systematic review of articles in English published in 2006-2022 using the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Searches were made in eight databases including Embase, PubMed and Cochrane Library. Random-effects meta-analysis was used to determine the incidence, mean interval and predictors of PBUB. RESULTS Eighteen studies (9034 patients) were included. The incidence of PBUB was 5.5% (95% CI 4.3-7.1). The mean time for it to occur was 11 days (95% CI 9.94-11.97). Model for End-stage Liver Disease (MELD) score (OR 1.162, 95% CI 1.047-1.291) and EBL done in emergency setting (OR 4.902, 95% CI 2.99-8.05) independently predicted post-ligation ulcer bleeding. Treatment included drugs, endoscopic procedures and transjugular intrahepatic portosystemic shunt. Refractory bleeding was treated with self-expandable metallic stents or balloon tamponade. Mortality was on average 22.3% (95% CI 14.1-33.6). CONCLUSIONS Patients with high MELD score and receiving EBL in an emergency setting are more prone to develop PBUB. Prognosis is still poor and the best therapeutic strategy to address remains to be ascertained.
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Affiliation(s)
- Maria de Brito Nunes
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Department of Internal Medicine, Hospital of Fribourg, Fribourg, Switzerland
- Graduate School for Health Sciences (GHS), University of Bern, Bern, Switzerland
| | - Matthias Knecht
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Reiner Wiest
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Jaume Bosch
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Annalisa Berzigotti
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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13
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Kaltenbach MG, Mahmud N. Assessing the risk of surgery in patients with cirrhosis. Hepatol Commun 2023; 7:e0086. [PMID: 36996004 PMCID: PMC10069843 DOI: 10.1097/hc9.0000000000000086] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 01/17/2023] [Indexed: 03/31/2023] Open
Abstract
Patients with cirrhosis have an increased perioperative risk relative to patients without cirrhosis. This is related to numerous cirrhosis-specific factors, including severity of liver disease, impaired synthetic function, sarcopenia and malnutrition, and portal hypertension, among others. Nonhepatic comorbidities and surgery-related factors further modify the surgical risk, adding to the complexity of the preoperative assessment. In this review, we discuss the pathophysiological contributors to surgical risk in cirrhosis, key elements of the preoperative risk assessment, and application of risk prediction tools including the Child-Turcotte-Pugh score, Model for End-Stage Liver Disease-Sodium, Mayo Risk Score, and the VOCAL-Penn Score. We also detail the limitations of current approaches to risk assessment and highlight areas for future research.
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Affiliation(s)
- Melissa G. Kaltenbach
- Division of Gastroenterology and Hepatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Nadim Mahmud
- Division of Gastroenterology and Hepatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Medicine, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania, USA
- Leonard David Institute of Health Economics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
- Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics, Epidemiology & Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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14
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Liu Z, Xu L, Qin N, Yang A, Chen Y, Huang D, Shu J. Prediction of esophageal and gastric varices rebleeding for cirrhotic patients based on deep learning. Biomed Signal Process Control 2023. [DOI: 10.1016/j.bspc.2022.104420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022]
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15
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Biolato M, Vitale F, Galasso T, Gasbarrini A, Grieco A. Minimum platelet count threshold before invasive procedures in cirrhosis: Evolution of the guidelines. World J Gastrointest Surg 2023; 15:127-141. [PMID: 36896308 PMCID: PMC9988645 DOI: 10.4240/wjgs.v15.i2.127] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Revised: 12/09/2022] [Accepted: 02/07/2023] [Indexed: 02/27/2023] Open
Abstract
Cirrhotic patients with severe thrombocytopenia are at increased risk of bleeding during invasive procedures. The need for preprocedural prophylaxis aimed at reducing the risk of bleeding in cirrhotic patients with thrombocytopenia who undergo scheduled procedures is assessed via the platelet count; however, establishing a minimum threshold considered safe is challenging. A platelet count ≥ 50000/μL is a frequent target, but levels vary by provider, procedure, and specific patient. Over the years, this value has changed several times according to the different guidelines proposed in the literature. According to the latest guidelines, many procedures can be performed at any level of platelet count, which should not necessarily be checked before the procedure. In this review, we aim to investigate and describe how the guidelines have evolved in recent years in the evaluation of the minimum platelet count threshold required to perform different invasive procedures, according to their bleeding risk.
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Affiliation(s)
- Marco Biolato
- Department of Medical and Surgical Sciences, CEMAD, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome 00168, Italy
- Department of Internal Medicine, Catholic University of Sacred Heart, Rome 00168, Italy
| | - Federica Vitale
- Department of Internal Medicine, Catholic University of Sacred Heart, Rome 00168, Italy
| | - Tiziano Galasso
- Department of Internal Medicine, Catholic University of Sacred Heart, Rome 00168, Italy
| | - Antonio Gasbarrini
- Department of Medical and Surgical Sciences, CEMAD, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome 00168, Italy
- Department of Internal Medicine, Catholic University of Sacred Heart, Rome 00168, Italy
| | - Antonio Grieco
- Department of Medical and Surgical Sciences, CEMAD, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome 00168, Italy
- Department of Internal Medicine, Catholic University of Sacred Heart, Rome 00168, Italy
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16
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Caiano LM, Riva N, Ageno W. Anticoagulant therapy for splanchnic vein thrombosis: recent updates for patients with liver cirrhosis. Expert Rev Hematol 2023; 16:121-129. [PMID: 36820873 DOI: 10.1080/17474086.2023.2184340] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2023]
Abstract
INTRODUCTION Liver cirrhosis is accompanied by several hemostatic alterations, which contribute to the current theory of "rebalanced hemostasis." Splanchnic vein thrombosis (SVT) is a frequent complication of liver cirrhosis (17-26% of the cirrhotic patients), and liver cirrhosis is a common risk factor for SVT (24-28% of SVT cases). AREAS COVERED This narrative review aims to describe the current state of the art on the anticoagulant treatment of cirrhotic SVT, with a particular focus on the possible role of the direct oral anticoagulants (DOACs) and recent guidelines on this topic. EXPERT OPINION Early anticoagulant therapy is recommended in cirrhotic patients with acute SVT, to obtain vessel recanalization and decrease the rates of portal hypertension-related complications. Gastroesophageal varices do not represent a contraindication to anticoagulation, if adequate prophylaxis of variceal bleeding is established, and varices band ligation can be safely performed without the need to stop the anticoagulant treatment. The conventional treatment of cirrhotic SVT consisted of low molecular weight heparin, as initial treatment of choice, eventually followed by vitamin K antagonists, but the DOACs can be considered as a reasonable alternative in patients with compensated liver cirrhosis.
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Affiliation(s)
- Lucia M Caiano
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Nicoletta Riva
- Department of Pathology, Faculty of Medicine and Surgery, University of Malta, Msida, Malta
| | - Walter Ageno
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
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17
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Zhang YY, Wang L, Shao XD, Zhang YG, Ma SZ, Peng MY, Xu SX, Yin Y, Guo XZ, Qi XS. Effects of postoperative use of proton pump inhibitors on gastrointestinal bleeding after endoscopic variceal treatment during hospitalization. World J Gastrointest Surg 2023; 15:82-93. [PMID: 36741070 PMCID: PMC9896494 DOI: 10.4240/wjgs.v15.i1.82] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Revised: 10/11/2022] [Accepted: 11/07/2022] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND Endoscopic variceal treatment (EVT) is recommended as the mainstay choice for the management of high-risk gastroesophageal varices and acute variceal bleeding in liver cirrhosis. Proton pump inhibitors (PPIs) are widely used for various gastric acid-related diseases. However, the effects of PPIs on the development of post-EVT complications, especially gastrointestinal bleeding (GIB), remain controversial.
AIM To evaluate the effects of postoperative use of PPIs on post-EVT complications in patients with liver cirrhosis during hospitalization.
METHODS Patients with a diagnosis of liver cirrhosis who were admitted to the Department of Gastroenterology of the General Hospital of Northern Theater Command, treated by an attending physician between January 2016 and June 2020 and underwent EVT during their hospitalization were included. Logistic regression analyses were performed to explore the effects of postoperative use of PPIs on the development of post-EVT complications during hospitalization. Odds ratios (ORs) with 95% confidence intervals (CIs) were calculated.
RESULTS A total of 143 patients were included. The incidence of post-EVT GIB and other post-EVT complications was 4.90% and 46.85%, respectively. In the overall analyses, postoperative use of PPIs did not significantly reduce the risk of post-EVT GIB (OR = 0.525, 95%CI = 0.113-2.438, P = 0.411) or other post-EVT complications (OR = 0.804, 95%CI = 0.413-1.565, P = 0.522). In the subgroup analyses according to the enrollment period, type and route of PPIs after the index EVT, use of PPIs before the index EVT, use of vasoactive drugs after the index EVT, indication of EVT (prophylactic and therapeutic), and presence of portal venous system thrombosis, ascites, and hepatocellular carcinoma, the effects of postoperative use of PPIs on the risk of post-EVT GIB or other post-EVT complications remain not statistically significant.
CONCLUSION Routine use of PPIs after EVT should not be recommended in patients with liver cirrhosis for the prevention of post-EVT complications during hospitalization.
