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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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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.
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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.
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Portal vein thrombosis (PVT) in patients with liver cirrhosis has attracted more and more attention in recent years, and it can increase portal venous pressure in patients with liver cirrhosis, aggravate esophageal and gastric varices, and even lead to rupture and bleeding. This article reviews the advances in the epidemiology, mechanism, and treatment of PVT with gastrointestinal bleeding in patients with liver cirrhosis under different conditions in China and globally. There are still controversies over the specific treatment method for PVT with gastrointestinal bleeding and the dose and course of anticoagulants at home and abroad, and a large number of high-evidence studies are still needed to clarify the detailed treatment methods for such diseases in the future.
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Objective To investigate the risk factors for rebleeding after emergency esophageal variceal ligation (EVL) in patients with liver cirrhosis. Methods A retrospective analysis was performed for the clinical and laboratory data of 290 patients with liver cirrhosis who underwent emergency EVL in The Fifth Medical Center of Chinese PLA General Hospital from January 2016 to December 2019, and according to the presence or absence of rebleeding within 1-year follow-up, they were divided into rebleeding group and non-rebleeding group. The t -test was used for comparison of normally distributed continuous data between two groups, and the Wilcoxon rank sum test was used for comparison of non-normally distributed continuous data between two groups; the chi-square test was used for comparison of categorical data between two groups. A multivariate logistic regression analysis was performed with the statistically significant factors as independent variables to screen out the independent risk factors for rebleeding after emergency EVL, and the receiver operating characteristic (ROC) curve was plotted to obtain the indices for predicting the probability of rebleeding and establish a predictive model. Results The univariate analysis showed that there were significant differences between the two groups in platelet count ( t =-1.888, P =0.047), Child-Pugh score ( χ 2 =5.975, P =0.049), albumin level ( t =-2.229, P =0.029), and splenic vein diameter ( t =3.808, P =0.001). The multivariate logistic regression analysis showed that Child-Pugh score (odds ratio [ OR ]=0.280, 95% confidence interval [ CI ]: 0.108-0.729, P =0.009), splenic vein diameter ( OR =1.549, 95% CI : 1.197-2.005, P =0.001) and albumin level ( OR =0.832, 95% CI : 0.729-0.949, P =0.006) were independent influencing factors for rebleeding after EVL. The predictive model based on these three factors had an area under the ROC curve of 0.796, with a sensitivity of 83.7% and a specificity of 74.5% at the cut-off value of -0.086. Conclusion Child-Pugh score, albumin level, and splenic vein diameter are independent risk factors for rebleeding after emergency EVL, and the combination of the three indices has the highest sensitivity and specificity in predicting rebleeding.
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Objective To investigate the clinical value of von Willebrand factor antigen-to-albumin ratio (VAR) score and glycocalicin index (GCI) score in predicting the development and classification of esophageal varices in comparison with von Willebrand factor antigen-to-platelet ratio (VITRO) score. Methods A retrospective analysis was performed for 146 patients with hepatitis B cirrhosis who were hospitalized from April 2020 to December 2021, and esophageal varices (EV) was diagnosed and graded with the results of gastroscopy as the standard. VITRO, VAR, and GCI were calculated, and their association with EV was analyzed. The t -test was used for comparison of normally distributed continuous data between two groups, and a one-way analysis of variance was used for comparison between multiple groups; the Mann-Whitney U test was used for comparison of non-normally distributed continuous data between two groups. The chi-square test was used for comparison of categorical data between groups. A logistic regression model analysis was used to identify the predictive factors for EV, and the receiver operating characteristic (ROC) curve was used to evaluate the diagnostic accuracy of each index. Results Gastroscopy showed 54 patients without EV, 30 with mild EV, 33 with moderate EV, and 29 with severe EV. The patients with EV had significantly higher VAR and GCI scores than those without EV ( t =-5.819 and -3.449, both P < 0.001). The linear regression analysis showed that VAR and GCI increased with the increase in EV grade ( P =0.002 and 0.005). The multivariate logistic regression analysis showed that VAR (odds ratio [ OR ]=1.46, 95% confidence interval [ CI ]: 1.21-1.75, P < 0.001) and GCI ( OR =1.84, 95% CI : 1.22-2.77, P =0.003) were independently associated with EV. VITRO score had an area under the ROC curve (AUC) of 0.718 in diagnosing EV and 0.863 in diagnosing severe EV, with the optimal cut-off values of 2.77 and 5.37, respectively. VAR and GCI had an AUC of 0.745 and 0.710, respectively, in diagnosing EV, with the optimal cut-off values of 8.88 and 1.70, respectively; VAR and GCI had an AUC of 0.755 and 0.787, respectively, in diagnosing severe EV, with the optimal cut-off values of 9.81 and 2.00, respectively. VAR combined with GCI had significantly better efficacy than VITRO in diagnosing EV ( P =0.009), with an AUC of 0.808, a sensitivity of 55.43%, and a specificity of 94.44%; VAR combined with GCI had an AUC of 0.869 in diagnosing severe EV, which was similar to VITRO ( P =0.421). Conclusion VAR and GCI scores are potential noninvasive markers for the prediction and risk stratification of EV in patients with hepatitis B cirrhosis.
