Fatores preditivos de morbidade associada à sangramento de varizes esofágicas em crianças com hipertensão porta / Predictive factors of morbidity associated with esophageal variceal bleeding in children with portal hypertension

ABSTRACT Background: Most data on the natural history of portal hypertension come from studies in adults. The morbidity rate of upper gastrointestinal bleeding (UGIB) in children with portal hypertension has not been systematically characterized. Objective: To describe the morbidity and mortality of UGIB in pediatric patients with portal hypertension and identify predictive factors for the occurrence of its main complications. Methods: This retrospective study included pediatric patients with cirrhotic portal hypertension or with extrahepatic portal vein obstruction (EHPVO). Mortality and UGIB complications within a period of up to 6 weeks of the bleeding were investigated. To determine the predictive factors of morbidity, a multivariate analysis was performed using logistic regression; all results were considered significant at P<0.05. Results: A total of 86 patients (51.2% with EHPVO and 48.8% with cirrhosis) had 174 bleeding events. Ascites was the most common complication (43.1% of all cases), being more prevalent in patients with cirrhosis (P<0.001). Cirrhosis was a predictor of the occurrence of any morbidity (OR 20.3). The need for blood transfusion was predictor of at least one complication (OR 5.8), ascites (OR 7.2) and infections (OR 3.8) in the general group and at least one complication (OR 11.3) and ascites (OR 5.8) in cirrhotic patients. The need for expansion was a predictor of any morbidity (OR 4.6) and infections (OR 3.9) in the general group, in addition to being predictor of infection in cirrhotic patients (OR 5.4). There were no deaths from UGIB in the six weeks post-bleeding. Conclusion: The study showed the relevance of morbidity after UGIB in pediatric patients with portal hypertension, especially in those with cirrhosis. The patients with hemodynamic instability requiring blood transfusion or expansion on admission are at increased risk of complications related to upper gastrointestinal bleeding and should be closely monitored.

RESUMO Contexto: A maioria dos dados sobre a história natural da hipertensão porta provém de estudos em adultos. A morbidade associada à hemorragia digestiva alta (HDA) em crianças com hipertensão porta ainda não foi sistematicamente estudada. Objetivo: Descrever a morbimortalidade da HDA em pacientes pediátricos com hipertensão porta e identificar fatores preditivos para a ocorrência de suas principais complicações. Métodos: Este estudo retrospectivo incluiu pacientes pediátricos com hipertensão porta cirrótica ou com obstrução extra-hepática da veia porta (OEHVP). A mortalidade e as complicações da HDA foram estudadas até seis semanas após o sangramento. Para determinar os fatores preditivos de morbidade, foi realizada análise multivariada por meio de regressão logística; todos os resultados foram considerados significativos com P<0,05. Resultados: Oitenta e seis pacientes (51,2% com OEHVP e 48,8% com cirrose) tiveram 174 eventos hemorrágicos. A ascite foi a complicação mais comum (43,1% de todos os casos), sendo mais prevalente em pacientes com cirrose (P<0,001). A cirrose foi preditor da ocorrência de pelo menos uma complicação (OR 20,3). A necessidade de transfusão sanguínea foi preditora de pelo menos uma complicação (OR 5,8), ascite (OR 7,2) e infecções (OR 3,8) no grupo geral e pelo menos uma complicação (OR 11,3) e ascite (OR 5,8) nos cirróticos. A necessidade de expansão foi preditor de qualquer morbidade (OR 4,6) e infecções (OR 3,9) no grupo geral, além de ser preditor de infecção em cirróticos (OR 5,4). Não houve óbitos por HDA nas 6 semanas pós-sangramento. Conclusão: O estudo mostrou a relevância da morbidade após HDA em pacientes pediátricos com hipertensão porta, principalmente naqueles com cirrose. Os pacientes com instabilidade hemodinâmica que necessitam de transfusão de sangue ou expansão na admissão têm risco aumentado de complicações relacionadas à hemorragia digestiva alta e devem ser monitorados de perto.

Factors influencing bilirubin elevation and its correlation with UGT1A1 gene polymorphism in the early postoperative period of transjugular intrahepatic portosystemic shunt / 中华肝脏病杂志