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Affiliation(s)
- Yi-Yan Zhang
- Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang 110840, Liaoning Province, China
- Postgraduate College, China Medical University, Shenyang 110122, Liaoning Province, China
| | - Le Wang
- Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang 110840, Liaoning Province, China
- Postgraduate College, China Medical University, Shenyang 110122, Liaoning Province, China
| | - Xiao-Dong Shao
- Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang 110840, Liaoning Province, China
| | - Yong-Guo Zhang
- Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang 110840, Liaoning Province, China
| | - Shao-Ze Ma
- Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang 110840, Liaoning Province, China
- Postgraduate College, Dalian Medical University, Dalian 116044, Liaoning Province, China
| | - Meng-Yuan Peng
- Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang 110840, Liaoning Province, China
| | - Shi-Xue Xu
- Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang 110840, Liaoning Province, China
- Postgraduate College, China Medical University, Shenyang 110122, Liaoning Province, China
| | - Yue Yin
- Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang 110840, Liaoning Province, China
- Postgraduate College, China Medical University, Shenyang 110122, Liaoning Province, China
| | - Xiao-Zhong Guo
- Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang 110840, Liaoning Province, China
| | - Xing-Shun Qi
- Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang 110840, Liaoning Province, China
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18
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Muacevic A, Adler JR, Awan SA, Shaikh AJ, Abbasi AA. Effectiveness of Proton Pump Inhibitor Therapy in the Prevention of Bleeding After Prophylactic Endoscopic Variceal Band Ligation. Cureus 2023; 15:e33932. [PMID: 36819375 PMCID: PMC9937675 DOI: 10.7759/cureus.33932] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/18/2023] [Indexed: 01/19/2023] Open
Abstract
Background Endoscopic variceal ligation (EVL) is a surgical intervention that can work well to curb variceal bleeding in people with liver cirrhosis. However, it could make ulcer bleeding worse and be fatal in some cases. The widespread use of proton pump inhibitors (PPI) in cirrhotic individuals with variceal bleeding is empirical rather than based on scientific data. According to many studies, PPIs reduce the size of post-EVL ulcers. This study aimed to see if PPI use could reduce rebleeding after endoscopy therapy in cirrhotic patients with variceal bleeding. Methodology A retrospective cross-sectional study was conducted at a tertiary care hospital from August 2019 to September 2021. Cirrhotic patients with bleeding gastroesophageal varices (GEVs) who had undergone EVL at the same hospital were enrolled in the study. Medical records were organized, and the sample was divided into two groups based on whether or not PPI was given. Both PPI and non-PPI patients had their endoscopic findings, initial hemostasis outcomes, rebleeding rates, bleeding-related mortality rates, and treatment-related comorbidities compared. Results A total of 46 patients were selected for the study and divided into two groups (PPI group n=28 and non-PPI group n=18). The majority of the patients were males. The PPI group had a mean age of 58.6 ±7.8 years, whereas the non-PPI group had a mean age of 53.6 ±4.4 years. Hepatitis B virus (HBV) infection was the most prevalent cause of cirrhosis in both groups. After endoscopic treatment, three patients (16%) in the non-PPI group suffered a variceal hemorrhage. Bleeding-related fatalities and the time it took for the bleeding to stop varied significantly between the two groups. History of variceal bleeding (relative risk (RR)=1.45; 95% confidence interval (CI), 1.60-7.67; p=0.02), presence of gastric varices (RR=2.23; 95% CI, 2.56-9.832; p=0.035), and not administering PPIs (RR =7.542; 95% CI, 3.98-29.13; p=0.008) were linked with rebleeding. The presence of red concurrent esophageal varices (RR=6.37; 95% CI, 0.562-15.342; p=0.002) and failure to provide PPIs (RR=2.3; 95% CI, 1.621-25.64; p=0.04) were linked with post-EVL bleeding in a multivariate analysis. Conclusions Proton pump inhibitors reduce the occurrence of early bleeding and adverse events after EVL in cirrhotic patients. Not prescribing PPIs and the presence of GEVs were substantially related to a higher risk of bleeding during preventative EVL. Not initiating PPI medication immediately was the sole predictor of bleeding complications in patients who had undergone EVL without gastric varix treatment. To lower the risk of post-EVL ulcer bleeding, we recommend PPI use in patients undergoing EVL.
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19
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Albumin-Bilirubin Grade as a Novel Predictor of the Development and Short-Term Survival of Post-Banding Ulcer Bleeding Following Endoscopic Variceal Ligation in Cirrhotic Patients. MEDICINA (KAUNAS, LITHUANIA) 2022; 58:medicina58121836. [PMID: 36557038 PMCID: PMC9788267 DOI: 10.3390/medicina58121836] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Revised: 12/10/2022] [Accepted: 12/12/2022] [Indexed: 12/15/2022]
Abstract
Background and Objectives: Endoscopic variceal ligation (EVL) is the primary and secondary treatment for acute esophageal variceal bleeding. Post-banding ulcer bleeding (PBUB) may lead to bleeding episodes following EVL, increasing mortality. The aim of this study was to evaluate the risk factors for PBUB and predict the 6-week mortality risk after PBUB. Materials and Methods: We retrospectively analyzed the data collected from cirrhotic patients with EVL from 2015 to 2017. The incidence of PBUB and the 6-week mortality rate were evaluated. Risk factors for PBUB and predictive factors for mortality after PBUB were analyzed. Results: A total of 713 patients were enrolled in this study. Among the studied subjects, the incidence of PBUB was 5.8% (N = 41). The 6-week mortality rate was 63.4% (26/41). In multivariate analysis, MELD score ≥20 (OR: 3.77, 95% CI: 1.94−7.33, p < 0.001), ALBI score of 3 (OR: 2.67, 95% CI: 1.34−5.3, p = 0.005) and the presence of gastric varices (OR: 2.1, 95% CI: 1.06−4.16, p = 0.03) were associated with the development of PBUB. Patients with ALBI grade 3 (OR: 4.8, 95% CI: 1.18−19.6, p = 0.029) and Child-Pugh scores B and C (OR: 16.67, 95% CI: 1.75−158.1, p = 0.014) were associated with 6-week mortality after PBUB. Conclusions: PBUB is a complication with low incidence but increased mortality following EVL. The ALBI grade is a useful score to predict not only the development of PBUB but also the 6-week mortality after PBUB.
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20
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Gralnek IM, Camus Duboc M, Garcia-Pagan JC, Fuccio L, Karstensen JG, Hucl T, Jovanovic I, Awadie H, Hernandez-Gea V, Tantau M, Ebigbo A, Ibrahim M, Vlachogiannakos J, Burgmans MC, Rosasco R, Triantafyllou K. Endoscopic diagnosis and management of esophagogastric variceal hemorrhage: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy 2022; 54:1094-1120. [PMID: 36174643 DOI: 10.1055/a-1939-4887] [Citation(s) in RCA: 99] [Impact Index Per Article: 33.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
1: ESGE recommends that patients with compensated advanced chronic liver disease (ACLD; due to viruses, alcohol, and/or nonobese [BMI < 30 kg/m2] nonalcoholic steatohepatitis) and clinically significant portal hypertension (hepatic venous pressure gradient [HVPG] > 10 mmHg and/or liver stiffness by transient elastography > 25 kPa) should receive, if no contraindications, nonselective beta blocker (NSBB) therapy (preferably carvedilol) to prevent the development of variceal bleeding.Strong recommendation, moderate quality evidence. 2: ESGE recommends that in those patients unable to receive NSBB therapy with a screening upper gastrointestinal (GI) endoscopy that demonstrates high risk esophageal varices, endoscopic band ligation (EBL) is the endoscopic prophylactic treatment of choice. EBL should be repeated every 2-4 weeks until variceal eradication is achieved. Thereafter, surveillance EGD should be performed every 3-6 months in the first year following eradication.Strong recommendation, moderate quality evidence. 3: ESGE recommends, in hemodynamically stable patients with acute upper GI hemorrhage (UGIH) and no history of cardiovascular disease, a restrictive red blood cell (RBC) transfusion strategy, with a hemoglobin threshold of ≤ 70 g/L prompting RBC transfusion. A post-transfusion target hemoglobin of 70-90 g/L is desired.Strong recommendation, moderate quality evidence. 4 : ESGE recommends that patients with ACLD presenting with suspected acute variceal bleeding be risk stratified according to the Child-Pugh score and MELD score, and by documentation of active/inactive bleeding at the time of upper GI endoscopy.Strong recommendation, high quality of evidence. 5 : ESGE recommends the vasoactive agents terlipressin, octreotide, or somatostatin be initiated at the time of presentation in patients with suspected acute variceal bleeding and be continued for a duration of up to 5 days.Strong recommendation, high quality evidence. 6 : ESGE recommends antibiotic prophylaxis using ceftriaxone 1 g/day for up to 7 days for all patients with ACLD presenting with acute variceal hemorrhage, or in accordance with local antibiotic resistance and patient allergies.Strong recommendation, high quality evidence. 7 : ESGE recommends, in the absence of contraindications, intravenous erythromycin 250 mg be given 30-120 minutes prior to upper GI endoscopy in patients with suspected acute variceal hemorrhage.Strong recommendation, high quality evidence. 8 : ESGE recommends that, in patients with suspected variceal hemorrhage, endoscopic evaluation should take place within 12 hours from the time of patient presentation provided the patient has been hemodynamically resuscitated.Strong recommendation, moderate quality evidence. 9 : ESGE recommends EBL for the treatment of acute esophageal variceal hemorrhage (EVH).Strong recommendation, high quality evidence. 10 : ESGE recommends that, in patients at high risk for recurrent esophageal variceal bleeding following successful endoscopic hemostasis (Child-Pugh C ≤ 13 or Child-Pugh B > 7 with active EVH at the time of endoscopy despite vasoactive agents, or HVPG > 20 mmHg), pre-emptive transjugular intrahepatic portosystemic shunt (TIPS) within 72 hours (preferably within 24 hours) must be considered.Strong recommendation, high quality evidence. 11 : ESGE recommends that, for persistent esophageal variceal bleeding despite vasoactive pharmacological and endoscopic hemostasis therapy, urgent rescue TIPS should be considered (where available).Strong recommendation, moderate quality evidence. 12 : ESGE recommends endoscopic cyanoacrylate injection for acute gastric (cardiofundal) variceal (GOV2, IGV1) hemorrhage.Strong recommendation, high quality evidence. 13: ESGE recommends endoscopic cyanoacrylate injection or EBL in patients with GOV1-specific bleeding.Strong recommendations, moderate quality evidence. 14: ESGE suggests urgent rescue TIPS or balloon-occluded retrograde transvenous obliteration (BRTO) for gastric variceal bleeding when there is a failure of endoscopic hemostasis or early recurrent bleeding.Weak recommendation, low quality evidence. 15: ESGE recommends that patients who have undergone EBL for acute EVH should be scheduled for follow-up EBLs at 1- to 4-weekly intervals to eradicate esophageal varices (secondary prophylaxis).Strong recommendation, moderate quality evidence. 16: ESGE recommends the use of NSBBs (propranolol or carvedilol) in combination with endoscopic therapy for secondary prophylaxis in EVH in patients with ACLD.Strong recommendation, high quality evidence.
