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Nuestro objetivo fue desarrollar un test diagnóstico para predecir la etiología de la Hemorragia Digestiva Alta Variceal (HDAV). Realizamos un estudio de cohorte retrospectivo. Se revisaron historias clínicas de pacientes mayores de 18 años con Hemorragia Digestiva Alta (HDA) que acudieron al servicio de emergencia del Hospital Cayetano Heredia (HCH) de Lima-Perú entre el 2019 a 2022, se recolectaron datos demográficos, de laboratorio y clínicos; posteriormente, se identificaron variables predictivas de HDAV mediante una regresión logística múltiple. A cada variable con capacidad predictiva se les asignó un puntaje con un punto de corte y sirvió para construir una escala predictiva de HDAV. Se incluyeron 197 historias clínicas de pacientes con HDA, de los cuales 127 (64%) tuvieron sangrado de causa no variceal, y, 70 (36%), variceal. Se identificaron 4 factores predictivos independientes: hematemesis (vómito rojo) (OR: 4,192, IC 95%: 1,586-11,082), recuento de plaquetas (OR: 3,786, IC 95%: 1,324-10,826), antecedente de HDA (OR: 2,634, IC 95%: 1,017-6,820), signos de enfermedad hepática crónica (OR: 11,244, IC 95%: 3,067-35,047), con los que se construyó una escala predictiva, con un punto de corte >7 y ≤7; que mostró una sensibilidad, especificidad, valor predictivo positivo, valor predictivo negativo, cociente de probabilidad positivo, y, negativo de 58,6%, 90,6%, 77,4%, 79,9%, 6,20, y 0,46 respectivamente. En conclusión, la escala predictiva con un punto de corte >7 es útil para predecir la presencia de la HDAV en pacientes que acuden a la emergencia por HDA.
Our objective was to develop a diagnostic test to predict the etiology of Variceal Upper Gastrointestinal Bleeding (VUGIB). We conducted a retrospective cohort study. Medical records of patients over 18 years of age with Upper Gastrointestinal Bleeding (UGIB) who attended the emergency service of Hospital Cayetano Heredia (HCH) in Lima-Peru between 2019 and 2022 were reviewed; demographic, laboratory and clinical data were collected. Subsequently, predictive variables of variceal upper gastrointestinal bleeding (VUGIB) were identified using multiple logistic regression. Each variable with predictive capacity was assigned a score with a cut-off point and served to build a predictive scale for VUGIB. 197 medical records of patients with UGIB were included, of which 127 (64%) had non-variceal bleeding, and 70 (36%), variceal. Four independent predictors were identified: hematemesis (red vomit) (OR: 4,192, 95% CI: 1.586-11.082), platelet count (OR: 3.786, 95% CI: 1.324-10.826), history of UGIB (OR: 2.634, 95% CI: 1.017-6.820), signs of chronic liver disease (OR: 11.244, 95% CI: 3.067-35.047), with which a predictive scale was constructed, with a cut-off point >7 and ≤7; which showed a sensitivity, specificity, positive predictive value, negative predictive value, positive likelihood ratio, and negative of 58.6%, 90.6%, 77.4%, 79.9%, 6.20, and 0.46 respectively. In conclusion, the predictive scale with a cut-off point >7 is useful for predicting the presence of VUGIB in patients who attend the emergency room for UGIB.
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Esophagogastric variceal bleeding (EGVB) is one of the main complications of decompensated portal hypertension, especially in patients with liver cirrhosis, and it often has a high mortality rate. Medication combined with endoscopy is the main prevention and treatment method for EGVB, while transjugular intrahepatic portosystemic shunt (TIPS) combined with variceal embolization can also be selected for some high-risk patients, and individualized diagnosis and treatment of portal hypertension based on hepatic venous pressure gradient should become the latest consensus and the main strategy. This article mainly reviews endoscopic therapy and TIPS for the prevention and treatment of EGVB patients with decompensated portal hypertension in terms of selection of indications, incidence rate of complications, and respective advantages and disadvantages.