Objective: To investigate the factors influencing total bilirubin elevation and its correlation with UGT1A1 gene polymorphism in the early postoperative period of transjugular intrahepatic portosystemic shunt (TIPS). Methods: 104 cases with portal hypertension and esophageal variceal hemorrhage (EVB) treated with elective TIPS treatment were selected as the study subjects and were divided into a bilirubin-elevated group and a normal bilirubin group according to the total bilirubin elevation level during the early postoperative period. Univariate analysis and logistic regression were used to analyze the factors influencing total bilirubin elevation in the early postoperative period. PCR amplification and first-generation sequencing technology were used to detect the polymorphic loci of the UGT1A1 gene promoter TATA box, enhancer c.-3279 T > G, c.211G > A, and c.686C > A. Logistic regression was used to analyze the correlation of four locus alleles and genotypes with elevated total bilirubin in the early postoperative period. Results: Among the 104 cases, 47 patients were in the bilirubin elevated group, including 35 males (74.5%) and 12 females (25.5%), aged (50.72 ± 12.56) years. There were 57 cases in the normal bilirubin group, including 42 males (73.7%) and 15 females (26.3%), aged (51.63 ± 11.10) years. There was no statistically significant difference in age (t = -0.391, P = 0.697) and gender (χ(2) = 0.008, P = 0.928) between the two groups of patients. Univariate analysis revealed that preoperative alanine transaminase (ALT) level (χ(2) = 5.954, P = 0.015), total bilirubin level (χ(2) = 16.638, P < 0.001), MELD score (χ(2) = 10.054, P = 0.018), Child-Pugh score (χ(2) = 6.844, P = 0.022), and postoperative portal vein branch development (χ(2) = 6.738, P = 0.034) were statistically significantly different between the two groups. Logistic regression analysis showed that preoperative ALT level, total bilirubin level, and portal vein branch development after TIPS were correlated with the elevated total bilirubin in the early postoperative period. The polymorphism of the c.211G > A locus of the UGT1A1 gene correlation had elevated total bilirubin in the early postoperative period of TIPS. The risk of elevated total bilirubin was increased in the population carrying allele A (P = 0.001, OR = 4.049) in the early postoperative period. Allelic polymorphisms in the TATA box promoter region and enhancer c.-3279 T > G and c.686C > A had no statistically significant difference between the bilirubin-elevated group and the normal bilirubin group. Conclusion: The preoperative ALT level, total bilirubin level, and portal vein branch development are correlated with the elevated total bilirubin in early postoperative patients. The polymorphisms of the UGT1A1 gene and enhancer c.211G > A are correlated with the occurrence of elevated total bilirubin in the early postoperative period of TIPS. Allele A carrier may have a higher risk of elevated total bilirubin in the early postoperative period.

Safety and clinical outcome of ultra-early oral nutrition after endoscopic treatment of gastroesophageal variceal bleeding in liver cirrhosis patients / 中华临床营养杂志

Objective:To investigate the safety and clinical outcome of ultra-early oral nutrition after endoscopic treatment of gastroesophageal variceal bleeding in liver cirrhosis patients.Methods:Cirrhotic patients with gastroesophageal variceal bleeding who received endoscopic treatment at the Endoscopic Center of Beijing Haidian Hospital were retrospectively included from January 2018 to January 2022. The patients were divided into ultra-early oral nutrition group where patients would fast for 4 hours after endoscopic treatment and routine treatment group where patients would fast for at least 48 hours after operation and receive parenteral nutrition during fasting. The rebleeding, infection events (including pulmonary infection, urinary infection, spontaneous bacterial peritonitis, etc.), hospitalization duration and hospital readmission were recorded and compared between the two groups.Results:A total of 96 patients were enrolled, including 52 with ultra-early oral nutrition, 44 with routine treatment. There was no significant difference in age, gender, BMI, cause of liver cirrhosis, Child-Pugh score, LDRf classification of gastroesophageal varices and degree of esophageal varices between the two groups ( P > 0.05). All patients were followed up for 6 weeks and there was no significant difference in incidence of rebleeding (5.8% vs 4.5%, P > 0.999), peritonitis (1.9% vs 4.5%, P = 0.883), pulmonary infection (5.8% vs 11.4%, P = 0.537) and urinary infection (3.8% vs 2.3%, P > 0.999) between the two groups. The non-inferiority analysis suggested that the safety defined as free from rebleeding in ultra-early oral nutrition group was not inferior to that in routine treatment group ( P = 0.0018). The hospitalization duration in ultra-early oral nutrition group was significantly shorter than that in routine treatment group (6 days vs 9 days, P < 0.001). The hospital readmission rate within 6 weeks in the ultra-early oral nutrition group tended to be lower than that in the routine treatment group (3.8% vs 9.1%, P = 0.526). Conclusion:Ultra-early oral nutrition after endoscopic treatment of gastroesophageal variceal bleeding in liver cirrhosis patients shows similar rebleeding risk compared with current practice and can shorten hospitalization duration.

Risk stratification in acute variceal bleeding: Far from an ideal score

OBJECTIVES: Acute variceal bleeding (AVB) results from rupture of esophageal or gastric varices. It is a life-threatening complication of portal hypertension. Nevertheless, it remains unclear how to predict adverse outcomes and identify high-risk patients. In variceal hemorrhage, high Child-Turcotte-Pugh (Child) and Model for End-stage Liver Disease (MELD) scores are associated with a worse prognosis. The Rockall system (Rockall), Glasgow-Blatchford (Blatchford), and AIMS65 scores have been validated for risk stratification for nonvariceal upper gastrointestinal bleeding; however, their use is controversial in AVB. The aim of this study was to compare the performance of Child, MELD, Rockall, Blatchford, and AIMS65 scores in risk stratification for rebleeding and/or mortality associated with AVB. METHODS: This retrospective study was conducted at a tertiary care hospital over 42 months. The outcomes were 6-week rebleeding and mortality. The AUROC was calculated for each score (1-0.9, 0.9-0.8, and 0.8-0.7, indicating excellent, good, and acceptable predictive power, respectively). RESULTS: In total, 222 patients were included. Six-week rebleeding and mortality rates were 14% and 18.5%, respectively. No score was useful for discriminating patients at a higher risk of rebleeding. The AUROCs were 0.59, 0.57, 0.61, 0.63, and 0.56 for Rockall, Blatchford, AIMS65, Child, and MELD scores, respectively. Prediction of 6-week mortality based on Rockall (AUROC 0.65), Blatchford (AUROC=0.60), and AIMS65 (AUROC=0.67) scores were also not considered acceptable. The AUROCs for predicting mortality were acceptable for Child and MELD scores (0.72 and 0.74, respectively). CONCLUSION: Rockall, Blatchford, and AIMS65 scores are not useful for predicting 6-week rebleeding or mortality in patients with AVB. Child and MELD scores can identify patients at higher risk for 6-week mortality but not for 6-week rebleeding.