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Affiliation(s)
- Ian M Gralnek
- Ellen and Pinchas Mamber Institute of Gastroenterology and Hepatology, Emek Medical Center, Afula, Israel.,Rappaport Faculty of Medicine Technion Israel Institute of Technology, Haifa, Israel
| | - Marine Camus Duboc
- Sorbonne Université, INSERM, Centre de Recherche Saint-Antoine (CRSA) & Assistance Publique-Hôpitaux de Paris (AP-HP), Endoscopic Center, Saint Antoine Hospital, Paris, France
| | - Juan Carlos Garcia-Pagan
- Barcelona Hepatic Hemodynamic Laboratory, Hospital Clinic, Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN-Liver), Barcelona, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain.,Centro de Investigación Biomédica Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain.,Liver Unit, Hospital Clínic de Barcelona, University of Barcelona, Barcelona, Spain
| | - Lorenzo Fuccio
- Gastroenterology Unit, Department of Medical and Surgical Sciences, IRCSS-S. Orsola-Malpighi, Hospital, Bologna, Italy
| | - John Gásdal Karstensen
- Gastroenterology Unit, Copenhagen University Hospital - Amager and Hvidovre, Copenhagen, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Tomas Hucl
- Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Ivan Jovanovic
- Euromedik Health Care System, Visegradska General Hospital, Belgrade, Serbia
| | - Halim Awadie
- Ellen and Pinchas Mamber Institute of Gastroenterology and Hepatology, Emek Medical Center, Afula, Israel
| | - Virginia Hernandez-Gea
- Barcelona Hepatic Hemodynamic Laboratory, Hospital Clinic, Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN-Liver), Barcelona, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain.,Centro de Investigación Biomédica Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain.,Liver Unit, Hospital Clínic de Barcelona, University of Barcelona, Barcelona, Spain
| | - Marcel Tantau
- University of Medicine and Pharmacy 'Iuliu Hatieganu' Cluj-Napoca, Romania
| | - Alanna Ebigbo
- Department of Gastroenterology, Universitätsklinikum Augsburg, Augsburg, Germany
| | | | - Jiannis Vlachogiannakos
- Academic Department of Gastroenterology, Medical School of National and Kapodistrian University of Athens, Laiko General Hospital, Athens, Greece
| | - Marc C Burgmans
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Konstantinos Triantafyllou
- Hepatogastroenterology Unit, Second Department of Propaedeutic Internal Medicine, Medical School, National and Kapodistrian University of Athens, Attikon University General Hospital, Athens, Greece
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21
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Giri S. Predictors of Post-EVL Ulcer Bleeding: More Questions That Need Answering. J Clin Gastroenterol 2022; 56:641. [PMID: 35648970 DOI: 10.1097/mcg.0000000000001726] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Affiliation(s)
- Suprabhat Giri
- Department of Gastroenterology, Seth GS Medical College and KEM Hospital Mumbai, Maharashtra, India
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22
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Bleeding From Band Ligation-induced Ulcers Following the Treatment of Esophageal Varices: A Retrospective Case-control Study. J Clin Gastroenterol 2022; 56:635-640. [PMID: 34653067 DOI: 10.1097/mcg.0000000000001618] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Accepted: 08/26/2021] [Indexed: 12/24/2022]
Abstract
GOAL Our study aimed to explore the incidence of bleeding from ulcers due to premature band slippage and to identify possible associated factors. BACKGROUND Band ligation (BL) plays a vital role in treating esophageal varices; however, the procedure carries a considerable risk of band slippage, variceal site ulcer formation, and posttreatment bleeding. MATERIALS AND METHODS We retrospectively reviewed the records of patients with esophageal varices who underwent endoscopic hemostasis by BL at our institution between 2015 and 2020. We statistically compared the patients with post-BL ulcer bleeding and those without (controls). The outcome variable was the development of BL-induced ulcer bleeding. The patients' demographics, clinical, and laboratory parameters, and BL procedure parameters were independent variables. Univariate followed by a multivariate logistic regression were performed to identify possible associated factors from the odds ratio (OR). RESULTS Of the 4579 eligible patients, 388 (8.5%) presented with post-BL ulcer bleeding. The presence of high-risk stigmata indicated a 1.271 times higher risk of bleeding [95% confidence interval (CI):1.018-1.587], and a greater number of varices was associated with an increased risk of post-BL ulcer bleeding [OR=1.184 (95% CI: 1.073-1.307)]. Conversely, the use of fewer bands per variceal site was associated with fewer bleeding incidents [OR=1.308 (95% CI: 1.090-1.569)]. Univariate analysis identified proton pump inhibitor as protective [OR=0.770 (95% CI: 0.603-0.983)]; however, the difference was not significant after multivariate analysis [OR=1.283 (95% CI: 1.003-1.640)]. CONCLUSIONS The overall incidence of post-BL ulcer bleeding was 8.5%. The presence of high-risk stigmata, higher number of varices, and bands per variceal site were associated with an increased risk of post-BL bleeding. The effect of adjuvant proton pump inhibitors was not statistically significant.
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23
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Lisman T, Caldwell SH, Intagliata NM. Haemostatic alterations and management of haemostasis in patients with cirrhosis. J Hepatol 2022; 76:1291-1305. [PMID: 35589251 DOI: 10.1016/j.jhep.2021.11.004] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Revised: 10/31/2021] [Accepted: 11/02/2021] [Indexed: 12/12/2022]
Abstract
Patients with cirrhosis frequently acquire complex changes in their haemostatic system including a decreased platelet count and decreased levels of various haemostatic proteins. Although historically patients with cirrhosis were thought to have a haemostasis-related bleeding tendency, it is now widely accepted that the haemostatic system of patients with cirrhosis remains in balance as a result of simultaneous changes in pro- and anti-haemostatic systems. The concept of rebalanced haemostasis has led to changes in clinical management, although firm evidence from well-designed clinical studies is largely lacking. For example, many invasive procedures in patients with cirrhosis and a prolonged prothrombin time are now performed without prophylaxis with fresh frozen plasma. Conversely, clinicians have become more aware of the need for anti-thrombotic therapy, even in those patients with abnormal routine coagulation tests. This paper will outline recent advances in pathogenesis, prevention and treatment of both bleeding and thrombotic complications in patients with cirrhosis. Among other topics, we will discuss the haemostatic status of acutely ill patients with cirrhosis, the various causes of bleeding in patients with cirrhosis, and how best to prevent or treat bleeding. In addition, we will discuss the hypercoagulable features of patients with cirrhosis, new insights into the pathogenesis of portal vein thrombosis, and how best to prevent or treat thromboses.
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Affiliation(s)
- Ton Lisman
- Surgical Research Laboratory and Section of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands.
| | - Stephen H Caldwell
- Division of Gastroenterology and Hepatology, Department of Medicine, Center for Coagulation in Liver Disease, University of Virginia Medical Center, Charlottesville VA, United States
| | - Nicolas M Intagliata
- Division of Gastroenterology and Hepatology, Department of Medicine, Center for Coagulation in Liver Disease, University of Virginia Medical Center, Charlottesville VA, United States
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24
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Villa E, Bianchini M, Blasi A, Denys A, Giannini EG, de Gottardi A, Lisman T, de Raucourt E, Ripoll C, Rautou PE. EASL Clinical Practice Guidelines on prevention and management of bleeding and thrombosis in patients with cirrhosis. J Hepatol 2022; 76:1151-1184. [PMID: 35300861 DOI: 10.1016/j.jhep.2021.09.003] [Citation(s) in RCA: 172] [Impact Index Per Article: 57.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Accepted: 09/13/2021] [Indexed: 12/11/2022]
Abstract
The prevention and management of bleeding and thrombosis in patients with cirrhosis poses several difficult clinical questions. These Clinical Practice Guidelines have been developed to provide practical guidance on debated topics, including current views on haemostasis in liver disease, controversy regarding the need to correct thrombocytopenia and abnormalities in the coagulation system in patients undergoing invasive procedures, and the need for thromboprophylaxis in hospitalised patients with haemostatic abnormalities. Multiple recommendations in this document are based on interventions that the panel feels are not useful, even though widely applied in clinical practice.
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25
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Alia MSA, Elsawy AA, Elarabawy RA, Hegazy HM. Predictors of early rebleeding after endoscopic therapy of first variceal bleeding in liver cirrhosis. EGYPTIAN LIVER JOURNAL 2021. [DOI: 10.1186/s43066-021-00119-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Despite the great advancement in therapeutic modalities for esophageal varices, early variceal rebleeding still occurs at high rates leading to an exaggeration of the morbidity and mortality for cirrhotic patients, so meticulous follow-up with optimum prediction and proper preventive measures for early variceal rebleeding are mandatory for increasing survival of those patients. In this respect, we evaluated the clinical, laboratory, abdominal ultrasound, and endoscopic criteria of variceal cirrhotic patients as possible risk predictors of early variceal rebleeding after endoscopic control of first variceal bleeding. All included patients were followed up blindly for 12 weeks after endoscopic control of bleeding for ascertainment of first variceal rebleeding. The demographic, clinical, laboratory, abdominal ultrasound, and upper gastrointestinal endoscopic criteria were evaluated for all patients at first admission.
Results
By univariate regression analysis, the statistically significant predictors for early variceal rebleeding were serum albumin, serum bilirubin, prothrombin concentration, Child-Pugh score, platelet count, spleen diameter, ascites, portal vein diameter and velocity, variceal size, variceal location, and red color sign. By using multivariate regression analysis, the most independent significant predictors were Child-Pugh score (sig: 0.001 and OR: 1.661), platelets count (sig: 0.000 and OR: 0.956), portal vein velocity (sig: 0.000 and OR: 0.664), variceal grading (sig: 0.000 and OR: 3.964), and variceal red color sign (sig: 0.000 and OR: 4.964). We used the multivariate regression coefficients for the significant predictors to build up early variceal rebleeding risk (EVRR) score with a significant discriminatory performance (AUC: 0.965 and sig: 0.000).
Conclusion
Child-Pugh score, platelet count, portal vein velocity, variceal grading, and variceal red color sign are independent risk predictors for early variceal rebleeding after successful control of first variceal bleeding in cirrhotic patients. Our proposed EVRR score could be helpful for the prediction of early variceal rebleeding in cirrhotic patients after endoscopic control of acute variceal bleeding; however, it should be externally validated in large prospective studies.