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Transjugular intrahepatic portosystemic shunt (TIPS) is a procedure to establish a portosystemic shunt between the hepatic vein and the portal vein via the jugular approach, so as to reduce portal venous pressure and control acute esophagogastric variceal bleeding (EGVB). The prognosis of EGVB has been improved significantly over the past few decades, and endoscopic variceal ligation combined with drug therapy is now recommended as the first-line treatment regimen for this disease. The latest research advances in the management of EGVB over the past decade have focused on the relatively new concept of "early" or "pre-emptive" TIPS, that is to say, early TIPS (within 72 hours after admission, ideally within 24 hours) is recommended for patients with EGVB who are at a relatively high risk of failure in standard treatment. This article briefly introduces the effect of early TIPS on controlling bleeding, mortality rate, and hepatic encephalopathy, the high-risk population for early TIPS, timing of intervention, cost effectiveness, the applications of early TIPS in a real-world setting, and recommendations for early TIPS in international guidelines and consensus statements.
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Liver stiffness measurement (LSM) has been widely used in predicting portal hypertension in clinical practice, and in recent years, spleen stiffness measurement (SSM) has also become a diagnostic tool. Studies have shown that SSM can predict portal hypertension and its complications such as esophagogastric variceal bleeding in patients with chronic liver diseases and assist in the risk stratification management of portal hypertension and esophagogastric variceal bleeding. It can accurately predict clinically significant portal hypertension, high-risk esophageal and gastric varices, decompensation rate, and mortality rate in patients with chronic liver diseases. At present, SSM data in most studies are obtained by detection using the liver equipment FibroScan Ⓡ (SSM@50 Hz). FibroScan Ⓡ 630 is a new scanner dedicated for SSM with a special mode for SSM (SSM@100 Hz). This article elaborates on the significance of SSM in predicting portal hypertension and briefly introduces the advantages and disadvantages of the new equipment for SSM.
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Transjugular intrahepatic portosystemic shunt （TIPS） has been recommended as a treatment method for cirrhotic portal hypertension in domestic and foreign guidelines， but there is still uncertainty in its therapeutic efficacy. More and more studies have shown that TIPS combined with collateral vessel embolization （TIPS+E） has certain advantages in the treatment of gastroesophageal variceal bleeding in liver cirrhosis. This article reviews the major studies on TIPS+E in China and globally， summarizes related recommendations in guidelines and the current status of clinical application， and proposes the issues that need to be solved， such as indication， hemodynamic criteria， and selection of materials for embolization， and large－sample multicenter randomized controlled trials are needed for further clarification.
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Objective:To investigate the safety and feasibility of the CHESS endoscpic ruler (CHESS ruler), and the consistency between the measured values and the interpretation values by endoscopic physician experience.Methods:From January 2021 to January 2022, a total of 105 liver cirrhosis patients with portal hypertension were prospectively enrolled from General Hospital, Xixia Branch Hospital, Ningnan Hospital of People′s Hospital of Ningxia Hui Autonomous Region (29 cases), and the First People′s Hospital of Yinchuan (25 cases), General Hospital of Ningxia Medical University (18 cases), Wuzhong People′s Hospital (10 cases), the Fifth People′s Hospital of Ningxia Hui Autonomous Region (10 cases), Shizuishan Second People′s Hospital (6 cases), Yinchuan Second People′s Hospital (5 cases), and Zhongwei People′s Hospital (2 cases) 8 hospitals. The clinical characteristics of all the patients, including gender, age, nationality, etiolog of liver cirrhosis, and Child-Pugh classification of liver function were recorded. A big gastroesophageal varices was defined as diameter of varices ≥5 mm. Endoscopist (associated chief physician) performed gastroscopy according to the routine gastroscopy procedures, and the diameter of the biggest esophageal varices was measured by experience and images were collected, and then objective measurement was with the CHESS ruler and images were