Efficacy analysis of transjugular intrahepatic portosystemic shunt in the treatment of esophago-gastric variceal bleeding complicated with cavernous transformation of the portal vein / 中华消化杂志

Objective:To explore the safety and efficacy of transjugular intrahepatic portosystemic shunt (TIPS) in the treatment of esophago-gastric variceal bleeding (EGVB) complicated with cavernous transformation of portal vein (CTPV).Methods:From January 1, 2015 to December 31, 2018, the clinical data of liver cirrhosis patients with EGVB and complicated with (CTPV group) or without (non-CTPV group) CTPV receiving TIPS at Nanjing Drum Tower Hospital, the Affiliated Hospital of Nanjing University Medical School were retrospectively analyzed. The success rate of operation, stent patency rate, recurrent bleeding rate, incidence and survival rate of hepatic encephalopathy of CTPV group and non-CTPV group were analyzed. Independent samples t test, Mann-Whitney U test and chi-square test were used for statistical analysis. Kaplan-Meier method was used for survival analysis. Results:A total of 37 liver cirrhosis patients with EGVB and CTPV receiving TIPS treatment were screened out, among which 10 patients (27.0%) failed the portal vein puncture during the TIPS and switched to endoscopic treatment, the success rate was 73.0%. A total of 460 liver cirrhosis patients with EGVB and non-CTPV received TIPS treatment, among which TIPS in 18 patients (3.9%) was failed, and the success rate was 96.1%. With 1∶2 ratio propensity matching, 54 patients were enrolled in non-CTPV group. In the CTPV group, after TIPS treatment, the average portal vein pressure decreased from (28.9±5.1) mmHg (1 mmHg=0.133 kPa) to (18.8±4.5) mmHg, and the difference was statistically significant ( t=7.122, P<0.01). The median follow-up time was 33 months(1 to 66 months). There were no significant differences between the CTPV group and the non-CTPV group in one-year of cumulative stent patency rate (75.0% vs. 86.8%), recurrent upper gastrointestinal bleeding rate of hepatic encephalopathy (21.0% vs. 10.0%), the incidence of hepatic encephalopathy (34.8% vs. 22.2%) and the survival rate (80.7% vs. 88.9%)(all P >0.05). Conclusion:TIPS is safe and effective in the treatment of liver cirrhosis patients with EGVB and CTPV, and does not increase the incidence of postoperative complications and long-term mortality.

Current status of prevention and treatment of esophagogastric variceal bleeding in cirrhotic portal hypertension patients in Ningxia region: a multicenter study / 中华消化外科杂志

