O uso contínuo da terlipressina após a ligadura endoscópica em hemorragia varicosa aguda necessita de mais evidências: um estudo piloto / Rational for continuing terlipressin after endoscopic variceal ligation in acute variceal haemorrhage needs further evidence: a pilot study

ABSTRACT Background Variceal hemorrhage (VH) is a medical emergency. Prompt endoscopic variceal ligation (EVL) is therapeutic. Terlipressin is used in VH and continued for 2—5 days even after EVL. As hemostasis is primarily achieved by EVL, the benefit of continuing trelipressin after EVL is unknown. Objective To evaluate the efficacy of continuing terlipressin after EVL to prevent re-bleed and mortality. Methods In this pilot study, after EVL 74 patients of VH were randomized into two treatment groups TG2 & TG5, received terlipressin (1 mg IV bolus q 4 hourly) for 2 days and 5 days respectively and one control group (TG0), received 0.9% normal saline (10 mL IV bolus q 4 hourly) and followed up for 8 weeks. Results A total of 9 (12.6%) patients had re-bleed with maximum 4 (5.6%) patients in TG5 group followed by 3 (4.2%) in TG2 and 2 (2.8%) in TG0 groups (P=0.670). The overall mortality was 15 (21.1%) patients, 6 (8.5%) patients in TG0 group, followed by 5 (7.0%) in TG5 and 4 (5.6%) in TG2 group (P=0.691). Adverse drug reactions were significantly higher in treatment groups with maximum 18 (24.32%) patients in TG5, followed by 8 (10.8%) in TG2 and 2 (2.7%) in TG0 groups (P=0.00). Duration of hospital stay was also significantly higher in treatment group, 6.63 (±0.65) days in TG5 followed by 3.64 (±0.57) in TG2 and 2.40 (±0.50) days in TG0 groups (P=0.00). Conclusion The rational for continuing terlipressin after EVL is doubtful as it didn't have any benefit for the prevention of re-bleed or mortality; rather it increased the risk of adverse drug reactions and duration of hospital stay. Further randomized clinical trials are encouraged to generate more evidence in support or against continuing terlipressin after EVL.

RESUMO Contexto A hemorragia varicosa (HV) é emergência médica. A ligadura endoscópica imediata das varizes (LEV) é terapêutica. A terlipressina é usada em HV e contínua por 2—5 dias mesmo após a LEV. Como a hemostasia é alcançada principalmente pela LEV, o benefício do uso contínuo da terlipressina após o evento é desconhecido. Objetivo Avaliar a eficácia da terlipressina contínua após a LEV para evitar o ressangramento e a mortalidade. Métodos Neste estudo piloto, após a LEV, 74 pacientes com HV foram randomizados em dois grupos de tratamento TG2 & TG5, que receberam terlipressina (1 mg EV em bolus a cada 4 horas) durante 2—5 dias, respectivamente, e um grupo controle (TG0), que receberam soro fisiológico normal de 0,9% (10 mL EV em bolus a cada 4 horas) e foram seguidos por 8 semanas. Resultados Um total de 9 (12,6%) pacientes tiveram ressangramento, 4 (5,6%) no grupo TG5, seguidos por 3 (4,2%) no TG2 e 2 (2,8%) no grupo TG0 (P=0,670). A mortalidade geral de pacientes foi de 15 (21,1%), 6 (8,5%) no grupo TG0, seguidos por 5 (7,0%) no TG5 e 4 (5,6%) no TG2 (P=0,691). As reações adversas de medicamentos foram significativamente maiores em grupos de tratamento em 18 (24,32%) pacientes no TG5, seguidos por 8 (10,8%) no TG2 e 2 (2,7%) em grupo TG0 (P=0,00). A duração da internação hospitalar também foi significativamente maior no grupo de tratamento, 6,63 (±0,65) dias no TG5, seguido por 3,64 (±0,57) em TG2 e 2,40 (±0,50) dias em grupos TG0 (P=0,00). Conclusão O uso racional para a continuação da terlipressina após a LEV é duvidoso, pois não teve qualquer benefício para a prevenção de ressangramento ou mortalidade; pelo contrário, aumentou o risco de efeitos adversos e duração da internação hospitalar. Outros ensaios clínicos randomizados são necessários para gerar mais evidências em apoio ou contra a terlipressina contínua após a LEV.