collected. The diameter of esophageal varices of 10 randomly selected patients (random number table method) was determined by 6 endoscopists (attending physician or associated chief physician) with experience or measured by CHESS ruler. Kappa test was used to test the consistency in the diameter of esophageal varices between measured values by CHESS ruler and the interpretation values by endoscopic physician experience.Results:Among 105 liver cirrhosis patients with portal hypertension, male 65 cases and female 40 cases, aged (54.8±12.2) years old, Han nationality 82 cases, Hui nationality 21 cases and Mongolian nationality 2 cases. The etiology of liver cirrhosis included chronic hepatitis B (79 cases), alcoholic liver disease (7 cases), autoimmune hepatitis (7 cases), chronic hepatitis C (2 cases), and other etiology (10 cases). Liver function of 32 cases was Child-Pugh A, Child-Pugh B 57 cases, and Child-Pugh C 16 cases. All 105 liver cirrhosis patients with cirrhotic portal hypertension were successfully measured the diameter of gastroesophageal varices by CHESS ruler, and the success rate of application of CHESS ruler was 100.0% (105/105). The procedure time from the CHESS ruler into the body to the exit of the body after measurement was (3.50±2.55) min. No complications happened in all the patients during measurement. Among 105 liver cirrhosis patients with cirrhotic portal hypertension, 96 cases (91.4%) were recognized as big gastroesophageal varices by the endoscopists. Totally 93 cases (88.6%) were considered as big gastroesophageal varices by CHESS ruler. Eight cases were recognized as big gastroesophageal varices by the endoscopist, however not by the CHESS ruler; 5 cases were recognized as big gastroesophageal varices by the CHESS ruler, but not by the endoscopists; 4 cases were not recognized as big gastroesophageal varices both by the endoscopists and CHESS ruler; 88 cases were recognized as big gastroesophageal varices both by the endoscopists and CHESS ruler. The missed diagnostic rate of big gastroesophageal varices by the endoscopists experience was 5.4% (5/93), and the Kappa value of consistency coefficient between the measurement by the CHESS ruler and the interpretation by endoscopists experience was 0.31 (95% confidence interval 0.03 to 0.60). The overall Kappa value of consistency coefficient by 6 endoscopists measured by CHESS ruler in big gastroesophageal varices diagnosis was 0.77 (95% confidence interval 0.61 to 0.93).Conclusion:As an objective measurement tool, CHESS ruler can make up for the deficiency of subjective judgment by endoscopists, accurately measure the diameter of gastroesophageal varices, and is highly feasible and safe.
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Objective:To investigate the efficacy of endoscopic histoacryl injection in cirrhotic patients with newly-developed esophagogastric varices (EGV) who have previously undergone splenectomy combined with pericardial devascularization.Methods:From January 2015 to January 2020, 125 cirrhotic patients with EGV treated with endoscopic histoacryl injection at the Department of Gastroenterology, Jinling Hospital, Medical School of Nanjing University, were included in the retrospective analysis. There were 45 patients in the group of splenectomy combined with pericardial devascularization (splenectomy group for short) and 80 patients in the non-splenectomy group. The efficacy of endoscopic treatment, postoperative variceal improvement, rebleeding rate, and complications were analyzed between the two groups.Results:Endoscopic histoacryl injection was successfully completed in all 125 patients, and the median volume of histoacryl was 4.5 mL. The overall effective rate in splenectomy and non-splenectomy group was 80.0% (36/45) and 57.5% (46/80), respectively. The difference in the number of significantly effective, effective, and ineffective cases between the two groups was statistically significant (16, 20, 9 cases, and 20, 26, 34 cases, respectively, χ 2=6.469, P=0.039). Two and 14 patients developed rebleeding in the splenectomy group and non-splenectomy group, respectively; and the difference in the rebleeding rate between the two groups was statistically significant (4.4% VS 17.5%, Log-rank P=0.039). No patient died within 1 year in either group, and no serious complications such as ectopic embolism occurred. Conclusion:After splenectomy combined with pericardial devascularization in cirrhotic patients with EGV and hypersplenism, the application of histoacryl has better short-term efficacy and can significantly reduce the rebleeding rate compared with the non-splenectomy group.