Objective:To investigate the current status of prevention and treatment of esophagogastric variceal bleeding (EVB) in cirrhotic portal hypertension patients in Ningxia region.Methods:The retrospective and descriptive study was conducted. The clinical data of 820 cirrhotic portal hypertension patients who were admitted to 21 medical centers in Niangxia region from January 2018 to December 2020 were collected, including 85 cases in Ningxia Hui Autonomous Region People′s Hospital, 73 cases in the Fifth People′s Hospital of Ningxia Hui Autonomous Region, 59 cases in the Wuzhong People′s Hospital, 52 cases in the Qingtongxia People′s Hospital, 50 cases in the Guyuan People′s Hospital, 47 cases in the Yuanzhou District People′s Hospital of Guyuan City, 47 cases in the Yinchuan Second People′s Hospital, 40 cases in the General Hospital of Ningxia Medical University, 40 cases in the Tongxin People′s Hospital, 35 cases in the Yinchuan First People′s Hospital, 34 cases in the Third People′s Hospital of Ningxia Hui Autonomous Region, 32 cases in the Zhongwei People′s Hospital, 30 cases in the Lingwu People′s Hospital, 30 cases in the Wuzhong New District Hospital, 30 cases in the Yanchi People′s Hospital, 29 cases in the Ningxia Hui Autonomous Region Academy of Traditional Chinese Medicine, 28 cases in the Shizuishan Second People′s Hospital, 25 cases in the Shizuishan First People′s Hospital, 21 cases in the Haiyuan People′s Hospital, 20 cases in the Pengyang People′s Hospital, 13 cases in the Longde People′s Hospital. There were 538 males and 282 females, aged (56±13)years. Observation indicators: (1) clinical charac-teristics of cirrhotic portal hypertension patients; (2) overall prevention and treatment of EVB in cirrhotic portal hypertension patients; (3) prevention and treatment of EVB in cirrhotic portal hypertension patients from different grade hospitals. Measurement data with normal distribution were represented as Mean± SD. Count data were described as absolute numbers, and comparison between groups was analyzed using the chi-square test. Results:(1) Clinical characteristics of cirrhotic portal hypertension patients: of 820 cirrhotic portal hypertension patients, 271 cases were in compensated stage and 549 cases were in decompensated stage. Of the 271 cases in compensated stage, there were 183 maels and 88 females, aged (53±12)years. There were 185 Han people, 85 Hui people and 1 case of other ethic group. The etiological data of liver cirrhosis showed 211 cases of viral hepatitis B, 4 cases of alcoholic liver disease, 8 cases of viral hepatitis C, and 48 cases of other etiology. There were 235 cases of Child-Pugh grade A and 36 cases lack of data. Of the 549 cases in decompensated stage, there were 355 males and 194 females, aged (57±14) years. There were 373 Han people, 174 Hui people and 2 cases of other ethic group. The etiological data of liver cirrhosis showed 392 cases of viral hepatitis B, 33 cases of alcoholic liver disease, 10 cases of viral hepatitis C, and 114 cases of other etiology. There were 80 cases of Child-Pugh grade A, 289 cases of grade B, 170 cases of grade C and 10 cases lack of data. (2) Overall prevention and treatment of EVB in cirrhotic portal hypertension patients: of 271 patients in compensated stage, 38 cases received non-selective β-blocker (NSBB) therapy, 16 cases received endoscopic treatment, 6 cases received interventional therapy. Of 549 patients in decompensated stage, 68 cases received NSBB therapy, 46 cases received endoscopic treatment, 28 cases received interventional therapy. (3) Prevention and treatment of EVB in cirrhotic portal hypertension patients from different grade hospitals: of 271 patients in compensated stage, 181 cases came from tertiary hospitals, of which 28 cases received NSBB therapy, 15 cases received endoscopic treatment, 6 cases received interventional therapy. Ninety cases came from secondary hospitals, of which 10 cases received NSBB therapy, 1 cases received endoscopic treatment. There was no significant difference in NSBB for prevention of EVB between tertiary and secondary hospitals ( χ2=0.947, P>0.05), while there was a significant difference in endoscopic treatment for prevention of EVB between tertiary and secondary hospitals ( χ2=5.572, P<0.05). Of 549 patients in decompensated stage, 309 cases came from tertiary hospitals, of which 22 cases received NSBB therapy, 29 cases received endoscopic treatment, 22 cases received interventional therapy. Two hundreds and fourty cases came from secondary hospitals, of which 46 cases received NSBB therapy, 17 cases received endoscopic treatment, 6 cases received interven-tional therapy. There were significant differences in NSBB and interventional therapy for prevention of EVB between tertiary and secondary hospitals ( χ2=18.065, 5.956, P<0.05). Conclusions:The proportion of receiving EUB prevention in cirrhotic portal hypertension in Ningxia is relatively low. For patients with compensated liver cirrhosis, the proportion of NSBB therapy and endoscopic treatment in the secondary hospitals was lower than that in tertiary hospitals. For patients with decompensated liver cirrhosis, the proportion of interventional treatment in secondary hospitals is lower than that of tertiary hospitals, but the proportion of NSBB in secondary hospitals taking is higher than that of tertiary hospitals.

Effects of Adjuvant Chinese Patent Medicine Therapy on Prevention of Variceal Rebleeding: A Retrospective Cohort Study / 中国结合医学杂志

OBJECTIVE@#To assess whether adjuvant Chinese patent medicines (CPMs) to standard treatment could reduce recurrent bleeding after variceal bleeding in cirrhotic patients.@*METHODS@#This study retrospectively collected 555 consecutive patients who recovered from variceal bleeding. A population-based cohort study was established depending on if adjuvant CPMs were administered to prevent rebleeding. A total of 139 patients who had taken ⩾28 cumulative defined daily doses (cDDDs) of CPMs were included in the CPMs cohort, and 416 patients who used 180 cDDDs of CPMs, respectively. The median rebleeding interval in the CPMs cohort was significantly larger compared with the non-CPMs cohort (113.5 vs. 93.0 days; P=0.008).@*CONCLUSION@#Adjuvant CPMs to standard therapy can significantly reduce the incidence of variceal rebleeding and delay the time to rebleeding.

CCI clinical practice guidelines: management of TIPS for portal hypertension (2019 edition) / 中华肝脏病杂志

Portal hypertension(PH) is one of the main complications of cirrhosis.Transjugular intrahepatic portosystemic shunt(TIPS) is the percutaneous creation of a conduit from the hepatic vein to the portal vein that is used to manage consequences of PH (i.e., variceal bleeding and refractory ascites) and used as a bridging therapy to liver transplant for decompensated cirrhosis. The following Clinical Practice Guidelines (CPGs) presents profession associational recommendations of the Chinese College of Interventionalists(CCI) on TIPS for PH. The CPGs was written by more than 30 experts in the field of TIPS in China (including interventional radiologists, liver surgeons, hepatologists and gastroenterologist, et al.). The panel of experts, produced these CPGs using evidence from PubMed and Cochrane database searches and combined with relevant expert consensuses and high quality clinical researches in China providing up to date guidance on TIPS for PH with the only purpose of improving clinical practice.