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Objective To develop an artificial neural network model to predict the risk of rebleeding within one year in cirrhotic patients with esophagogastric variceal bleeding. Methods We retrospectively collected 441 cirrhotic patients with esophagogastric variceal bleeding hospitalized at Beijing Ditan Hospital, Capital Medical University, from August 2008 to October 2017. The enrolled patients were followed up for one year. According to the primary endpoint which was rebleeding within one year, patients were divided into rebleeding (249 cases) and non-rebleeding (192 cases) groups. Fisher exact test or chi-square test were used for comparison of categorical data. Comparison of continuous data with normal distribution between groups was performed using t test, while comparison of non-normally distributed data was performed by Mann-Whitney U test. Cox univariate and multivariate regression were used to identify independent factors affecting rebleeding within one year in cirrhotic patients with esophagogastric variceal bleeding, and then an artificial neural network prediction model was constructed using identified factors. The predictive performance of the model was evaluated using the area under the receiver operating characteristic curve (AUC). Results In total, 249 (56.5%) patients developed esophagogastric variceal rebleeding within one year. Cox multivariate regression showed INR (AHR=1.566, 95%CI: 1.023~2.398, P=0.039) and NLR (AHR=1.033, 95%CI: 1.009~1.058, P=0.006) were risk factors for 1-year rebleeding, while CHB (AHR=0.769, 95%CI: 0.597~0.991, P=0.042), Na (AHR=0.967, 95%CI: 0.936~0.999, P=0.044), endoscopic (AHR=0.829, 95%CI: 0.743~0.926, P=0.001) and surgical treatment (AHR=0.246, 95%CI: 0.120~0.504, P < 0.001) were protective factors. Using the above six independent influence factors, we successfully constructed an artificial neural network model (https://lixuan.me/annmodel/myg-v3/). The model's ability to predict 1-year rebleeding had an AUC of 0.782 (95%CI: 0.740-0.825), which was higher than 0.672 (95%CI: 0.622-0.722, P < 0.001) of Cox regression model, 0.557 (95%CI: 0.504-0.610, P < 0.001) of Child-Pugh and 0.562 (95%CI: 0.509-0.616, P < 0.001) of MELD scores. Conclusion The artificial neural network model has good individualized prediction performance and can be used as a risk assessment tool for esophagogastric variceal rebleeding.
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Objective To analyze the rebleeding rate in hepatocellular carcinoma (HCC) patients with portal vein tumor thrombus (PVTT) after endoscopic treatment of esophagogastric variceal bleeding and then assessed the risk factors of the rebleeding in the patients. Methods This study retrospectively recruited 169 hepatitis B-associated HCC patients complicated with PVTT and esophagogastric variceal bleeding treated by endoscopy in Department of Gastroenterology, Beijing Ditan Hospital from September 2008 to December 2016. Among them, 47 patients had PVTT Ⅱ, 67 patients had PVTT Ⅲ, and 55 patients had PVTT Ⅳ. Their clinicopathological and follow-up data were retrieved from the medical records and statistically analyzed. Continuous data were compared among groups using ANOVA or Kruskal-Wallis H test. Categorial data were compared among groups using Chi-square test or corrected Fisher test. The Kaplan-Meier curves and Log-rank test were performed to analyze the rebleeding rate and cumulative survival rates after treatment. The univariate multivariate Cox regression analyses were used to identify the risk factors affecting the rebleeding of patients. Results Compared with PVTT Ⅱ and Ⅲ, PVTT Ⅳ patients had a higher serum level of the direct bilirubin ( Z =6.153, P =0.046). The endoscopy treatment successfully blocked esophagogastric variceal bleeding in all patients. There was no significant difference in the rebleeding rates within six months and a year after the treatment (all P > 0.05). It was also no statistically significant difference in cumulative survival rates in six months and l-, 2-, and 3-year after the treatment in PVTT Ⅱ, Ⅲ, and Ⅳ patients (all P > 0.05). Cox multivariate regression analysis showed that hepatic encephalopathy ( HR =3.643, 95% CI : 2.099-6.325, P < 0.001), γ-glutamyltransferase ( HR =1.002, 95% CI : 1.000-1.005, P =0.029), AFP ( HR =1.000, 95% CI : 1.000-1.000, P =0.002) and numbers of tumor lesions ( HR =1.647, 95% CI : 1.011-2.684, P =0.045) were all independent risk factors for 1-year rebleeding in these PVTT patients with esophagogastric variceal bleeding after endoscopic treatment. Conclusion Endoscopic hemostasis is a feasible treatment option for HCC patients with PVTT and esophagogastric variceal bleeding. However, there was no significant difference in the rebleeding and cumulative survival rates in these patients. Furthermore, hepatic encephalopathy, γ-glutamyltransferase, AFP and numbers of tumor lesions were all independent risk factors for 1-year rebleeding in these patients.