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Objective:To evaluate the clinical efficacy of laparoscopic splenectomy and azygoportal disconnection (LSD) with intraoperative endoscopic variceal ligation (LSDL) in the treatment of esophagogastric variceal bleeding (EVR).Method:In this study,90 cirrhotic patients with esophagogastric variceal bleeding (EVB) were divided to receive either LSD ( n=45) or LSDL ( n=45) from Jan 2020 and Dec 2021. Results:There were no significant differences in estimated blood loss, incidence of blood transfusion, time to first flatus, off-bed activity and postoperative hospital stay between the two groups (all P>0.05). Compared with LSD group, operation time was longer in LSDL group[ (140±21) min vs. (150±19) min, t=2.420, P=0.018]. LSDL was associated with significantly decreased EVR rate in one year follow-up (2% vs. 18%, P=0.030). Univariate analysis and multivariate logistic regression revealed that LSDL was a significant independent protective factor for EVR as compared with LSD ( P<0.05). Conclusion:LSDL procedure is not only technically feasible and safe, it also contributed to lower postoperative EVR risk than single LSD.
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Objective:To evaluate the long-term risk of rebleeding in patients with acute esophageal and gastric variceal bleeding and portal vein thrombosis after endoscopic treatment in liver cirrhosis.Methods:From January to December 2022, 57 patients with acute esophageal and gastric variceal bleeding who were treated by endoscopy in the emergency department of the Zhongshan Hospital affiliated to the Fudan University were included in the study. According to the results of portal vein CT angiography (CTA), the patients were divided into thrombosis group and non thrombosis group. We compared the basic information and endoscopic treatment status of two groups of patients. All patients were followed up until 1 year after endoscopic treatment or April 15, 2023, and re bleeding and survival were recorded during the follow-up period. The influencing factors of rebleeding after 1 year of treatment were analyzed.Results:The patient′s age was (55.9±11.4)years old, mainly male [78.95%(45/57)]. The average time from initial bleeding to endoscopic treatment for all patients was (6.6±2.8)days. There was no statistically significant difference between the two groups in terms of age, sex, combined liver malignancy, Child-pugh score, first bleeding form, ascites, and first laboratory examination results (including hemoglobin, platelet, Prothrombin time, creatinine) (all P>0.05). There was no statistically significant difference in the history of endoscopic treatment, bleeding distance from endoscopic treatment, the proportion of patients with esophageal varices and gastric varices, the proportion of patients with esophageal varices treated with ligation, and the proportion of patients with gastric varices treated with tissue glue between the two groups (all P>0.05). A total of 2 patients died after surgery, and 12 patients experienced rebleeding, including 10 in the thrombotic group and 2 in the non thrombotic group. Kaplan Meier analysis showed that the 1-year rebleeding rate in the thrombotic group was significantly higher than that in the non thrombotic group (59.02% vs 24.71%, RR=6.002, 95% CI: 1.06-34.00, P=0.020 8). Cox multivariate regression analysis suggests that the presence of portal vein thrombosis ( HR=7.669, 95% CI: 1.453-40.472, P=0.016) was an independent risk factor for recurrent bleeding after endoscopic treatment of acute esophageal and gastric variceal bleeding for one year. Conclusions:Portal vein thrombosis in liver cirrhosis increases the risk of recurrent bleeding after endoscopic treatment for acute esophageal and gastric variceal bleeding for one year. For patients with acute Upper gastrointestinal bleeding complicated with portal vein thrombosis, regular endoscopic and ultrasonic follow-up, individualized endoscopic sequential and selective anticoagulation therapy should be carried out.
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According to the pathophysiological characteristics, upper gastrointestinal bleeding can be divided into acid related disease bleeding and esophageal and gastric varices bleeding. Esophageal and gastric variceal bleeding is a common critical condition of Portal hypertension, with dangerous onset and high mortality. With the improvement of endoscopic treatment technology, endoscopy has become the first line treatment plan for esophageal and gastric variceal bleeding. The commonly used endoscopic management methods for varicose veins include variceal ligation, tissue glue combined with sclerosing agent embolization, ultrasound guided coil combined with tissue glue embolization, and other management measures. Early identification of gastrointestinal bleeding related to varicose veins, stratified diagnosis and treatment of high-risk patients, reasonable selection of endoscopic examination timing, and personalized decision-making of treatment choices are key to improving efficacy.