Study on correlation between serum 25-hydroxyvitamin D3 level and esophageal variceal bleeding in cirrhotic patients / 中华肝脏病杂志

Objective@#To explore the correlation between serum 25-hydroxyvitamin D3 (25[OH]D3) levels and esophageal variceal bleeding (EVB) in cirrhotic patients.@*Methods@#Eighty-three cases with liver cirrhosis hospitalized from November 2016 to January 2017 were collected. The patients were divided into bleeding group (51 cases) and non-bleeding group (32 cases) depending on the presence or absence of bleeding under gastroscopy. Serological tests were performed on both groups, including hemoglobin (Hb), albumin (ALB), alkaline phosphatase (ALP),γ-glutamyltransferase (GGT), interleukin-6 (IL-6), and 25-hydroxyvitamin D3 (25[OH]D3). Both groups were analyzed by univariate analysis. The differences between both groups were compared by t-test, after normality test. The other variables were compared by Mann-Whitney U test. The correlation between the relevant variables and EVB were analyzed by Spearman's rank correlation and a multivariate analysis. Cases with primary biliary cirrhosis were relatively low in number (four cases in bleeding group, accounting for 8%, 10 cases in non-bleeding group, accounting for 31%). The effects of ALP and GGT on serum 25(OH)D3 level were analyzed by stratified analysis. Moreover, ALP and GGT levels were divided into two and three groups: < 140 U/L and >140 U/L and < 30 U/L, > 30 U/L, and ~≤60 U/L.@*Results@#Bleeding group had low levels of hemoglobin (t= -2.827,P= 0.005), alkaline phosphatase (t= -3.097,P= 0.002), gamma-glutamyltransferase (t= -2.292,P= 0.022), and 25(OH)D3 (t= -3.134,P= 0.002) than non-bleeding group. Both groups (P> 0.05) had similar levels of albumin, interleukin-6, AAR, and FIB-4. Logistic regression analysis showed that 25(OH)D3, alkaline phosphatase and hemoglobin were independent risk factors for EVB. Spearman’s correlation coefficient analysis showed that 25(OH)D3was significantly positively and negatively correlated with interleukin-6 (r= 0.306,P= 0.005) and albumin (r= -0.327,P= 0.003). Stratified analysis showed that serum 25(OH)D3 level was lower in ALP≤140U/L group and the bleeding group, and the difference was statistically significant than non-bleeding group (P= 0.007), while the serum level of 25(OH)D3was decreased in both groups for alkaline phosphatase > 140 U/L group, and the difference was not statistically significant (P= 0.051). Furthermore, in the GGT > 60 U/L group, the serum level of 25(OH)D3was significantly lower in the bleeding group, and the difference was statistically significant in non-bleeding group (P= 0.003), while the difference between the two groups was not statistically significant (P> 0.05) in GGT≤30 U/ L, > 30 U/L, and ~≤60 U/L group.@*Conclusion@#Serum 25(OH)D3level was significantly lower in EVB cirrhotic patients, and it was an independent risk factor for EVB. Serum 25(OH)D3 low levels was more apparent with ALP normalization or GGT level > 60 U/L.

CCI clinical practice guidelines: management of TIPS for portal hypertension (2019 edition) / 中华肝脏病杂志

Portal hypertension(PH) is one of the main complications of cirrhosis.Transjugular intrahepatic portosystemic shunt(TIPS) is the percutaneous creation of a conduit from the hepatic vein to the portal vein that is used to manage consequences of PH (i.e., variceal bleeding and refractory ascites) and used as a bridging therapy to liver transplant for decompensated cirrhosis. The following Clinical Practice Guidelines (CPGs) presents profession associational recommendations of the Chinese College of Interventionalists(CCI) on TIPS for PH. The CPGs was written by more than 30 experts in the field of TIPS in China (including interventional radiologists, liver surgeons, hepatologists and gastroenterologist, et al.). The panel of experts, produced these CPGs using evidence from PubMed and Cochrane database searches and combined with relevant expert consensuses and high quality clinical researches in China providing up to date guidance on TIPS for PH with the only purpose of improving clinical practice.

Clinical therapeutic effects of endoscopic drug therapy for treatment of patients with acute esophageal and gastric variceal bleeding / 中国中西医结合急救杂志