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26
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O'Shea RS, Davitkov P, Ko CW, Rajasekhar A, Su GL, Sultan S, Allen AM, Falck-Ytter Y. AGA Clinical Practice Guideline on the Management of Coagulation Disorders in Patients With Cirrhosis. Gastroenterology 2021; 161:1615-1627.e1. [PMID: 34579936 DOI: 10.1053/j.gastro.2021.08.015] [Citation(s) in RCA: 60] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- Robert S O'Shea
- Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland Clinic Lerner College of Medicine, Cleveland, Ohio
| | - Perica Davitkov
- Division of Gastroenterology and Hepatology, Veterans Affairs Northeast Ohio Health Care System, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Cynthia W Ko
- Division of Gastroenterology, University of Washington, Seattle, Washington
| | - Anita Rajasekhar
- Division of Hematology and Oncology, Department of Medicine, University of Florida College of Medicine, Gainesville, Florida
| | - Grace L Su
- Division of Gastroenterology, Department of Medicine, University of Michigan, Ann Arbor, Michigan; Ann Arbor Veterans Affairs Healthcare System, Ann Arbor, Michigan
| | - Shahnaz Sultan
- Division of Gastroenterology, Hepatology, and Nutrition, University of Minnesota, Minneapolis, Minnesota
| | - Alina M Allen
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Yngve Falck-Ytter
- Division of Gastroenterology and Hepatology, Veterans Affairs Northeast Ohio Health Care System, Case Western Reserve University School of Medicine, Cleveland, Ohio
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27
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Intagliata NM, Davitkov P, Allen AM, Falck-Ytter YT, Stine JG. AGA Technical Review on Coagulation in Cirrhosis. Gastroenterology 2021; 161:1630-1656. [PMID: 34579937 DOI: 10.1053/j.gastro.2021.09.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Nicolas M Intagliata
- Division of Gastroenterology and Hepatology, University of Virginia, Charlottesville, Virginia
| | - Perica Davitkov
- Division of Gastroenterology and Hepatology, Veterans Affairs Northeast Ohio Health Care System, Cleveland, Ohio; Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Alina M Allen
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Yngve T Falck-Ytter
- Division of Gastroenterology and Hepatology, Veterans Affairs Northeast Ohio Health Care System, Cleveland, Ohio; Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Jonathan G Stine
- Liver Center, Division of Gastroenterology and Hepatology, Pennsylvania State University Milton S. Hershey Medical Center, Hershey, Pennsylvania
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28
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Yokoyama S, Ishizu Y, Ishigami M, Honda T, Kuzuya T, Ito T, Hinoki A, Sumida W, Shirota C, Tainaka T, Makita S, Yokota K, Uchida H, Fujishiro M. Factors associated with bleeding after endoscopic variceal ligation in children. Pediatr Int 2021; 63:1223-1229. [PMID: 33464654 DOI: 10.1111/ped.14614] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Revised: 01/07/2021] [Accepted: 01/14/2021] [Indexed: 12/23/2022]
Abstract
BACKGROUND Endoscopic variceal ligation (EVL) is a widely accepted treatment for esophagogastric varices in patients with portal hypertension (PHT). It is used for urgent treatment and prophylactic treatment of esophagogastric varices in pediatric as well as adult patients. However, major life-threatening adverse events such as early rebleeding can occur. Although early rebleeding after EVL among children and adolescents has been reported, the risk factors remain obscure. This study evaluated the risk factors for early rebleeding after EVL in children and adolescents. METHODS The subjects were children and adolescents (<18 years) with PHT who underwent EVL for esophagogastric varices. Early rebleeding was defined as hematemesis, active bleeding, or blood retention in the stomach, confirmed by esophagogastroduodenoscopy from 2 h to 5 days after EVL. RESULTS A total of 50 EVL sessions on 22 patients were eligible for this study. There were four episodes of early rebleeding. No other major adverse event has occurred. Multivariate analysis showed that EVL implemented at cardiac varices just below the esophagogastric junction (EGJ), within 5 mm from the EGJ, is the independent factor for a higher risk of early rebleeding: odds ratio 18.2 (95% confidence interval: 1.40-237.0), P = 0.02. CONCLUSIONS Children and adolescents who undergo EVL for cardiac varices just below the EGJ have a higher risk of early rebleeding than those who do not.
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Affiliation(s)
- Shinya Yokoyama
- Department of Gastroenterology and Hepatology, Nagoya University, Graduate School of Medicine, Nagoya-shi, Japan
| | - Yoji Ishizu
- Department of Gastroenterology and Hepatology, Nagoya University, Graduate School of Medicine, Nagoya-shi, Japan
| | - Masatoshi Ishigami
- Department of Gastroenterology and Hepatology, Nagoya University, Graduate School of Medicine, Nagoya-shi, Japan
| | - Takashi Honda
- Department of Gastroenterology and Hepatology, Nagoya University, Graduate School of Medicine, Nagoya-shi, Japan
| | - Teiji Kuzuya
- Department of Gastroenterology and Hepatology, Nagoya University, Graduate School of Medicine, Nagoya-shi, Japan
| | - Takanori Ito
- Department of Gastroenterology and Hepatology, Nagoya University, Graduate School of Medicine, Nagoya-shi, Japan
| | - Akinari Hinoki
- Department of Pediatric Surgery, Nagoya University, Graduate School of Medicine, Nagoya-shi, Japan
| | - Wataru Sumida
- Department of Pediatric Surgery, Nagoya University, Graduate School of Medicine, Nagoya-shi, Japan
| | - Chiyoe Shirota
- Department of Pediatric Surgery, Nagoya University, Graduate School of Medicine, Nagoya-shi, Japan
| | - Takahisa Tainaka
- Department of Pediatric Surgery, Nagoya University, Graduate School of Medicine, Nagoya-shi, Japan
| | - Satoshi Makita
- Department of Pediatric Surgery, Nagoya University, Graduate School of Medicine, Nagoya-shi, Japan
| | - Kazuki Yokota
- Department of Pediatric Surgery, Nagoya University, Graduate School of Medicine, Nagoya-shi, Japan
| | - Hiroo Uchida
- Department of Pediatric Surgery, Nagoya University, Graduate School of Medicine, Nagoya-shi, Japan
| | - Mitsuhiro Fujishiro
- Department of Gastroenterology and Hepatology, Nagoya University, Graduate School of Medicine, Nagoya-shi, Japan
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29
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Veitch AM, Radaelli F, Alikhan R, Dumonceau JM, Eaton D, Jerrome J, Lester W, Nylander D, Thoufeeq M, Vanbiervliet G, Wilkinson JR, Van Hooft JE. Endoscopy in patients on antiplatelet or anticoagulant therapy: British Society of Gastroenterology (BSG) and European Society of Gastrointestinal Endoscopy (ESGE) guideline update. Gut 2021; 70:1611-1628. [PMID: 34362780 PMCID: PMC8355884 DOI: 10.1136/gutjnl-2021-325184] [Citation(s) in RCA: 79] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2021] [Accepted: 06/20/2021] [Indexed: 12/17/2022]
Abstract
This is a collaboration between the British Society of Gastroenterology (BSG) and the European Society of Gastrointestinal Endoscopy (ESGE), and is a scheduled update of their 2016 guideline on endoscopy in patients on antiplatelet or anticoagulant therapy. The guideline development committee included representatives from the British Society of Haematology, the British Cardiovascular Intervention Society, and two patient representatives from the charities Anticoagulation UK and Thrombosis UK, as well as gastroenterologists. The process conformed to AGREE II principles and the quality of evidence and strength of recommendations were derived using GRADE methodology. Prior to submission for publication, consultation was made with all member societies of ESGE, including BSG. Evidence-based revisions have been made to the risk categories for endoscopic procedures, and to the categories for risks of thrombosis. In particular a more detailed risk analysis for atrial fibrillation has been employed, and the recommendations for direct oral anticoagulants have been strengthened in light of trial data published since the previous version. A section has been added on the management of patients presenting with acute GI haemorrhage. Important patient considerations are highlighted. Recommendations are based on the risk balance between thrombosis and haemorrhage in given situations.
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Affiliation(s)
- Andrew M Veitch
- Gastroenterology, Royal Wolverhampton Hospitals NHS Trust, Wolverhampton, UK
| | | | - Raza Alikhan
- Haematology, Cardiff and Vale University Health Board, Cardiff, UK
| | | | | | | | - Will Lester
- Department of Haematology, Queen Elizabeth Hospital, Birmingham, UK
| | - David Nylander
- Gastroenterology, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Mo Thoufeeq
- Gastroenterology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | | | - James R Wilkinson
- Interventional Cardiology, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Jeanin E Van Hooft
- Gastroenterology and Hepatology, Leiden University Medical Centre, Leiden, The Netherlands
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30
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Veitch AM, Radaelli F, Alikhan R, Dumonceau JM, Eaton D, Jerrome J, Lester W, Nylander D, Thoufeeq M, Vanbiervliet G, Wilkinson JR, van Hooft JE. Endoscopy in patients on antiplatelet or anticoagulant therapy: British Society of Gastroenterology (BSG) and European Society of Gastrointestinal Endoscopy (ESGE) guideline update. Endoscopy 2021; 53:947-969. [PMID: 34359080 PMCID: PMC8390296 DOI: 10.1055/a-1547-2282] [Citation(s) in RCA: 52] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
This is a collaboration between the British Society of Gastroenterology (BSG) and the European Society of Gastrointestinal Endoscopy (ESGE), and is a scheduled update of their 2016 guideline on endoscopy in patients on antiplatelet or anticoagulant therapy. The guideline development committee included representatives from the British Society of Haematology, the British Cardiovascular Intervention Society, and two patient representatives from the charities Anticoagulation UK and Thrombosis UK, as well as gastroenterologists. The process conformed to AGREE II principles, and the quality of evidence and strength of recommendations were derived using GRADE methodology. Prior to submission for publication, consultation was made with all member societies of ESGE, including BSG. Evidence-based revisions have been made to the risk categories for endoscopic procedures, and to the categories for risks of thrombosis. In particular a more detailed risk analysis for atrial fibrillation has been employed, and the recommendations for direct oral anticoagulants have been strengthened in light of trial data published since the previous version. A section has been added on the management of patients presenting with acute GI haemorrhage. Important patient considerations are highlighted. Recommendations are based on the risk balance between thrombosis and haemorrhage in given situations.
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Affiliation(s)
- Andrew M. Veitch
- Department of Gastroenterology, Royal Wolverhampton NHS Trust, Wolverhampton, United Kingdom
| | | | - Raza Alikhan
- Department of Haematology Cardiff and Vale University Health Board, Cardiff, United Kingdom
| | - Jean-Marc Dumonceau
- Department of Gastroenterology, Charleroi University Hospitals, Charleroi, Belgium
| | | | | | - Will Lester
- Department of Haematology University Hospitals Birmingham NHS Foundation Trust, Birmingham,
| | - David Nylander
- Department of Gastroenterology, The Newcastle-upon-Tyne NHS Foundation Trust, Newcastle-upon-Tyne
| | - Mo Thoufeeq
- Department of Gastroenterology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield
| | | | - James R. Wilkinson
- Department of Interventional Cardiology, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom
| | - Jeanin E. van Hooft
- Department of Gastroenterology and Hepatology, Leiden University Medical Centre, Leiden, Netherlands
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31
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Alvaro D, Caporaso N, Giannini EG, Iacobellis A, Morelli M, Toniutto P, Violi F. Procedure-related bleeding risk in patients with cirrhosis and severe thrombocytopenia. Eur J Clin Invest 2021; 51:e13508. [PMID: 33539542 PMCID: PMC8244048 DOI: 10.1111/eci.13508] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Revised: 12/16/2020] [Accepted: 01/29/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Gaps of knowledge still exist about the potential association between severe thrombocytopenia and increased risk of procedure-associated bleeding in patients with liver disease. METHODS In this narrative review, we aimed at examining the association between procedure-related bleeding risk and platelet count in patients with cirrhosis and severe thrombocytopenia in various settings. We updated to 2020 a previously conducted literature search using MEDLINE/PubMed and EMBASE. The search string included clinical studies, adult patients with chronic liver disease and thrombocytopenia undergoing invasive procedures, any interventions and comparators, and haemorrhagic events of any severity as outcome. RESULTS The literature search identified 1276 unique publications, and 15 studies met the inclusion criteria and were analysed together with those identified by the previous search. Most of the new studies included in our analysis did not assess the association between post-procedural bleeding risk and platelet count alone in patients with chronic liver disease. Furthermore, some results could have been biased by prophylactic platelet transfusions. A few studies found that severe thrombocytopenia may be predictive of bleeding following percutaneous liver biopsy, dental extractions, percutaneous ablation of liver tumours and endoscopic polypectomy. CONCLUSIONS Currently available literature cannot support definitive conclusions about the appropriate target platelet counts to improve the risk of bleeding in cirrhotic patients who underwent invasive procedures; moreover, it showed enormous variability in the use of prophylactic platelet transfusions.