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Hepatic venous pressure gradient (HVPG) is the "gold standard" for the diagnosis of portal hypertension, which could be applied in the evaluation of liver cirrhosis. Combined use of HVPG with model for end-stage liver disease (MELD) scoring system may more accurately match the donors and recipients undergoing liver transplantation for liver cirrhosis, select the appropriate timing of surgery, and provide guidance for bridging treatment for patients on the waiting list for liver transplantation. Besides, HVPG may also predict clinical prognosis of liver transplant recipients, and provide evidence for early detection and intervention of potential complications. Therefore, the value of HVPG in preoperative evaluation and prognosis prediction of liver transplant recipients was reviewed, aiming to provide guidance for clinical diagnosis and treatment of liver transplant recipients before and after surgery.
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In order to standardize the diagnosis, treatment and management of esophagogastric variceal bleeding (EVB) in cirrhotic portal hypertension, the Chinese Society of Hepatology, Chinese Society of Gastroenterology, and Chinese Society of Digestive Endoscopology of Chinese Medical Association organized relevant experts, reviewed domestic and international latest progress in clinical research on EVB in cirrhotic portal hypertension, and followed the evidence of evidence-based medicine to update the Guidelines on the Management of EVB in Cirrhotic Portal Hypertension. The guideline provides recommendations for the diagnosis, treatment and management of EVB in cirrhotic portal hypertension and aims to improve the level of clinical treatment of EVB in cirrhotic portal hypertension.
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Objective To investigate the value of Baveno Ⅶ criteria versus Expanded Baveno Ⅶ criteria in screening for high-risk varices (HRV) in patients with compensated advanced chronic liver disease (cACLD). Methods A total of 146 patients with cACLD who were admitted to Beijing Shijitan Hospital, Capital Medical University, from January 2016 to December 2018 were enrolled, and according to the absence or presence of HRV based on gastroscopy, they were divided into HRV group with 68 patients and control group with 78 patients. Clinical data, liver stiffness measurement (LSM), and gastroscopy findings were analyzed, and different Baveno Ⅶ criteria were analyzed in terms of their sensitivity and specificity in the diagnosis of HRV. The Mann-Whitney U test and the McNemar test were used for comparison of continuous data between groups, and the chi-square test was used for comparison of categorical data between groups. A univariate logistic regression analysis was performed for the variables used to predict HRV, and a multivariate analysis was performed for the variables with P 20 kPa or PLT 25 kPa or PLT < 110×10 9 /L was associated with HRV (both P < 0.05). LSM and PLT had an area under the ROC curve of 0.797 (95% confidence interval [ CI ]: 0.723-0.859) and 0.789 (95% CI : 0.714-0.852), respectively, in the diagnosis of HRV. There were significant differences in the prevalence rates of esophageal and gastric varices and HRV between the patients who met Baveno Ⅶ criteria and those who did not meet such criteria ( χ 2 =23.14 and 23.14, both P < 0.001), as well as between the patients who met Expanded Baveno Ⅶ criteria and those who did not meet such criteria ( χ 2 =43.51 and 25.71, both P < 0.001). Although a higher proportion of patients were exempted from gastroscopy based on Expanded Baveno Ⅶ criteria (32.9% vs 13.7%), Baveno Ⅶ criteria had higher sensitivity (0.98 vs 0.88) and negative predictive value (0.95 vs 0.83) and could better avoid the missed diagnosis of HRV (1.0% vs 9.3%). Conclusion Baveno Ⅶ criteria are more suitable for the screening for HRV in cACLD patients in China.