Outcomes of patients treated with Sengstaken-Blakemore tube for uncontrolled variceal hemorrhage

BACKGROUND/AIMS: The aim of this study was to investigate the mortality, bleeding control rate, and their associated predictors in patients treated with Sengstaken-Blakemore (SB) tube for uncontrolled variceal hemorrhage associated with hemodynamic instability or failure of endoscopic treatment. METHODS: The clinical data of 66 consecutive patients with uncontrolled variceal hemorrhage treated with SB tube at Gyeongsang National University Hospital from October 2010 to October 2015 were retrospectively analyzed. RESULTS: The overall success rate of initial hemostasis with SB tube was 75.8%, and the independent factors associated with hemostasis were non-intubated state before SB tube (odds ratio, 8.50; p = 0.007) and Child-Pugh score < 11 (odds ratio, 15.65; p = 0.022). Rebleeding rate after successful initial hemostasis with SB tube was 22.0%, and esophageal rupture occurred in 6.1%. Mortality within 30 days was 42.4%, and the related independent factors with mortality were failure of initial hemostasis with SB tube (hazard ratio, 6.24; p < 0.001) and endotracheal intubation before SB tube (hazard ratio, 2.81; p = 0.018). CONCLUSIONS: Since the era of endoscopic band ligation, SB tube might be a beneficial option as a temporary salvage treatment for uncontrolled variceal hemorrhage. However, rescue therapy had a high incidence of fatal complication and rebleeding.

Esophageal Non-variceal Hemorrhage:A Retrospective Analysis of 175 Cases / 胃肠病学

Background:Esophageal non-variceal hemorrhage is relatively uncommon in clinical,however,it can be life-threatening in severe cases. Thus,retrospective analysis of esophageal non-variceal hemorrhage could provide important evidence for its diagnosis and treatment. Aims:To analyze the clinical characteristics of esophageal non-variceal hemorrhage. Methods:A total of 175 cases of esophageal non-variceal hemorrhage from January 2006 to December 2016 at Daping Hospital were enrolled. Gender,age,cause of bleeding,location of bleeding,season of onset,treatment and prognosis were retrospectively analyzed. Results:The ratio of male to female was 3. 5: 1 in 175 patients with esophageal non-variceal hemorrhage,73. 1％ of patients were middle-aged and elderly. The main cause of bleeding of esophageal non-variceal hemorrhage were cardiac mucosal laceration syndrome (46. 9％),esophageal cancer (23. 4％),esophageal ulcer (12. 6％)and esophageal foreign body (12. 0％). The most common site of bleeding was lower esophagus (70. 9％). Fifty-one patients accepted endoscopic treatment or surgery. After treatment,142 patients (81. 1％)were cured or improved,and death was occurred in 27 patients (15. 4％). Conclusions:The incidence of esophageal non-variceal hemorrhage is higher in male than in female,and is commonly seen in middle-aged and elderly patients. The most common cause of bleeding of esophageal non-variceal hemorrhage is cardiac mucosal laceration syndrome,and the most common site of bleeding is lower esophagus. Medicine combined with endoscopic treatment is effective for most of the patients.

Tracheoesophageal Fistula in the Treatment of Gastric Variceal Hemorrhage with Sengstaken-Blakemore Tube

The Sengstaken-Blakemore tube (SB tube) is used to control esophageal or gastric variceal bleeding in emergencies, and various complications have been reported following its use. Tracheoesophageal fistula (TEF) is an extremely rare complication after SB tube insertion. We herein present a case of an 80-year-old female patient who experienced TEF after repeated insertion of the SB tube to control recurrent gastric variceal hemorrhage.