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Affiliation(s)
- Domenico Alvaro
- Department of Translational and Precision MedicineSapienza University of RomeRomeItaly
| | - Nicola Caporaso
- Department of Clinical Medicine and SurgeryUniversity of Naples 'Federico II'NaplesItaly
| | - Edoardo Giovanni Giannini
- Gastroenterology UnitDepartment of Internal MedicineUniversity of Genoa, IRCCS‐Ospedale Policlinico San MartinoGenoaItaly
| | - Angelo Iacobellis
- Division of GastroenterologyFondazione IRCCS Casa Sollievo della SofferenzaFoggiaItaly
| | | | - Pierluigi Toniutto
- Hepatology and Liver Transplantation UnitAzienda Sanitaria Universitaria IntegrataAcademic HospitalUdineItaly
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Cifci S, Ekmen N. Evaluation of Non-invasive Fibrosis Markers in Predicting Esophageal Variceal Bleeding. Clin Endosc 2021; 54:857-863. [PMID: 34034454 PMCID: PMC8652170 DOI: 10.5946/ce.2021.028] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Accepted: 01/10/2021] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND/AIMS Esophageal variceal bleeding (EVB) is an important cause of mortality and morbidity in liver cirrhosis. In this study, we aimed to predict the possibility of EVB in patients with cirrhosis using a non-invasive score. METHODS A total of 359 patients with cirrhosis were divided into two groups based on the presence or absence of EVB. ChildTurcotte-Pugh (CTP) score, a model for end-stage liver disease, aspartate aminotransferase to alanine aminotransferase ratio, aspartate aminotransferase to platelet ratio index (APRI), fibrosis-4-index (FIB-4), aspartate aminotransferase to alanine aminotransferase ratio/platelet ratio index (AARPRI), and S-index were measured for all participants. Receiver operating characteristic curves were obtained for all parameters, and the optimal cut-off value was determined in predicting EVB. RESULTS In patients with EVB, the number of platelets (PLT) were low (p<0.001) and APRI, AARPRI, FIB-4, and S-index were significantly higher than those in patients without EBV. APRI, AARPRI, FIB-4, PLT, and S-index were statistically significant predictors of EVB (p<0.05). CONCLUSION FIB-4 and AARPRI, which are non-invasive markers of fibrosis, can be used to predict EVB. In addition, the 66.5 109/L cut-off value for PLT is important for EVB.
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Affiliation(s)
- Sami Cifci
- Department of Gastroenterology, İstanbul Basaksehir Cam-Sakura City Hospital, Istanbul, Turkey
| | - Nergiz Ekmen
- Department of Gastroenterology Gazi University Medical Faculty, Ankara, Turkey
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33
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Kovalic AJ, Satapathy SK. Secondary Prophylaxis of Variceal Bleeding in Liver Cirrhosis. VARICEAL BLEEDING IN LIVER CIRRHOSIS 2021:77-121. [DOI: 10.1007/978-981-15-7249-4_7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2025]
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Bleeding After Elective Interventional Endoscopic Procedures in a Large Cohort of Patients With Cirrhosis. Clin Transl Gastroenterol 2020; 11:e00288. [PMID: 33337822 PMCID: PMC7748214 DOI: 10.14309/ctg.0000000000000288] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Accepted: 11/06/2020] [Indexed: 01/28/2023] Open
Abstract
INTRODUCTION: Elective therapeutic endoscopy is an important component of care of cirrhotic patients, but there are concerns regarding the risk of bleeding. This study examined the incidence, risk factors, and outcomes of bleeding after endoscopic variceal ligation (EVL), colonoscopic polypectomy, and endoscopic retrograde cholangiopancreatography with sphincterotomy in cirrhotic patients. METHODS: A cohort study of patients with cirrhosis who underwent the above procedures at a single center between 2012 and 2014 was performed. Patients with active bleeding at the time of procedure were excluded. Patients were followed for 30 days to assess for postprocedural bleeding and for 90 days for mortality. RESULTS: A total of 1,324 procedures were performed in 857 patients (886 upper endoscopies, 358 colonoscopies, and 80 endoscopic retrograde cholangiopancreatograpies). After EVL, bleeding occurred in 2.8%; after polypectomy, bleeding occurred in 2.0%; and after sphincterotomy, bleeding occurred in 3.8%. Independent predictors of bleeding after EVL and polypectomy included younger age and lower hemoglobin. For EVL, bleeding was also associated with infection and model for end-stage liver disease-Na. International normalized ratio was associated with bleeding in univariate analysis only, and platelet count was not associated with bleeding in any procedure. Bleeding after EVL was associated with 29% 90-day mortality, and bleeding after polypectomy was associated with 14% mortality. Of the 3 patients with postsphincterotomy bleeding, none were outliers regarding their baseline characteristics. DISCUSSION: In patients with cirrhosis, bleeding occurs infrequently after elective therapeutic endoscopy and is associated with younger age, lower hemoglobin, and high mortality. Consideration of these risk factors may guide appropriate timing and preprocedural management to optimize outcomes.
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de Oliveira Souza E, D'Amico ÉA, Flores da Rocha TR, Marcondes Ferreira C, Medeiros Batista J, Carneiro D'Albuquerque LA, Carrilho FJ, Queiroz Farias A. Preservation of platelet function in patients with cirrhosis and thrombocytopenia undergoing esophageal variceal ligation. Hepatobiliary Pancreat Dis Int 2020; 19:555-560. [PMID: 31982344 DOI: 10.1016/j.hbpd.2019.12.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Accepted: 12/27/2019] [Indexed: 02/05/2023]
Abstract
BACKGROUND Thrombocytopenia is a possible risk factor for bleeding after band ligation of esophageal varices. However, elevated von Willebrand factor (VWF) in cirrhosis improves platelet function and could decrease this risk. Our objective was to assess platelet function in patients with cirrhosis undergoing esophageal variceal ligation (EVL). METHODS The assessment consisted of platelet count, antigen and activity of VWF and VWF-cleaving protease ADAMTS-13 activity, and a platelet adhesion and aggregation test simulating vascular flow in vivo (Impact-RⓇ) prior to EVL. RESULTS Totally 111 patients were divided into three groups according to platelet count: (1) < 50 × 109/L (n = 38, 34.2%); (2) 50 × 109/L to 100 × 109/L (n = 47, 42.3%); and (3) > 100 × 109/L (n = 26, 23.4%). No statistically significant difference was found in the aggregate size of platelets [group 1: 41.0 (31.8-67.3) µm2; group 2: 47.0 (33.8-71.3) µm2; and group 3: 47.0 (34.0-66.0) µm2; P = 0.60] and no significant correlation was found between aggregate size and platelet count (Spearman r = 0.07; P = 0.47). Surface coverage was 4.1% (2.8%-6.7%), 8.5% (4.0%-10.0%), and 9.0% (7.1%-12.0%) (P < 0.001) in groups 1, 2 and 3, respectively and correlated with platelet count (Spearman r = 0.39; P < 0.0001). There was no significant difference between groups in VWF or ADAMTS-13. Post-EVL bleeding occurred in six (5.4%) patients (n = 2 in group 1, n = 1 in group 2, and n = 3 in group 3; P = 0.32). Patients with bleeding had higher MELD scores [15.0 (11.3-20.3) versus 12.0 (10.0-15.0); P = 0.025], but no difference was demonstrated for platelet function parameters. CONCLUSION Platelet function is preserved even in the presence of thrombocytopenia, including in the patients with post-EVL bleeding.
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Affiliation(s)
- Evandro de Oliveira Souza
- Division of Gastroenterology and Hepatology, University of Sao Paulo School of Medicine, Av. Dr. Eneas Carvalho de Aguiar, 255, 9th floor, office 9159, Sao Paulo, SP 05403-000, Brazil.
| | - Élbio Antônio D'Amico
- Hemostasis Laboratory, Hematology Service, University of Sao Paulo School of Medicine, Av. Dr. Eneas Carvalho de Aguiar, 255, 2nd floor, Sao Paulo, SP 05403-000, Brazil
| | - Tânia Rúbia Flores da Rocha
- Hemostasis Laboratory, Hematology Service, University of Sao Paulo School of Medicine, Av. Dr. Eneas Carvalho de Aguiar, 255, 2nd floor, Sao Paulo, SP 05403-000, Brazil
| | - Caroline Marcondes Ferreira
- Division of Gastroenterology and Hepatology, University of Sao Paulo School of Medicine, Av. Dr. Eneas Carvalho de Aguiar, 255, 9th floor, office 9159, Sao Paulo, SP 05403-000, Brazil
| | - Juliana Medeiros Batista
- Division of Gastroenterology and Hepatology, University of Sao Paulo School of Medicine, Av. Dr. Eneas Carvalho de Aguiar, 255, 9th floor, office 9159, Sao Paulo, SP 05403-000, Brazil
| | - Luiz Augusto Carneiro D'Albuquerque
- Division of Gastroenterology and Hepatology, University of Sao Paulo School of Medicine, Av. Dr. Eneas Carvalho de Aguiar, 255, 9th floor, office 9159, Sao Paulo, SP 05403-000, Brazil
| | - Flair José Carrilho
- Division of Gastroenterology and Hepatology, University of Sao Paulo School of Medicine, Av. Dr. Eneas Carvalho de Aguiar, 255, 9th floor, office 9159, Sao Paulo, SP 05403-000, Brazil
| | - Alberto Queiroz Farias
- Division of Gastroenterology and Hepatology, University of Sao Paulo School of Medicine, Av. Dr. Eneas Carvalho de Aguiar, 255, 9th floor, office 9159, Sao Paulo, SP 05403-000, Brazil
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Proton-pump-inhibitor use associated with lower short-term rebleeding and mortality in patients receiving esophageal variceal band ligation: a retrospective cohort study. Eur J Gastroenterol Hepatol 2020; 32:1571-1578. [PMID: 32868651 DOI: 10.1097/meg.0000000000001905] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND The impact of proton-pump inhibitor (PPI) therapy on subsequent hemorrhage and mortality after variceal hemorrhage is unclear. AIM Evaluate the associations of PPI use with upper gastrointestinal bleeding (UGIB) and death within 30 days of undergoing esophageal variceal band ligation (EBL) separately in inpatient and outpatient settings. METHODS Retrospective review of cirrhotic patients with variceal hemorrhage who underwent EBL between 2005 and 2018. Endoscopic findings, PPI use at admission (inpatients only), PPI use at discharge (inpatients and outpatients), and adverse outcomes data (liver transplant, UGIB, transjugular intrahepatic portosystemic shunt, and death within 30 days of discharge or death during hospitalization) were reviewed. RESULTS A total of 446 patients (164 inpatients, 282 outpatients) were included. The most commonly observed outcomes were death within 30 days of discharge in inpatients (12.8%), UGIB within 30 days of discharge in inpatients (21.3%), and UGIB within 30 days of discharge in outpatients (8.5%). For inpatients, prescription of PPI at discharge was associated with a lower risk of bleeding within 30 days (odds ratio: 0.30, P = 0.025) and death within 30 days (odds ratio = 0.16, P = 0.002). No other significant associations of PPI with death or UGIB were reported. CONCLUSION Post-EBL PPI therapy is associated with reduced risk of bleeding and death within 30 days after variceal hemorrhage in hospitalized patients.