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ABSTRACT Background: In natural history of cirrhosis, variceal bleeding is one of the earliest decompensations to happen, and, if adequately managed, survival is improved. Gastric varices have challenges in management due to their location, size and propensity to bleed. The N-butyl 2-cyanoacrylate (NBC) glue application has emerged as definitive therapy in bleeding gastric varices. Here we present our experience with use of NBC in management of gastric and difficult cases of esophageal varices. Methods: A total of 75 patients underwent NBC glue application for varices which included 69 patients with gastric varices and six patients with esophageal varices. All the procedures were done with flexible endoscope and sclerotherapy needle after due precautionary measures. Results: Hemostasis was varices in all patients after endotherapy. The average quantity of glue used was 2.75±0.95 mL. Complete obliteration with single session of NBC application was achieved in 55 patients. Re-bleeding occurred in five patients within 5 days of index event. 20 patients had in-hospital mortality but none was related to gastrointestinal bleeding. 6-week all-cause mortality was 26 (35%). Conclusion: Glue therapy with NBC is a life saving therapy in patients with bleeding gastric varices and esophageal varices not amenable to endoscopic variceal ligation or sclerotherapy.
RESUMO Contexto: Na história natural da cirrose, o sangramento de varizes é uma das primeiras descompensações a acontecer e, se adequadamente controlada, a sobrevivência é melhorada. Varizes gástricas têm desafios na sua gestão devido à sua localização, tamanho e propensão a sangrar. A aplicação de cola N butil 2-cianoacrilato (NBC) surgiu como terapia definitiva em varizes gástricas sangrantes. Apresentamos nossa experiência com o uso da NBC na gestão de casos gástricos e difíceis de varizes esofágicas. Métodos: Um total de 75 pacientes foram submetidos à aplicação de cola NBC para varizes que incluiu 69 pacientes com varizes gástricas e seis pacientes com varizes de esôfago. Todos os procedimentos foram feitos com endoscópio flexível e agulha de escleroterapia após as devidas medidas de precaução. Resultados: A hemostasia foi alcançada em todos os pacientes após a endoterapia. A quantidade média de cola utilizada foi de 2,75+0,95 mL. A obliteração completa com sessão única de aplicação da NBC foi alcançada em 55 pacientes. O reexame ocorreu em cinco pacientes dentro de 5 dias após o evento de índice. 20 pacientes tiveram mortalidade hospitalar, mas nenhum foi relacionado com o sangramento gastrointestinal. A mortalidade após 6 semanas foi de 26 (35%). Conclusão: A terapia de cola com a NBC é uma terapia que salva vidas em pacientes com varizes gástricas hemorrágicas e varizes esofágicas não condizíveis à ligadura endoscópica ou escleroterapia.
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Abstract Pregnancy in non-cirrhotic portal hypertension (NCPH) is an uncommon condition. Its management is challenging both to the obstetricians as well as to the gastroenterologists due to the lack of more extensive studies and standard clinical practice guidelines. These patients are at increased risk of portal hypertension (PTH) complications, especially variceal bleeding, and with an increased incidence of adverse maternal and fetal outcomes. Hence, a multidisciplinary approach is required for management of pregnancy in NCPH. This short review describes the different aspects of pregnancy with NCPH, emphasizing specific strategies for preventing and managing PTH from the preconceptional period to postpartum.
Resumo A gravidez na hipertensão portal não cirrótica (HPNC) é uma condição incomum. Seu manejo é desafiador tanto para os obstetras quanto para os gastroenterologistas devido à falta de estudos mais extensos e diretrizes de prática clínica padrão. Esses pacientes apresentam risco aumentado de complicações da hipertensão portal (PTH) especialmente sangramento por varizes e têm maior incidência de desfechos maternos e fetais adversos. Portanto uma abordagem multidisciplinar é necessária para o manejo da gravidez na NCPH. Esta breve revisão descreve os diferentes aspectos da gravidez com HPNC enfatizando estratégias específicas para prevenção e manejo do PTH desde o período pré-concepcional até o pós-parto.
