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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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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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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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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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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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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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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.
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Humans , Female , Pregnancy , Pregnancy Outcome , Esophageal and Gastric Varices , Hypertension, Portal/prevention & controlABSTRACT
Objective:To study the factors influencing short-term prognosis of patients with Budd-Chiari syndrome (B-CS) presenting with upper gastrointestinal bleeding and to assess the predictive value of platelet-albumin-bilirubin score (PALBI) on death within 30 d in these patients.Methods:A retrospective study was conducted on 74 patients with B-CS who presented with upper gastrointestinal bleeding and were treated at the First Affiliated Hospital of Zhengzhou University from January 2014 to February 2020. There were 51 males and 23 females, with age of (46.5±11.1) years old. These patients were divided into the survival group ( n=58) and the death group ( n=16) according to the disease outcomes up to 30 d of follow-up. Factors influencing short-term deaths of these patients were analyzed, and the predictive values of PALBI, ALBI, CTP and MELD scores on short-term prognosis of the patients were assessed. The receiver operating characteristic (ROC) curves were plotted, and the areas under the curve (AUC) were calculated and compared. Results:The differences between patients in the survival and death groups for white blood cell, platelet, PALBI score, PALBI classification, ALBI score, CTP score, MELD score, and presence or absence of hepatic encephalopathy were significantly different (all P<0.05). Multivariate logistic regression analysis showed that CTP score≥10 or CTP grade C ( OR=1.669, 95% CI: 1.048-2.661), and PALBI score >-2.09 or PALBI grade 3 ( OR=5.245, 95% CI: 2.128-12.924) were independent risk factors for predicting death within 30 days. The areas under the ROC curves for PALBI, ALBI, CTP and MELD score were 0.89, 0.72, 0.77 and 0.76, with the cut-off values of -1.92, -1.60, 8.50 and 13.60, respectively. The differences between the PALBI score and ALBI, CTP scores were significantly different ( P<0.05). Conclusion:The PALBI score showed a positive predictive value on short-term prognostic assessment of patients with B-CS presenting with upper gastrointestinal bleeding. It was comparable to the effect of the MELD score but was significantly better than the ALBI and CTP scores.
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Objective:To investigate the effect of hepatic venous pressure gradient (HVPG) on the prevention of rebleeding in cirrhotic patients of hepatitis B with gastroesophageal variceal hemorrhage receiving endoscopic therapy, and its influence on prognosis.Methods:Fifty eight patients with esophageal and gastric varices due to cirrhosis of hepatitis B admitted to Minhang Hospital Affiliated to Fudan University (from January 2019 to September 2021, n=18) and Zhongshan Hospital Affiliated to Fudan University (from January to September 2017, n=40) were retrospectively included. All of them underwent HVPG determination and endoscopic treatment. They were divided into HVPG≤18 mmHg group and HVPG>18 mmHg group. The rebleeding and survival status of these patients with endoscopic treatment was compared after a follow-up period of 2 years, and Cox regression was performed to analyze the related factors for rebleeding and survival. Results:A total of 58 individuals were included, which were divided into two groups: HVPG≤18 mmHg group (35) and HVPG>18 mmHg group (23). During the 2-year follow-up after the first endoscopic treatment, 13 patients (22.41%) developed rebleeding, including 4 patients in the HVPG≤18 mmHg group and 9 patients in the HVPG>18 mmHg group. The non-bleeding rate in HVPG≤18 mmHg group was significantly higher than that in HVPG>18 mmHg group (91.3% vs 68.7%, RR=3.54, 95% CI: 1.08-11.60, P=0.026), and the difference was statistically significant. Four patients died, including 1 patient in the HVPG≤18 mmHg group and 3 patients in the HVPG>18 mmHg group. There was no statistically significant difference in 2-year survival between the two groups (96.7% vs 86.5%, RR=4.44, 95% CI: 0.45-43.58, P=0.162). Cox regression multivariate analysis was used to analyze the above data, and the results suggested portal vein thrombosis ( HR=3.826, 95% CI: 1.263-11.585, P=0.018), HVPG>18 mmHg ( HR=4.243, 95% CI: 1.290-13.955, P=0.017) were independent risk factors for rebleeding in 2 years after endoscopic therapy. Conclusions:For patients with high HVPG, it should be fully evaluated and considered to receive other pressure lowering therapy, and treatment conversion should be carried out as soon as possible after endoscopic treatment failure.