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Giannini EG, Bodini G, Marabotto E, Plaz Torres MC, Zentilin P, Furnari M. Risk factors for bleeding following oesophageal band ligation: Providing further evidence to ameliorate clinical practice. Dig Liver Dis 2020; 52:792-793. [PMID: 32402747 DOI: 10.1016/j.dld.2020.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Accepted: 04/09/2020] [Indexed: 12/11/2022]
Affiliation(s)
- Edoardo G Giannini
- Gastroenterology Unit, Department of Internal Medicine, University of Genoa, IRCCS-Ospedale Policlinico San Martino, Viale Benedetto XV, no.6, 16132 Genoa, Italy.
| | - Giorgia Bodini
- Gastroenterology Unit, Department of Internal Medicine, University of Genoa, IRCCS-Ospedale Policlinico San Martino, Viale Benedetto XV, no.6, 16132 Genoa, Italy
| | - Elisa Marabotto
- Gastroenterology Unit, Department of Internal Medicine, University of Genoa, IRCCS-Ospedale Policlinico San Martino, Viale Benedetto XV, no.6, 16132 Genoa, Italy
| | - Maria Corina Plaz Torres
- Gastroenterology Unit, Department of Internal Medicine, University of Genoa, IRCCS-Ospedale Policlinico San Martino, Viale Benedetto XV, no.6, 16132 Genoa, Italy
| | - Patrizia Zentilin
- Gastroenterology Unit, Department of Internal Medicine, University of Genoa, IRCCS-Ospedale Policlinico San Martino, Viale Benedetto XV, no.6, 16132 Genoa, Italy
| | - Manuele Furnari
- Gastroenterology Unit, Department of Internal Medicine, University of Genoa, IRCCS-Ospedale Policlinico San Martino, Viale Benedetto XV, no.6, 16132 Genoa, Italy
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Maida M, Sferrazza S, Maida C, Morreale GC, Vitello A, Longo G, Garofalo V, Sinagra E. Management of antiplatelet or anticoagulant therapy in endoscopy: A review of literature. World J Gastrointest Endosc 2020; 12:172-192. [PMID: 32843928 PMCID: PMC7415229 DOI: 10.4253/wjge.v12.i6.172] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Revised: 05/09/2020] [Accepted: 05/20/2020] [Indexed: 02/06/2023] Open
Abstract
Endoscopic procedures hold a basal risk of bleeding that depends on the type of procedure and patients’ comorbidities. Moreover, they are often performed in patients taking antiplatelet and anticoagulants agents, increasing the potential risk of intraprocedural and delayed bleeding. Even if the interruption of antithrombotic therapies is undoubtful effective in reducing the risk of bleeding, the thromboembolic risk that follows their suspension should not be underestimated. Therefore, it is fundamental for each endoscopist to be aware of the bleeding risk for every procedure, in order to measure the risk-benefit ratio for each patient. Moreover, knowledge of the proper management of antithrombotic agents before endoscopy, as well as the adequate timing for their resumption is essential.
This review aims to analyze current evidence from literature assessing, for each procedure, the basal risk of bleeding and the risk of bleeding in patients taking antithrombotic therapy, as well as to review the recommendation of American society for gastrointestinal endoscopy, European society of gastrointestinal endoscopy, British society of gastroenterology, Asian pacific association of gastroenterology and Asian pacific society for digestive endoscopy guidelines for the management of antithrombotic agents in urgent and elective endoscopic procedures.
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Affiliation(s)
- Marcello Maida
- Gastroenterology and Endoscopy Unit, S. Elia-Raimondi Hospital, Caltanissetta 93100, Italy
| | - Sandro Sferrazza
- Gastroenterology and Endoscopy Unit, Santa Chiara Hospital, Trento 38123, Italy
| | - Carlo Maida
- U.O.C di Medicina Interna con Stroke Care, Dipartimento di Promozione della Salute, Materno-Infantile, di Medicina Interna e Specialistica di Eccellenza “G. D’Alessandro”, University of Palermo, Palermo 93100, Italy
| | | | - Alessandro Vitello
- Gastroenterology and Endoscopy Unit, S. Elia-Raimondi Hospital, Caltanissetta 93100, Italy
| | - Giovanni Longo
- Cardiology Unit, S. Elia-Raimondi Hospital, Caltanissetta 93100, Italy
| | - Vincenzo Garofalo
- Gastroenterology and Endoscopy Unit, S. Elia-Raimondi Hospital, Caltanissetta 93100, Italy
| | - Emanuele Sinagra
- Gastroenterology and Endoscopy Unit, Istituto San Raffaele Giglio, Cefalù 90015, Italy
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Sigal SH, Sherman Z, Jesudian A. Clinical Implications of Thrombocytopenia for the Cirrhotic Patient. ACTA ACUST UNITED AC 2020; 12:49-60. [PMID: 32341665 PMCID: PMC7166072 DOI: 10.2147/hmer.s244596] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2020] [Accepted: 03/10/2020] [Indexed: 02/06/2023]
Abstract
Thrombocytopenia is a frequent complication in patients with cirrhosis. As many as 84% of patients with cirrhosis have thrombocytopenia, and it is an independent variable indicative of advanced disease and poor prognosis. Although there is great concern that it may aggravate bleeding during surgical procedures, there is limited evidence to inform decisions regarding the treatment of cirrhotic patients with thrombocytopenia undergoing invasive procedures. Finally, there is evidence that platelets play a significant role in liver regeneration. In this report, the clinical implications of thrombocytopenia in cirrhotic patients are reviewed. The utility of platelet counts in the prognosis of cirrhosis and relationship to complications of advanced liver disease, including portal hypertension, esophageal varices, and hepatocellular carcinoma. The impact of low platelet counts on bleeding complications during invasive procedures is outlined. Finally, the role of platelets and potential adverse impact in liver regeneration is reviewed.
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Affiliation(s)
- Samuel H Sigal
- Department of Medicine, Montefiore Medical Center, Bronx, NY, USA
| | - Zachary Sherman
- Department of Medicine, Weill Cornell Medical Center, New York, NY, USA
| | - Arun Jesudian
- Department of Medicine, Weill Cornell Medical Center, New York, NY, USA
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Wang AJ, Wang J, Zheng XL, Liao WD, Yu HQ, Gong Y, Gan N, You Y, Guo GH, Xie BS, Zhong JW, Hong JB, Liu L, Shu X, Zhu Y, Li BM, Zhu X. Second-look endoscopy-guided therapy under sedation prevents early rebleeding after variceal ligation for acute variceal bleeding. J Dig Dis 2020; 21:170-178. [PMID: 32031737 DOI: 10.1111/1751-2980.12847] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Revised: 02/04/2020] [Accepted: 02/04/2020] [Indexed: 12/11/2022]
Abstract
OBJECTIVES To investigate whether second-look endoscopy (SLE)-guided therapy could be used to prevent post-endoscopic variceal ligation (EVL) early bleeding. METHODS Consecutive cirrhotic patients with large esophageal varices (EV) receiving successful EVL for acute variceal bleeding (AVB) or secondary prophylaxis were enrolled. The patients were randomized into a SLE group and a non-SLE group (NSLE) 10 days after EVL. Additional endoscopic interventions as well as proton pump inhibitors and octreotide administration were applied based on the SLE findings. The post-EVL early rebleeding and mortality rates were compared between the two groups. RESULTS A total of 252 patients were included in the final analysis. Post-EVL early rebleeding (13.5% vs 4.8%, P = 0.016) and bleeding-caused mortality (4.8% vs 0%, P = 0.013) were more frequently observed in the NSLE group than in the SLE group. However, post-EVL early rebleeding and mortality rates were reduced by SLE in patients receiving EVL for AVB only but not in those receiving secondary prophylaxis. Patients with Child-Pugh classification B to C at randomization (hazard ratio [HR] 8.77, P = 0.034), AVB at index EVL (HR 3.62, P = 0.003), discontinuation of non-selective β-blocker after randomization (HR 4.68, P = 0.001) and non-SLE (HR 2.63, P = 0.046) were more likely to have post-EVL early rebleeding. No serious adverse events occurred during SLE. CONCLUSION SLE-guided therapy reduces post-EVL early rebleeding and mortality rates in cirrhotic patients with large EV receiving EVL for AVB.