Subject(s)
Humans , Female , Pregnancy , Pregnancy Outcome , Esophageal and Gastric Varices , Hypertension, Portal/prevention & controlABSTRACT
Introduction: Portal hypertension still represents an important health problem worldwide. In the search for knowledge regarding this syndrome, experimental studies with animal models have proven to be useful to point the direction to be taken in future randomized clinical trials. Purpose: To validate the experimental model of portal hypertension and esophagogastric varices in a medium-sized animal. Methods: This study included five minipigs br1. Midline laparotomy with dissection of the portal vein and production of a calibrated stenosis of this vein was performed. Measurement of pressure in the portal venous and digestive endoscopic were performed before and five weeks after the production of a stenosis. Results: All animals were 8 months old, average weight of 17 ± 2.5 kg. The mean pressure of the portal vein immediately before the partial ligation of the portal vein was 8.9 + 1.6 mm Hg, with 26.6 + 5.4 mm Hg in the second measurement five weeks later (p < 0.05). No gastroesophageal varices or hypertensive portal gastropathy were seen at endoscopy procedures in our sample at any time in the study. Conclusion: Portal vein ligation in minipigs has been validated in the production of portal hypertension, but not in the formation of esophageal varices.
Subject(s)
Animals , Swine, Miniature/surgery , Esophageal and Gastric Varices/surgery , Hypertension, Portal/surgeryABSTRACT
Portal hypertension is not only the outcome of liver cirrhosis, but also the main cause of gastroesophageal varices, and variceal bleeding may lead to dangerous conditions and even endanger the life of patients. Therefore, standardization of endoscopic screening, prevention of first-time bleeding, emergency hemostasis, and prevention of secondary bleeding after hemostasis are of great importance for the prevention and treatment of gastroesophageal variceal bleeding. At present, the treatment measures for emergency hemostasis mainly include circulatory resuscitation, pharmacotherapy, endoscopic therapy, interventional radiology, and transjugular intrahepatic portosystemic shunt for patients who may fail in routine treatment. Secondary preventive measures mainly include traditional nonselective β-receptor blocker (NSBB) or carvedilol combined with endoscopic variceal ligation, transjugular intrahepatic portosystemic shunt, and balloon-occluded retrograde transvenous obliteration. In addition, traditional Chinese medicine or integrated traditional Chinese and Western medicine therapy also play an important role in the treatment of gastroesophageal variceal bleeding, especially in the fields of primary and secondary prevention. This article reviews the research advances in the role of integrated traditional Chinese and Western medicine therapy in the diagnosis and treatment of gastroesophageal variceal bleeding due to liver cirrhosis in recent years, in order to provide a reference for clinicians to select appropriate diagnosis and treatment regimens.
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Objective:To explore the value of CT portal vein imaging combined with liver function indexes in predicting the risk of esophageal variceal bleeding in patients with liver cirrhosis.Methods:A total of 82 patients with liver cirrhosis complicated with gastric fundus esophageal varices in Wanbei Coal-Electricity Group General Hospital were selected and divided into bleeding group (24 cases) and non-bleeding group (58 cases) according to the occurrence of gastric fundus esophageal varices bleeding within 6 weeks after admission. General data of the two groups, CT portal vein imaging parameters at admission including diameter of main portal vein (MPV), diameter of splenic vein (SPV), diameter of left gastric vein (LGV), serum liver function indexes including alanine aminotransferase (ALT), aspartate aminotransferase (AST), total bilirubin (TBIL) levels were compared between the two groups, and analyzed the value of CT portal vein imaging parameters and serum liver function indexes levels in predicting the risk of gastric fundus esophageal varices bleeding.Results:The age and diameter of MPV, SPV, LGV in bleeding group were higher than those in the non-bleeding group: (55.17 ± 12.02) years vs. (53.71 ± 10.48) years, (18.05 ± 2.74) mm vs. (15.22 ± 2.18) mm, (13.68 ± 1.35) mm vs. (12.26 ± 1.43) mm, (6.82 ± 1.38) mm vs. (5.30 ± 0.94) mm; the levels of serum ALT, AST, TBIL in bleeding group were lower than those in the non-bleeding group: (23.71 ± 5.74) U/L vs. (34.95 ± 8.26) U/L, (27.65 ± 6.61) U/L vs. (39.29 ± 10.24) U/L, (17.20 ± 5.49) U/L vs. (26.13 ± 7.85) U/L, there were statistical differences ( P<0.05). The results of receiver operating characteristic curve showed that the area under the curve (AUC) of combined index to predict gastric fundus esophageal varices bleeding was 0.889 (95% CI 0.812-0.967), and the sensitivity and specificity were 83.34% and 81.03%, respectively. Conclusions:CT portal vein imaging combined with liver function indexes has a good value in predicting the risk of gastric fundus esophageal varices bleeding in liver cirrhosis.