Clinical outcomes of balloon-occluded retrograde transvenous obliteration for the treatment of gastric variceal hemorrhage in Korean patients with liver cirrhosis: a retrospective multicenter study

BACKGROUND/AIMS: This study evaluated the clinical outcomes of balloon-occluded retrograde transvenous obliteration (BRTO) for the treatment of hemorrhage from gastric varices (GV) in Korean patients with liver cirrhosis (LC). METHODS: We retrospectively analyzed data from 183 LC patients who underwent BRTO for GV bleeding in 6 university-based hospitals between January 2001 and December 2010. RESULTS: Of the 183 enrolled patients, 49 patients had Child-Pugh (CP) class A LC, 105 had CP class B, and 30 had CP class C at the time of BRTO. BRTO was successfully performed in 177 patients (96.7%). Procedure-related complications (e.g., pulmonary thromboembolism and renal infarction) occurred in eight patients (4.4%). Among 151 patients who underwent follow-up examinations of GV, 79 patients (52.3%) achieved eradication of GV, and 110 patients (72.8%) exhibited marked shrinkage of the treated GV to grade 0 or I. Meanwhile, new-appearance or aggravation of esophageal varices (EV) occurred in 54 out of 136 patients who underwent follow-up endoscopy (41.2%). During the 36.0+/-29.2 months (mean+/-SD) of follow-up, 39 patients rebled (hemorrhage from GV in 7, EV in 18, nonvariceal origin in 4, and unknown in 10 patients). The estimated 3-year rebleeding-free rate was 74.8%, and multivariate analysis showed that CP class C was associated with rebleeding (odds ratio, 2.404; 95% confidence-interval, 1.013-5.704; P=0.047). CONCLUSIONS: BRTO can be performed safely and effectively for the treatment of GV bleeding. However, aggravation of EV or bleeding from EV is not uncommon after BRTO; thus, periodic endoscopy to follow-up of EV with or without prophylactic treatment might be necessary in LC patients undergoing BRTO.

Relationship between the hepatic venous pressure gradient and first variceal hemorrhage in patients with cirrhosis: a multicenter retrospective study in Korea

BACKGROUND/AIMS: Variceal hemorrhage is one of the major complications of cirrhosis and is associated with significant mortality and morbidity. The development of gastroesophageal varices and variceal hemorrhage is the most direct consequence of portal hypertension. Correlations between the hepatic venous pressure gradient (HVPG) and first variceal hemorrhage were examined. METHODS: Patients with cirrhosis who underwent HVPG measurement between July 2009 and September 2010 were enrolled (n=535). All patients underwent esophagogastroduodenoscopy to enable the evaluation of gastroesophageal varices. RESULTS: The HVPG for all patients was 16.46+/-7.05 mmHg (mean+/-SD), and was significantly higher among those with first variceal hemorrhage than in those without it. The HVPG was significantly correlated with both Child-Turcotte-Pugh (r=0.488, P<0.001) and Model for End-stage Liver Disease (r=0.478, P<0.001) scores. An HVPG value of 11 mmHg was predictive of first variceal hemorrhage with a sensitivity of 92.4% and a specificity of 27.7%. CONCLUSIONS: The HVPG was higher in patients with first variceal hemorrhage than in those without it.

Comparison of Somatostatin and Vasopressin in the Control of Acute Esophageal Variceal Hemorrhage: A Prospective Randomized Trial / 대한간학회지

BACKGROUND/AIMS: Although endoscopic band ligation or injection sclerotherapy are the current standard therapies for bleeding esophageal varices, the best method for initial control is unclear. The aim of this prospective study was to compare the efficacy and toxicity of somatostatin and vasopressin in the management of esophageal variceal hemorrhage. METHODS: From March, 1997 to September, 1998, 28 consecutive cirrhotic patients admitted to the Yonsei Medical Center because of active variceal bleeding were included in this trial. The patients were randomized to receive either somatostatin (15 patients) or vasopressin (13 patients) for 48 hours. RESULTS: There were no significant differences between the two treatment groups in relation to Child's classification, amount of bleeding before randomization and units of blood transfused during therapy. Initial control of bleeding was achieved in 13 (86.7%) patients receiving somatostatin and in 10 (76.9%) of those treated with vasopressin. However, two patients in the somatostatin group and two in the vasopressin group bled again during treatment. Therefore complete control of bleeding during the 48 hours of therapy was achieved in 11 (73.4%) patients treated with somatostatin and in eight (61.5%) of those receiving vasopressin. Differences were observed in complications associated with each therapy. Vasopressin produced complications in four patients (chest pain in two, hypertension in one and hyponatremia-induced seizure in one) while somatostatin produced minor complication in one patient. CONCLUSIONS: This study suggests that somatostatin is efficacious in controlling acute hemorrhage from esophageal varices and has a lower risk of adverse effects than vasopressin.