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Affiliation(s)
- An Jiang Wang
- Department of Gastroenterology and Hepatology, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province, China
| | - Jian Wang
- Department of Gastroenterology and Hepatology, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province, China
| | - Xue Lian Zheng
- Department of Pharmacy, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province, China
| | - Wang Di Liao
- Department of Gastroenterology and Hepatology, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province, China
| | - Hui Qiang Yu
- Department of Health Statistics, School of Public Health, Nanchang University, Nanchang, Jiangxi Province, China
| | - Yue Gong
- Department of Gastroenterology and Hepatology, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province, China
| | - Na Gan
- Department of Gastroenterology and Hepatology, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province, China
| | - Yu You
- Department of Gastroenterology and Hepatology, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province, China
| | - Gui Hai Guo
- Department of Gastroenterology and Hepatology, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province, China
| | - Bu Shan Xie
- Department of Gastroenterology and Hepatology, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province, China
| | - Jia Wei Zhong
- Department of Gastroenterology and Hepatology, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province, China
| | - Jun Bo Hong
- Department of Gastroenterology and Hepatology, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province, China
| | - Li Liu
- Department of Gastroenterology and Hepatology, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province, China
| | - Xu Shu
- Department of Gastroenterology and Hepatology, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province, China
| | - Yin Zhu
- Department of Gastroenterology and Hepatology, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province, China
| | - Bi Min Li
- Department of Gastroenterology and Hepatology, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province, China
| | - Xuan Zhu
- Department of Gastroenterology and Hepatology, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province, China
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Dueñas E, Cachero A, Amador A, Rota R, Salord S, Gornals J, Xiol X, Castellote J. Ulcer bleeding after band ligation of esophageal varices: Risk factors and prognosis. Dig Liver Dis 2020; 52:79-83. [PMID: 31395524 DOI: 10.1016/j.dld.2019.06.019] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2018] [Revised: 04/30/2019] [Accepted: 06/23/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND Post-banding ulcer bleeding is a rare complication of endoscopic band ligation of esophageal varices with high morbidity and mortality. There exist no management guidelines for this complication. AIMS To determine the incidence, outcome and risk factors of post-banding ulcer bleeding. METHODS Data for cirrhotic patients with acute variceal bleeding during a six-year period were prospectively collected, and all band ligation sessions performed were retrospectively analyzed. Demographic, analytic and endoscopic data were recorded, as well as complications, outcome and management of each episode of post-banding ulcer bleeding. RESULTS The study includes 521 band ligation sessions performed on 175 patients. There were 24 cases of post-banding ulcer bleeding in 21 patients (incidence 4.6%). Independent risk factors for post-banding ulcer bleeding were MELD score, hepatocellular carcinoma and total beta-blocker dose. Mortality during the bleeding episode was 23.8%. Active bleeding or adherent clots at the time of endoscopy was associated with treatment failure or death. CONCLUSIONS Post-banding ulcer bleeding is an uncommon but severe complication of esophageal banding. Patients with hepatocellular carcinoma, poor liver function and a low beta-blocker dose have higher risk of post-banding ulcer bleeding. An aggressive treatment should be considered in case of active bleeding at endoscopy.
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Affiliation(s)
- Eva Dueñas
- Hepatology Unit. Gastroenterology Department. Hospital of Bellvitge. ICS. Research group of Hepato-biliary and pancreatic diseases. IDIBELL. Barcelona University. L'Hospitalet de LLobregat. Barcelona. Spain
| | - Alba Cachero
- Hepatology Unit. Gastroenterology Department. Hospital of Bellvitge. ICS. Research group of Hepato-biliary and pancreatic diseases. IDIBELL. Barcelona University. L'Hospitalet de LLobregat. Barcelona. Spain
| | - Alberto Amador
- Hepatology Unit. Gastroenterology Department. Hospital of Bellvitge. ICS. Research group of Hepato-biliary and pancreatic diseases. IDIBELL. Barcelona University. L'Hospitalet de LLobregat. Barcelona. Spain
| | - Rosa Rota
- Hepatology Unit. Gastroenterology Department. Hospital of Bellvitge. ICS. Research group of Hepato-biliary and pancreatic diseases. IDIBELL. Barcelona University. L'Hospitalet de LLobregat. Barcelona. Spain
| | - Silvia Salord
- Hepatology Unit. Gastroenterology Department. Hospital of Bellvitge. ICS. Research group of Hepato-biliary and pancreatic diseases. IDIBELL. Barcelona University. L'Hospitalet de LLobregat. Barcelona. Spain
| | - Joan Gornals
- Hepatology Unit. Gastroenterology Department. Hospital of Bellvitge. ICS. Research group of Hepato-biliary and pancreatic diseases. IDIBELL. Barcelona University. L'Hospitalet de LLobregat. Barcelona. Spain
| | - Xavier Xiol
- Hepatology Unit. Gastroenterology Department. Hospital of Bellvitge. ICS. Research group of Hepato-biliary and pancreatic diseases. IDIBELL. Barcelona University. L'Hospitalet de LLobregat. Barcelona. Spain
| | - José Castellote
- Hepatology Unit. Gastroenterology Department. Hospital of Bellvitge. ICS. Research group of Hepato-biliary and pancreatic diseases. IDIBELL. Barcelona University. L'Hospitalet de LLobregat. Barcelona. Spain.
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Lima TB, Santos LAA, Nunes HRDC, Silva GF, Caramori CA, Qi X, Romeiro FG. Safety and efficacy of risedronate for patients with esophageal varices and liver cirrhosis: a non-randomized clinical trial. Sci Rep 2019; 9:18958. [PMID: 31831865 PMCID: PMC6908659 DOI: 10.1038/s41598-019-55603-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Accepted: 11/22/2019] [Indexed: 02/07/2023] Open
Abstract
Despite the high prevalence of osteoporosis in liver cirrhosis, the indication of bisphosphonates for patients with esophageal varices has been avoided due to risk of digestive mucosal damage. Therefore, this study aimed to evaluate the safety profile of risedronate treatment for patients with osteoporosis, liver cirrhosis and esophageal varices with low risk of bleeding. A total of 120 patients were allocated into two groups according to their bone mineral density measured by dual-energy X-ray absorptiometry. In the intervention group, 57 subjects with osteoporosis received oral risedronate at 35 mg weekly plus daily calcium and vitamin D supplementation. In the control group, 63 subjects with osteopenia received only calcium and vitamin D. The groups received the treatment for one year and underwent surveillance endoscopies at six and 12 months, as well as a control dual-energy X-ray absorptiometry after a 12-month follow-up. The study received Institutional Review Board approval. The groups had not only comparable Model for End-stage Liver Disease score and esophageal varices degree, but also similar incidence of digestive adverse effects. A significant improvement was achieved in the intervention group in the lumbar spine T score (p < 0.001). The results suggest that risedronate may be safely used in liver cirrhosis and esophageal varices with low bleeding risk under endoscopic surveillance, thus allowing bone mass recovery.
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Affiliation(s)
- Talles Bazeia Lima
- Internal Medicine Department, Gastroenterology Division - São Paulo State University (UNESP), Botucatu Medical School, São Paulo, Brazil
| | - Lívia Alves Amaral Santos
- Internal Medicine Department, Gastroenterology Division - São Paulo State University (UNESP), Botucatu Medical School, São Paulo, Brazil
| | | | - Giovanni Faria Silva
- Internal Medicine Department, Gastroenterology Division - São Paulo State University (UNESP), Botucatu Medical School, São Paulo, Brazil
| | - Carlos Antonio Caramori
- Internal Medicine Department, Gastroenterology Division - São Paulo State University (UNESP), Botucatu Medical School, São Paulo, Brazil
| | - Xingshun Qi
- General Hospital of Shenyang Military Command, Liaoning, Sheng, China
| | - Fernando Gomes Romeiro
- Internal Medicine Department, Gastroenterology Division - São Paulo State University (UNESP), Botucatu Medical School, São Paulo, Brazil.
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Leith D, Mookerjee RP. Variceal Bleeding. EVIDENCE‐BASED GASTROENTEROLOGY AND HEPATOLOGY 4E 2019:619-644. [DOI: 10.1002/9781119211419.ch41] [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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Jamwal KD, Maiwall R, Sharma MK, Kumar G, Sarin SK. Case Control Study of Post-endoscopic Variceal Ligation Bleeding Ulcers in Severe Liver Disease: Outcomes and Management. J Clin Transl Hepatol 2019; 7:32-39. [PMID: 30944817 PMCID: PMC6441646 DOI: 10.14218/jcth.2018.00059] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Revised: 01/18/2019] [Accepted: 01/25/2019] [Indexed: 12/17/2022] Open
Abstract
Background and Aims: The management of post-endoscopic variceal ligation (EVL) bleeding ulcers (PEBUs) is currently based on local expertise and patients liver disease status. The present retrospective study investigated associations between the endoscopic morphology of PEBUs and patient outcomes. Methods: Patients underwent EVL (primary or secondary), from January 2015 to January 2018, in two tertiary care hospitals in India (ILBS New Delhi and Dharamshila Narayana New Delhi). Mortality rates were determined at post-EVL day five and week six. PEBUs were typified based on Jamwal & Sarin classification system as follows: A, ulcer with active spurting; B, ulcer with ooze; C, ulcer base with visible vessel or clot; and D, clean or pigmented base. Results: Of 3854 EVL procedures, 141 (3.6%) patients developed PEBU, and 46/141 (32.6%) suffered mortality. Among the former, the PEBU types A, B, C, and D accounted for 17.7, 26.2, 36.3, and 19.8%, respectively. Of those who died, 39.1, 30.4, 21.7, and 8.8% had PEBU types A, B, C, and D. Treatments included transjugular intrahepatic portosystemic shunts (TIPS), esophageal self-expandable metal stent (SEMS), glue and sclerosant injection, Sengstaken-Blakemore tube placement and liver transplant. On univariate analysis, no correlation with hepatic venous pressure gradient, TIPS placement, size of varices, or number of bands was found. The Model for End-Stage Liver Disease (MELD)-sodium score correlated positively with outcome. After adjusting for MELD-sodium score, mortality was best predicted by type-A ulcer (p = 0.024; OR 8.95, CI 1.34-59.72). Conclusions: PEBU occurred in 3.6% of a large EVL cohort. Stratifying patients based on PEBU type can help predict outcomes, independent of the MELD-sodium score. Classifying PEBUs by endoscopic morphology may inform treatment strategies, and warrants further validation.
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Affiliation(s)
- Kapil D. Jamwal
- Department of Gastroenterology, Artemis Hospital Gurugram, Haryana, India
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
- Department of Gastroenterology, Dharamshila Narayana Superspeciality Hospital, New Delhi, India
- *Correspondence to: Kapil D. Jamwal, Department of Gastroenterology, Artemis Hospital, Gurugram, Haryana 122001, India. Tel: +91-1245111111, E-mail:
| | - Rakhi Maiwall
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Manoj K. Sharma
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Guresh Kumar
- Department of Research and Biostatistics, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Shiv K. Sarin
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
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Li Y, Guo X, Bai Z, Shao X, Wang R, Li H, Qi X. Banana may be forbidden after endoscopic variceal ligation: a case report. Transl Gastroenterol Hepatol 2019; 4:13. [PMID: 30976716 PMCID: PMC6414354 DOI: 10.21037/tgh.2019.01.11] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2018] [Accepted: 01/27/2019] [Indexed: 02/05/2023] Open
Abstract
Acute variceal hemorrhage (AVH) is a devastating complication of liver cirrhosis. Endoscopic variceal ligation (EVL) is a useful endoscopic treatment for AVH with few complications. However, the issue regarding management of early re-bleeding after EVL still needs to be concerned. Furthermore, the dietary principle after EVL is unclear. There is no consensus regarding what food should be eaten after EVL. In this paper, we reported a patient who ate a banana after an EVL and then developed early re-bleeding episodes.