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Objective:To investigate the correlation between thromboelastography (TEG) and portal vein thrombosis in patients with cirrhotic esophagogastric varices.Methods:210 hospitalized patients with cirrhotic esophagogastric varices treated in Zhongshan Hospital Affiliated to Fudan University from December 2016 to December 2017 were retrospectively included. They were divided into portal vein thrombosis group (PVT group) and non portal vein thrombosis group (NPVT group) according to whether they were complicated with portal vein thrombosis. The correlation between the results of TEG coagulation reaction time (R value), coagulation time (K value), αAngle, maximum amplitude (MA) and coagulation composite index (CI) and portal vein thrombosis was analyzed. The characteristics of coagulation status in patients with portal vein thrombosis in cirrhosis were compared.Results:A total of 91 patients (43.3%) were complicated with portal vein thrombosis. The R value in the PVT group was significantly lower than that of NPVT group [5.49(5.22-5.77) vs 5.98(5.76-6.20), P=0.006]. Logistic regression analysis showed that Child Pugh grade ( OR=2.883, 95% CI: 1.630-5.098, P<0.001) and R value ( OR=0.739, 95% CI: 0.575-0.950, P=0.018) were independently associated risk factors of PVT. The R value of patients was significantly correlated with Child Pugh grade ( r=0.147, P=0.034), platelet ( r=-0.358, P<0.001), prothrombin time (PT) ( r=0.334, P<0.001) and international standardized ratio (INR) ( r=0.328, P<0.001). Conclusions:The decrease of TEG-R value is closely related to PVT in liver cirrhosis.
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Objective:To establish a nomogram model for individualized prediction of poor prognosis in patients with cirrhosis of esophagogastric variceal bleeding (EGVB), and verify its efficacy, so as to provide a scientific basis for the prevention and treatment of EGVB.Methods:The clinical data of 389 patients with cirrhosis of EGVB from January 2010 to December 2018 in Hangzhou Hospital of Zhejiang Medical and Health Group were retrospectively analyzed. All patients were followed up for 3 years, including 232 cases with poor prognosis (poor prognosis group) and 157 cases with good prognosis (good prognosis group). The general clinical data and laboratory results were compared between 2 groups. Receiver operating characteristic (ROC) curve was used to analyze the optimal cut-off value of poor prognosis factors in patients with cirrhosis of EGVB; multivariate Logistic regression analysis was used to analyze independent risk factors of poor prognosis in patients with cirrhosis of EGVB. A nomogram model to predict poor prognosis in patients with cirrhosis of EGVB was established with R language software 4.0 "rms" package. Internal validation of the nomogram model was performed using correction curves, and the prediction efficiency of the nomogram model was evaluated using decision curves.Results:The age, ascites rate, liver surface roughness rate, end-stage liver disease model score (MELD score), Child-Turcotte-Pugh score (CTP score), alanine aminotransferase (ALT), aspartate transaminase (AST), international standard ratio (INR) and total bilirubin (TBIL) in poor prognosis group were significant higher than those in good prognosis group: (62.48 ± 6.21) years old vs. (58.71 ± 5.93) years old, 51.29% (119/232) vs. 35.03% (55/157), 60.78% (141/232) vs. 42.03% (66/157), (13.89±1.93) scores vs. (11.32 ± 1.69) scores, (8.93 ± 0.77) scores vs. (7.46 ± 0.63) scores, (37.73 ± 5.21) U/L vs. (32.13 ± 5.03) U/L, (64.19 ± 11.31) U/L vs. (57.36 ± 10.29) U/L, 1.73 ± 0.41 vs. 1.61 ± 0.39 and (24.31 ± 2.63) μmol/L vs. (19.86 ± 2.17) μmol/L, the albumin, hemoglobin and serum sodium were significantly lower than those in good prognosis group: (36.21 ± 4.51) g/L vs. (39.12 ± 4.96) g/L, (86.31 ± 8.27) g/L vs. (92.28 ± 9.67) g/L and (136.58 ± 18.24) mmol/L vs. (141.21 ± 19.26) mmol/L, and there were statistical differences ( P<0.01 or<0.05). ROC curve analysis results show that the optimal cut-off values of age, MELD score, CTP score, albumin, ALT, AST, hemoglobin, INR, TBIL and serum sodium for predicting poor prognosis in patients with cirrhosis