Objective To observe the effects of endoscopic drug therap on hemostasis, re-bleeding and the risk of occurrence of complication in patients with acute esophageal and gastric variceal bleeding (EGVB). Methods A retrospective method was conducted, and 100 patients with EGVB who were admitted to the Affiliated Hospital of Yan'an University from June 2015 to June 2017 were enrolled. According to the difference in treatment methods, they were divided into an endoscopy Sclerotherapy and Ligation group and transjugular intrahepatic portosystemic shunt (TIPS) group, 50 cases in each group. The TIPS group was treated with TIPS; the endoscopy Sclerotherapy and Ligation group underwent endoscopic variceal sclerotherapy, endoscopic esophageal variceal ligation and postoperative non-selective β blockers oral administration. After 2 years of follow-up, the patients' hemostasis, re-bleeding at acute stage, survival situation and the incidences of complications were recorded. Before treatment and 2 weeks after treatment, the levels of serum albumin (Alb), total bilirubin (TBil) and platelet count (PLT) were measured by Hitachi automatic biochemical analyzer in the two groups. Results The success rate of hemostasis in the endoscopy Sclerotherapy and Ligation group was significantly higher than that in the TIPS group [98.0% (49/50) vs. 82.0% (41/50) ], and the recurrence rate of varices, during 1- and 2-year follow-up, the recurrence rate of bleeding and the incidences of complications were significantly lower than those in TIPS group [the recurrence rate of varicose veins: 6.0% (3/50) vs. 24.0 (12/50), 1-year re-bleeding rate: 12.0% (6/50) vs. 30.0% (15/50), 2-year re-bleeding rate: 42.0% (21/50) vs. 66.0% (33/50), esophageal ulcer: 2.0% (1/50) vs. 14.0% (7/50), upper abdominal discomfort: 2.0% (1/50) vs. 14.0% (7/50), hepatic encephalopathy:4.0% (2/50) vs. 16.0% (8/50), chest pain: 6.0% (3/50) vs. 20.0% (10/50), all P < 0.05]. After treatment, the levels of Alb and PLT in the endoscopy Sclerotherapy and Ligation group were higher than those in the TIPS group [Alb (g/L):43.84±4.34 vs. 40.83±3.21, PLT (×109/L): 26.33±3.37 vs. 21.12±3.89, both P < 0.05], and the TBil was lower than that in the TIPS group (μmol/L: 13.82±4.32 vs. 19.33±4.59). Conclusion Endoscopic Sclerotherapy and Ligation can significantly improve the effect of hemostasis of patients with acute EGVB, the rate of re-bleeding does not increase compared with that of western medicine group using TIPS, and the incidences of complications are significantly lower than those of applying TIPS.

¿Son útiles las prótesis metálicas autoexpandibles en el control de la hemorragia digestiva varicosa refractaria? / Are self-expanding metal prostheses useful for controlling refractory variceal digestive hemorrhaging?

Resumen El sangrado varicoso es una urgencia médica con altas tasas de morbimortalidad. De los pacientes que llegan para recibir manejo hospitalario, hasta un 10% no responden a medidas hemostáticas convencionales, por lo que se ha planteado el uso de prótesis metálicas autoexpandibles para el manejo con resultados prometedores de dichos pacientes. En el presente documento se discute la literatura mundial disponible acerca de la experiencia en el uso de dichos dispositivos; la eficacia en el control agudo; el pronóstico a largo plazo; el tipo de prótesis utilizadas y las alternativas, complicaciones y retos del manejo de pacientes con esta técnica, que puede considerarse emergente en nuestro medio.

Abstract Variceal bleeding is a medical emergency which has high rates of morbidity and mortality. Up to 10% of these patients treated in hospitals do not respond to conventional hemostatic measures. For this reason, the use of self-expanding metal stents (SEMS) has been proposed for management of these patients. It has had promising results. This paper discusses the literature available internationally about experience with the use of SEMS, their efficacy for acute control, long-term patient prognoses, types of stents, alternatives, complications, and challenges for the use of SEMS for patient management that should be considered in our environment.

Balloon-Occluded Retrograde Transvenous Obliteration versus Transjugular Intrahepatic Portosystemic Shunt for the Management of Gastric Variceal Bleeding

BACKGROUND/AIMS: Gastric varices (GVs) are a major cause of upper gastrointestinal bleeding in patients with liver cirrhosis. The current treatments of choice are balloon-occluded retrograde transvenous obliteration (BRTO) and the placement of a transjugular intrahepatic portosystemic shunt (TIPS). We aimed to compare the efficacy and outcomes of these two methods for the management of GV bleeding. METHODS: This retrospective study included consecutive patients who received BRTO (n=157) or TIPS (n=19) to control GV bleeding from January 2005 to December 2014 at a single tertiary hospital in Korea. The overall survival (OS), immediate bleeding control rate, rebleeding rate and complication rate were compared between patients in the BRTO and TIPS groups. RESULTS: Patients in the BRTO group showed higher immediate bleeding control rates (p=0.059, odds ratio [OR]=4.72) and lower cumulative rebleeding rates (log-rank p=0.060) than those in the TIPS group, although the difference failed to reach statistical significance. There were no significant differences in the rates of complications, including pleural effusion, aggravation of esophageal varices, portal hypertensive gastropathy, and portosystemic encephalopathy, although the rate of the progression of ascites was significantly higher in the BRTO group (p=0.02, OR=7.93). After adjusting for several confounding factors using a multivariate Cox analysis, the BRTO group had a significantly longer OS (adjusted hazard ratio [aHR]=0.44, p=0.01) and a longer rebleeding-free survival (aHR=0.34, p=0.001) than the TIPS group. CONCLUSIONS: BRTO provides better bleeding control, rebleeding-free survival, and OS than TIPS for patients with GV bleeding.