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Affiliation(s)
- Yingying Li
- Department of Gastroenterology, General Hospital of Northern Theater Command (formerly General Hospital of Shenyang Military Area), Shenyang 110840, China
- Postgraduate College, Jinzhou Medical University, Jinzhou 121001, China
| | - Xiaozhong Guo
- Department of Gastroenterology, General Hospital of Northern Theater Command (formerly General Hospital of Shenyang Military Area), Shenyang 110840, China
| | - Zhaohui Bai
- Department of Gastroenterology, General Hospital of Northern Theater Command (formerly General Hospital of Shenyang Military Area), Shenyang 110840, China
- Postgraduate College, Shenyang Pharmaceutical University, Shenyang 110840, China
| | - Xiaodong Shao
- Department of Gastroenterology, General Hospital of Northern Theater Command (formerly General Hospital of Shenyang Military Area), Shenyang 110840, China
| | - Ran Wang
- Department of Gastroenterology, General Hospital of Northern Theater Command (formerly General Hospital of Shenyang Military Area), Shenyang 110840, China
| | - Hongyu Li
- Department of Gastroenterology, General Hospital of Northern Theater Command (formerly General Hospital of Shenyang Military Area), Shenyang 110840, China
| | - Xingshun Qi
- Department of Gastroenterology, General Hospital of Northern Theater Command (formerly General Hospital of Shenyang Military Area), Shenyang 110840, China
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Intagliata NM, Argo CK, Stine JG, Lisman T, Caldwell SH, Violi F. Concepts and Controversies in Haemostasis and Thrombosis Associated with Liver Disease: Proceedings of the 7th International Coagulation in Liver Disease Conference. Thromb Haemost 2018; 118:1491-1506. [PMID: 30060258 PMCID: PMC6202935 DOI: 10.1055/s-0038-1666861] [Citation(s) in RCA: 124] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2017] [Accepted: 05/17/2018] [Indexed: 12/12/2022]
Affiliation(s)
- N. M. Intagliata
- Department of Gastroenterology and Hepatology, University of Virginia, Charlottesville, Virginia, United States
| | - C. K. Argo
- Department of Gastroenterology and Hepatology, University of Virginia, Charlottesville, Virginia, United States
| | - J. G. Stine
- Department of Medicine, Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania, United States
| | - T. Lisman
- Department of Surgery, University Medical Centre Groningen, Groningen, The Netherlands
| | - S. H. Caldwell
- Department of Gastroenterology and Hepatology, University of Virginia, Charlottesville, Virginia, United States
| | - F. Violi
- I Clinica Medica, Department of Internal Medicine and Medical Specialties, Sapienza University of Rome, Rome, Italy
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47
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Aggeletopoulou I, Konstantakis C, Manolakopoulos S, Triantos C. Role of band ligation for secondary prophylaxis of variceal bleeding. World J Gastroenterol 2018; 24:2902-2914. [PMID: 30018485 PMCID: PMC6048424 DOI: 10.3748/wjg.v24.i26.2902] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Revised: 06/05/2018] [Accepted: 06/25/2018] [Indexed: 02/06/2023] Open
Abstract
AIM To summarize and critically examine the role of band ligation in secondary prophylaxis of variceal bleeding in patients with cirrhosis.
METHODS A literature review was performed using the MEDLINE and PubMed databases. The search terms consisted of the words “endoscopic band ligation” OR “variceal band ligation” OR “ligation” AND “secondary prophylaxis” OR “secondary prevention” AND “variceal bleeding” OR “variceal hemorrhage” AND “liver cirrhosis”. The data collected from relevant meta-analyses and from the most recent randomized studies that were not included in these meta-analyses were used to evaluate the role of endoscopic band ligation in an effort to demonstrate the most recent advances in the treatment of esophageal varices.
RESULTS This study included 11 meta-analyses published from 2002 to 2017 and 10 randomized trials published from 2010 to 2017 that evaluated the efficacy of band ligation in the secondary prophylaxis of variceal bleeding. Overall, the results proved that band ligation was superior to endoscopic sclerotherapy. Moreover, the use of β-blockers in combination with band ligation increased the treatment effectiveness, supporting the current recommendations for secondary prophylaxis of variceal bleeding. The use of transjugular intrahepatic portosystemic shunt was superior to combination therapy regarding rebleeding prophylaxis, with no difference in the survival rates; however, the results concerning the hepatic encephalopathy incidence were conflicting. Recent advances in the management of secondary prophylaxis of variceal bleeding have targeted a decrease in portal pressure based on the pathophysiological mechanisms of portal hypertension.
CONCLUSION This review suggests that future research should be conducted to enhance current interventions and/or to develop innovative treatment options with improved clinical endpoints.
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Affiliation(s)
| | | | - Spilios Manolakopoulos
- 2nd Department of Internal Medicine, Hippokration General Hospital of Athens, Athens 11527, Greece
| | - Christos Triantos
- Department of Gastroenterology, University Hospital of Patras, Patras 26504, Greece
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48
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Giannini EG, Giambruno E, Brunacci M, Plaz Torres MC, Furnari M, Bodini G, Zentilin P, Savarino V. Low Fibrinogen Levels Are Associated with Bleeding After Varices Ligation in Thrombocytopenic Cirrhotic Patients. Ann Hepatol 2018; 17:830-835. [PMID: 30145561 DOI: 10.5604/01.3001.0012.0775] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
INTRODUCTION AND AIM EVBL is a procedure frequently performed in cirrhotic patients for primary prophylaxis of bleeding. Patients with cirrhosis display various degrees of alteration of common coagulation parameters, and it is not known whether these alterations may predict post-EVBL bleeding. To evaluate factors predictive of post-endoscopic variceal band ligation (EVBL) bleeding in cirrhotic patients with thrombocytopenia. METHODS We included 109 patients with cirrhosis undergoing EVBL for primary prophylaxis of variceal bleeding. Common coagulation parameters (INR, fibrinogen levels) and complete haemogram were obtained in all patients and evaluated subdividing patients in bleeders and non bleeders following EVBL. RESULTS The incidence of post-EVBL bleeding was 5.5% (6 patients). INR and platelet counts, considered as continuous or dichotomous variables according to common cut-offs (i.e., INR>1.5, platelet count <50x109/L) were not predictors of post-EVBL bleeding. Patients who bled had significantly lower fibrinogen levels [146 mg/dL (98 - 262) versus 230 mg/dL (104 - 638), P=0.009], and no other biochemical or clinical predictors of bleeding were identified. A fibrinogen cut-off of 179 mg/dL had 98.6% negative predictive value for bleeding. CONCLUSION low fibrinogen levels are associated with an increased risk of bleeding following prophylactic EVBL in cirrhotic patients, and might be used to stratify patients' risk. However, due to their preliminary nature, these findings need to be confirmed in larger populations.
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Affiliation(s)
- Edoardo G Giannini
- Gastroenterology Unit, Department of Internal Medicine, University of Genoa, Ospedale Policlinico San Martino - IRCCS per l'Oncologia, Genoa, Italy
| | - Elisa Giambruno
- Gastroenterology Unit, Department of Internal Medicine, University of Genoa, Ospedale Policlinico San Martino - IRCCS per l'Oncologia, Genoa, Italy
| | - Mattteo Brunacci
- Gastroenterology Unit, Department of Internal Medicine, University of Genoa, Ospedale Policlinico San Martino - IRCCS per l'Oncologia, Genoa, Italy
| | - Maria Corina Plaz Torres
- Gastroenterology Unit, Department of Internal Medicine, University of Genoa, Ospedale Policlinico San Martino - IRCCS per l'Oncologia, Genoa, Italy
| | - Manuele Furnari
- Gastroenterology Unit, Department of Internal Medicine, University of Genoa, Ospedale Policlinico San Martino - IRCCS per l'Oncologia, Genoa, Italy
| | - Giorgia Bodini
- Gastroenterology Unit, Department of Internal Medicine, University of Genoa, Ospedale Policlinico San Martino - IRCCS per l'Oncologia, Genoa, Italy
| | - Patrizia Zentilin
- Gastroenterology Unit, Department of Internal Medicine, University of Genoa, Ospedale Policlinico San Martino - IRCCS per l'Oncologia, Genoa, Italy
| | - Vincenzo Savarino
- Gastroenterology Unit, Department of Internal Medicine, University of Genoa, Ospedale Policlinico San Martino - IRCCS per l'Oncologia, Genoa, Italy
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49
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Goenka MK, Goenka U, Tiwary IK, Rai V. Use of self-expanding metal stents for difficult variceal bleed. Indian J Gastroenterol 2017; 36:468-473. [PMID: 29368190 DOI: 10.1007/s12664-017-0800-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2017] [Accepted: 11/05/2017] [Indexed: 02/04/2023]
Abstract
BACKGROUND/AIM Patients with variceal band ligation (VBL)-induced ulcer bleeding and those with persisting bleeding in spite of VBL carry a high mortality. Balloon tamponade and transjugular intrahepatic portosystemic shunt have limitations in terms of complications, cost, and availability. The aim was to evaluate the efficacy of Sx-Ella Danis stent in persistent or complicated variceal bleeding. METHODS Twelve patients with either persistent variceal bleeding or VBL-induced ulcer bleeding were treated with the placement of Sx-Ella Danis stents. The patients were followed up for mortality, complications, and efficacy to control bleeding. RESULTS Stents were inserted successfully in all 12 patients (with immediate hemostasis). There was an immediate cessation of bleeding in all 12 patients with no stent-related complication. Five out of 12 patients died during 30 days post-procedure due to worsening encephalopathy or sepsis. Enteral feeding could be started in all 12 patients 6 h after stent placement. One patient had bleeding 10 days after stent removal and was re-stented but expired 7 days later. Stents were removed in eight patients at a mean duration of 17.5 days. (range 7 to 30 days). CONCLUSIONS Sx-Ella Danis stent is a useful modality to control persistent variceal bleeding as well VBL-related ulcer bleeding.
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Affiliation(s)
- M K Goenka
- Institute of Gastrosciences, Apollo Gleneagles Hospitals, Kolkata, 700 054, India.
| | - Usha Goenka
- Department of Clinical Imaging and Interventional Radiology, Apollo Gleneagles Hospitals, Kolkata, 700 054, India
| | - I K Tiwary
- Institute of Gastrosciences, Apollo Gleneagles Hospitals, Kolkata, 700 054, India
| | - Vijay Rai
- Institute of Gastrosciences, Apollo Gleneagles Hospitals, Kolkata, 700 054, India
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50
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Low skeletal muscle mass predicts early mortality in cirrhotic patients with acute variceal bleeding. Nutrition 2017; 42:87-91. [DOI: 10.1016/j.nut.2017.06.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Revised: 05/04/2017] [Accepted: 06/17/2017] [Indexed: 12/12/2022]
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