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Objective:To systematically evaluate the efficacy and safety of tissue adhesive combined with lauromacrogol (modified Sandwich method) for gastric varices.Methods:Literature in the Cochrane Library, PubMed, EMbase, CNKI, VIP and Wanfang were searched by two independent researchers from the establishment of the databases to June 30, 2020, and qualified data from the eligible literature were extracted. Revman 5.3 was used to analyze outcomes including hemostatic efficiency, incidence of postoperative fever, chest and abdominal pain, ulcer, ectopic embolism and complications, and postoperative re-bleeding rate (Mantel-Haenszel method).Results:A total of 8 randomized controlled trials including 898 patients were included in this meta-analysis. The results showed that compared with the classic Sandwich method, the modified version had a better hemostatic effect ( P=0.01, OR=2.07, 95% CI: 1.17-3.68) and a lower incidence of postoperative ectopic embolism ( P=0.001, OR=0.06, 95% CI: 0.01-0.34). There were no significant differences in the incidences of postoperative fever ( P=0.58, OR=0.86, 95% CI: 0.52-1.44), chest and abdominal pain ( P=0.83, OR=0.95, 95% CI: 0.58-1.56), local ulcer ( P=0.31, OR=0.66, 95% CI: 0.30-1.47) , re-bleeding ( P=0.14, OR=0.76, 95% CI: 0.53-1.09) or overall incidence of adverse reactions ( P=0.24, OR=0.66, 95% CI: 0.33-1.32). Conclusion:The modified Sandwich method of tissue adhesive combined with lauromacrogol is an effective and safe method in the treatment of gastric varices.
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Objective:To evaluate the regular endoscopic therapy for esophageal and gastric variceal bleeding (EGVB) in patients with liver cirrhosis.Methods:A total of 305 patients of EGVB with liver cirrhosis who received endoscopic hemostasis in Nanjing Drum Tower Hospital between January 2015 and January 2018 were included in the retrospective cohort study. Patients were divided into the regular endoscopic treatment group ( n=145) and the irregular endoscopic treatment group ( n=160). The primary outcome measure was rebleeding rate, and the secondary outcome measures were follow-up time, rebleeding interval and rebleeding mortality. Results:There were no significant differences between the two groups in terms of gender composition, average age, etiology composition, the cause of disease under or out of control, liver reserve function, or administration of non-selective β-blockers ( P>0.05), and the baseline data were comparable. The rebleeding rate was 11.7% (17/145) in the regular endoscopic treatment group and 41.9% (67/160) in the irregular endoscopic treatment group ( χ2=38.74, P<0.001). The follow-up time, rebleeding intervals and mortalies of rebleeding in the regular endoscopic treatment group and the irregular endoscopic treatment group were 28.14±11.11 months and 21.10±12.37 months ( t=5.21, P<0.001), 12.0 (6.0, 23.0) months and 1.0 (1.0, 6.0) months ( U=164.00, P<0.001), and 1.4% (2/145) and 10.6% (17/160) ( χ2=11.13, P=0.001), respectively. Conclusion:Compared with irregular endoscopic treatment, regular endoscopic treatment of EGVB in patients with liver cirrhosis has more clinical significance, which can significantly reduce the rebleeding rate, prolong the rebleeding interval, and reduce the mortality of rebleeding.