Drugs combined with endoscopic therapy versus transjugular intrahepatic portosystemic shunt in management of esophageal and gastric variceal bleeding / 中国内镜杂志

Objective To compare the short term and long term efficacy of drugs combined with endoscopic therapy (ET) and transjugular intrahepatic portosystemic shunt (TIPS) in treatment of esophageal and gastric variceal bleeding (EGVB) in cirrhotic patients. Methods We reviewed 120 cases of patients admitted for acute esophageal and gastric variceal bleeding from January 2010 to December 2014, treated with drugs combined with endoscopy (n = 77) or TIPS (n = 43). The incidence of failure to control bleeding, long term rebleeding, mortality and complications were compared. Results Patients treated with TIPS had a higher probability of remaining free of bleeding or rebleeding than patients receving drugs+ET (59.7％ vs. 81.4％, P < 0.05). The incidence of hepatic encephalopathy in the drugs + ET group was lower than that in the TIPS group (13.2％ vs 27.9％, P < 0.05). There was no significant difference in the control of acute bleeding (96.1％ vs 97.7％, P > 0.05) and mortality (10.4％ vs. 4.7％, P > 0.05) between the two groups. Conclusions Both drugs+ET and TIPS surgery can control EGVB well, TIPS can better prevent the occurrence of rebleeding but will lead to a higher incidence of hepatic encephalopathy.

Endoscopic variceal ligation as primary prophylaxis for oesophageal variceal bleeding at a Malaysian tertiary hospital

@#Objective: Approximately one-third of patients with esophageal varices will develop bleeding which is a major cause of morbidity and mortality in patients with liver cirrhosis. Currently, the two most widely used modalities to prevent variceal bleeding are pharmacologic and oendoscopic variceal band ligation (EVL). However, EVL has been associated with significant complications. Hence we aim to evaluate and to identify the epidemiology, demography, and complications of EVL at our local Malaysian tertiary hospital. Method: This is a retrospective study of all the patients that had undergone endoscopic variceal surveillance at the Gastroenterology endoscopy unit, Serdang Hospital from 1st January 2015 to 31st March 2017. Patients’ demography, aetiologies of liver cirrhosis, platelet level and international normalised ratio (INR) prior banding procedure, and the post EVL complications were recorded and further analysed with SPSS version 16. Results: In this study, 105 patients were screened for varices. Fifty-five of them had undergone EVL, with a quarter of the patients requiring repeated ligation. There was a male preponderance with 76.4%. 56.4% of patients were in age from 40-59 years. The majority of our patients were of the Malay ethnicity. The major aetiology for liver cirrhosis in our patients was viral hepatitis with Hepatitis C (31.0%), and Hepatitis B (20.0%). Most of our patients had platelet count >50,000 and INR <1.5 prior to EVL. There was no major complication in all of our subjects.

Advance in endoscopic treatment of esophageal variceal bleeding / 中国综合临床

Esophageal variceal bleeding is the most dangerous complications of portal hypertension caused by cirrhosis.It is a common emergency of digestive diseases,with characteristics of a large amount of bleeding,difficulties in rescue and high mortality.Treatment methods include drug therapy,surgical treatment, interventional therapy,combined therapy,endoscopic therapy,etc.Endoscopic therapy has become the main means to treat EVB because of its high success rate of hemostasis,little trauma and rapid hemostasis.With the continuous improvement of endoscopic equipment and technology,endoscopic treatment plays a more prominent role in the rescue process.This article reviews the endoscopic treatment of esophageal variceal bleeding.

Endoscopic variceal ligation versus endoscopic variceal sclerotherapy in treatment of esophageal variceal bleeding:a meta-analysis / 中国内镜杂志

Objective To make a systematical review of the efficacy and safety of endoscopic variceal ligation versus endoscopic variceal sclerotherapy for treatment of esophageal variceal bleeding. Methods We electronically searched databases including PubMed, Web of Science, The Cochrane Library (Issue 2, 2016), CNKI, WanFang Data and from Jan., 1980, to Mar., 2015, collected randomized controlled trials (RCTs) about EVL versus EVS for the patients of esophageal variceal bleeding. Then, meta-analysis was performed using RevMan 5.3 software. Results A total of 24 studies including 2020 patients were included. The results of meta-analysis showed that, there were no signiifcant differences in the variceal eradication rate (RR=1.04, 95%CI 0.99 to 1.09, P=0.090) between the EVL group and the EVS group; Compared with the EVS group, the EVL group could significantly reduce the rate of variceal rebleeding (RR=0.69, 95%CI 0.59 to 0.81, P=0.000), the rate of mortality (RR=0.76, 95%CI 0.63 to 0.90, P=0.002) and the rate of complication (RR=0.41, 95%CI 0.26 to 0.63, P=0.000), but the rate of variceal recurrent rate of EVS group was lower than that of the EVL group (RR=1.67, 95%CI 1.40 to 2.01,P=0.000). Conclusion Current evidence shows that, the variceal eradication rate between EVL and EVS is similar, but the EVL has less incidence of variceal rebleeding and mortality and complication.