of EGVB were 55 years old, 14.20 scores, 9.30 scores, 35 g/L, 38 U/L, 67 U/L, 88 g/L, 1.90 scores, 25 μmol/L and 135 mmol/L, respectively. Multivariate Logistic regression analysis results showed that age≥55 years old, ascites, MELD score ≥14.20 scores, CTP score ≥9.30 scores, albumin<35 g/L and INR≥1.90 were independent risk factors for poor prognosis in patients with cirrhosis of EGVB ( HR = 1.528, 1.439, 1.637, 1.795, 1.521 and 1.596; 95% CI 1.165 to 1.891, 1.088 to 1.790, 1.308 to 1.966, 1.385 to 2.205, 1.262 to 1.780 and 1.259 to 1.933; P<0.05 or<0.01). To construct a nomogram model that integrates independent risk factors for poor prognosis in patients with cirrhosis of EGVB, the predictive power of the model was good (C-index 0.839, 95% CI 0.781 to 0.948). The corrected curve of nomogram model to predict poor prognosis in patients with cirrhosis of EGVB was close to the ideal curve; when the high risk threshold>0.02, nomogram model provided a significant additional clinical net benefit to predict poor outcome in patients with cirrhosis of EGVB, which was higher than the individual risk factors. Conclusions:The nomogram model based on age, ascites, MELD score, CTP score, albumin, INR and other independent risk factors that affect the high risk of poor prognosis in patients with cirrhosis of EDVB has great clinical value in screening and identifying high risk of poor prognosis in patients with cirrhosis of EDVB.
ABSTRACT
Objective:To evaluate the value of modified gastroscopic laryngeal mask airway (LMA) for airway management under general anesthesia in the patients with liver cirrhosis undergoing endoscopic esophageal variceal ligation (EVL).Methods:Sixty-two American Society of Anesthesiologists physical status Ⅱor Ⅲ patients with liver cirrhosis of either sex, aged 25-64 yr, with body mass index of 18-30 kg/m 2, undergoing endoscopic EVL with general anesthesia, were divided into 2 groups ( n=31 each) using a random number table method: tracheal tube group (group T) and modified gastroscopic LMA group (group L). After induction of anesthesia, a tracheal tube was inserted in group T, and a modified gastroscopic LMA was inserted and the patients were mechanically ventilated to maintain P ETCO 2 at 30-40 mmHg in group L. Successful tracheal intubation or insertion of modified gastroscopic LMA, successful ligator insertion and duration of ligator insertion were recorded.The occurrence of intraoperative hypotension, bradycardia and hypoxemia and consumption of propofol and remifentanil were recorded.At 1 min after tracheal intubation or right placement of LMA (T 1), immediately after the ligator insertion (T 2) and at the end of operation (T 3), Peak (P peak) and mean (P mean) airway pressure were monitored, and airway leak pressure in group L was measured.The extubation time, duration of post-anesthesia care unit stay and bucking during extubation were recorded.The occurrence of sore throat and nausea and vomiting was recorded within 6 h after operation.Postoperative satisfaction scores of endoscopists and patients were also recorded. Results:Sixty-one patients were finally enrolled in the study, with 31 in group T and 30 in group L. Compared with group T, no significant changes were found in the success rate of tracheal intubation or LMA placement, success rate of ligator insertion, P mean at each time point, incidence of postoperative nausea and vomiting, and postoperative satisfaction score of endoscopists ( P>0.05), duration of the ligator insertion was significantly shortened, P peak at each time point was decreased, the incidence of intraoperative hypotension and bradycardia was decreased, the consumption of propofol and remifentanil was reduced, the incidence of bucking during extubation and postoperative sore throat was reduced, and extubation time and duration of post-anesthesia care unit stay was shortened, and satisfaction scores of patients were increased in group L ( P<0.05). No hypoxemia was found in two groups.Airway leak pressure was maintained at 24-26 cmH 2O at each time point in group L. Conclusions:Modified gastroscopic LMA can be safely and effectively used for airway management under general anesthesia in the patients with liver cirrhosis undergoing EVL.