Effects of transjugular intrahepatic portosystemic shunt combined with left gastric vein embolization on the liver function of patients with liver cirrhosis / 中华消化杂志

Objective To compare the difference in the effects on liver function between transjugular intrahepatic portosystemic shunt (TIPS) alone and the combination of TIPS and left gastric vein embolization (LGVE) in patients with liver cirrhosis.Methods This research was a retrospective study.From September 2014 to September 2015,31 patients with liver cirrhosis underwent TIPS (TIPS group) and 29 patients with liver cirrhosis underwent TIPS combined with LGVE (TIPS+LGVE group) were enrolled.The data of the liver function of patients before and after operation were collected and the Child-Pugh score and model for end-stage liver disease (MELD) were also calculated.Student's t test and chi-squared test were performed for statistical analysis.Results The preoperative portal vein pressures of TIPS group and TIPS+LGVE group were (28.48±2.77) mmHg (1 mmHg=0.133 kPa) and (28.38± 2.92) mmHg,respectively.And after operation,the portal vein pressures decreased to (17.81 ± 1.47) mmHg and (17.97 ± 2.04) mmHg,respectively,and the differences were both statistically significant (t=18.908 and 11.648,both P＜0.01).At 12 months after operation,Child-Pugh score of TIPS+ LGVE group was 5.69 ± 1.19,which was significantly lower than that before operation (7.03±1.76),and the difference was statistically significant (t=3.398,P=0.001),which was also lower than that of TIPS group at the same time point (6.52 ± 1.54),and the difference was statistically significant (t =2.303,P=0.025).At 12 months after operation,the component ratio of patients with Child-Pugh grade A of TIPS±LGVE group was 89.7％ (26/29),which was higher than that before operation (44.8％,13/29),and the difference was statistically significant (x2=13.228,P＜0.01).The component ratio of patients with Child-Pugh grade B was 6.9 ％ (2/29),which was lower than that before operation (41.4 ％,12/29),and the difference was statistically significant (x2 =9.416,P＜ 0.01).Conclusions TIPS significantly reduces portal vein pressure in patients with liver cirrhosis and it does not deteriorate liver function of patients in the long term.The combination of TIPS and LGVE is better than TIPS alone in improving liver function in patients with liver cirrhosis,especially in improvig long-term liver function in patients of Child-Pugh A and B grade.

Cost-Utility of Terlypressin in the Treatment of Esophageal and Gastric Variceal Bleeding / 中国药学杂志

OBJECTIVE: To evaluate the cost-utility of terlypressin compared with somatostatin in the treatment of esophageal and gastric variceal bleeding(EGVB) in China. METHODS: A discrete event simulation model was created with four transition states: bleeding, no bleeding, rebleeding, and death. Transition probability of the model is derived from Meta analysis of the published literature. Used to calculate the quality of life in transition states health utility value source of literature. Cost data was sourced from (the listing price) of medical institutions. One-way sensitivity analyses were performed. RESULTS: In the base case scenario, results showed that terlypressin was more costly and more effective compared with somatostatin, and that incremental cost-utility ratios were 65 478.84 Yuan/QALY. Sensitivity analyses showed that the model was robust, and that all incremental cost-utility ratios were below 110 289.46 Yuan/QALYs, which is far less than three times gross domestic product (GDP) per capita in China. If using the treatment duration in the instructions to calculate drug costs in the sensitivity analysis, treatment with terlypression has lower cost and better effectiveness. CONCLUSION: The model indicates that terlypressin is most likely to be cost-effective versus somatostatin.

The Efficacy and Safety of Endoscopic Esophageal Varix Ligation combined with Omeprazole and Octreotide in the Treatment of Esophageal Variceal Bleeding / 现代生物医学进展

Objective:To explore the efficacy and safety of endoscopic esophageal varix ligation (EVL) combined with omeprazole and octreotide in the treatment of esophageal variceal bleeding.Methods:127 patients with cirrhosis complicated with esophageal variceal hemorrhage diagnosed and treated in our hospital from May 2014 to May 2016 were divided into the study group and the control group.The control group was treated with omeprazole and octreotide on the basis of conventional therapy,while the study group was treated with endoscopic esophageal variceal ligation (EVL) on the basis of control group.The clinical efficacy,hospitalization condition,incidence of adverse reactions and rebleeding rate after treatment of the two groups were analyzed.Results:All the patients in the study group were successfully operated.In the control group,10 patients showed hematemesis and melena,among which 1 patient wastreated with surgery.After treatment,the c lini cal effi cacy of the study group was superi or to the control group,and the di fference was stati sti cally significant (P＜0.05).During the treatment period,the hemostasis time,blood transfusion time,hospital stay and hospitalization expenses of the study gronp were significantly lower than those of the control group (P＜0.05).In the study group and the control group,10 cases and 7 cases respectively had nausea and vomiting,esophageal foreign body sensation,dizziness,palpitations,pain,bloating,increased facces frequency,fever and other adverse reactions,and the incidence of increased faeces frequency of control group was significantly higher than that of the study group (P＜0.05),but the incidence of other adverse reactions and the total incidence showed no significant difference between two groups (P＞0.05).The rate of rebl eeding was si gni fi cantly lower in the study group at 0.5,1,3,6 and 12 months after treatment than those in the control group(P＜0.05).Conclusion:Endoscopic ligation combined with omeprazole and octreotide was effective in the treatment of esophageal variceal bleeding,which could be effective,rapid hemostasis,reduce the hospital stay,hospitalization cost and rebleeding rate with high safety.