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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 investigate the efficacy of endoscopic ligation combined with traditional Chinese medicine (TCM) syndrome differentiation-based treatment in the secondary prevention of esophageal variceal bleeding (EVB) in patients with liver cirrhosis. Methods A total of 108 EVB patients who were admitted to Department of Liver Cirrhosis, Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine from April 2015 to February 2021 and underwent endoscopic ligation were enrolled, among whom 59 patients with TCM treatment were enrolled as Chinese and Western medicine group, and 49 patients without TCM treatment were enrolled as Western medicine group. The two groups were compared in terms of the incidence rate of rebleeding, mortality rate, and the improvement rate of portal hypertensive gastropathy. The t -test was used for comparison of normally distributed continuous data between groups, and the Mann-Whitney U rank sum test was used for comparison of non-normally distributed continuous data between groups; the chi-square test or the Fisher's exact test was used for comparison of categorical data between two groups; a Cox regression analysis was used to evaluate the risk factors for rebleeding. Results Compared with the Western medicine group, the Chinese and Western medicine group had a significantly lower rebleeding rate within 13-24 months after ligation (2% vs 12%, P =0.045), a significantly lower mortality rate of rebleeding (2% vs 12%, P =0.045), and a significantly higher overall response rate of portal hypertensive gastropathy (90% vs 77%, P =0.04). Underlying diseases (mainly including diabetes, hypertension, and heart disease) and Child-Pugh class for liver function were significant risk factors for rebleeding (all P < 0.05). Conclusion Ligation combined with TCM treatment can significantly reduce the incidence rate of delayed rebleeding and the mortality rate of EVB and improve the degree of portal hypertensive gastropathy, which provides a new strategy for ligation combined with TCM treatment to improve the overall response of EVB secondary prevention.
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Gastroesophageal variceal bleeding is the life-threating complication of cirrhotic portal hypertension, and transjugular intrahepatic portosystemic shunt (TIPS) is an effective therapy for portal hypertension-related complications. TIPS can be used for the prevention of first-time bleeding in patients with recurrent or intractable ascites. TIPS should be performed as early as possible for patients at a high risk of acute variceal bleeding (Child-Pugh class C 7 points with active bleeding on endoscopy or hepatic venous pressure > 20 mmHg). TIPS is an effective salvage therapy for acute variceal bleeding with failure after standard treatment, and is also a second-line option for preventing variceal rebleeding.
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Previous studies believe that patent paraumbilical vein in cirrhotic portal hypertension can reduce portal venous flow, portal venous pressure, and the development of esophageal varices and esophageal variceal bleeding, but there are still controversies over this issue in clinical practice. This article reviews the formation of portal systemic collateral circulation, the characteristics of the paraumbilical vein, the definition and diagnosis of patent paraumbilical vein, and the influence of patent paraumbilical vein on the development of esophageal varices and esophageal variceal bleeding, and it is believed that patent paraumbilical vein may not reduce the development of esophageal varices and esophageal variceal bleeding. Contrary to the previous points of view, patent paraumbilical vein should be regarded as a manifestation of the progression of cirrhotic portal hypertension, which can lead to the complications such as hepatic encephalopathy, and therefore, targeted prevention measures should be adopted in clinical practice.
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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.
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Animals , Swine, Miniature/surgery , Esophageal and Gastric Varices/surgery , Hypertension, Portal/surgeryABSTRACT
Objective:To explore the efficacy and safety of inflatable balloon compression-assisted endoscopic injection sclerotherapy (bc-EIS) in the treatment of esophago-gastric fundal varices (EGV).Methods:From June 12 to September 12, 2020, at the First Affiliated Hospital of Anhui Medical University, 38 patients with EGV who underwent bc-EIS were prospectively selected, the amount and the injection points of sclerosing medication were calculated, whether the injection point was bleeding during operation (no bleeding, oozing, spurting), whether compression was needed to stop bleeding (no need, needle sheath compression to stop bleeding, transparent cap compression to stop bleeding), early rebleeding after operation (72 h to 6 weeks after operation), delayed bleeding (six weeks after operation) were observed, and the number of treatments to achieve the complete elimination of varices were recorded. The postoperative follow-up period was one, three and six months to evaluate the efficacy and complications of bc-EIS. Descriptive methods were used for statistical analysis.Results:Among the 38 patients with EGV, there were 24 males and 14 females, aged (53.2±11.3) years old (ranged from 30 to 79 years old). During bc-EIS operation, the dosage of sclerosing medication of each patient was (20.03 ±7.49) mL (ranged from 6 to 40 mL), and the injection points of sclerosing medication were 4.97±1.83 (ranged from 2 to 10). The rates of complete disappearance of varices after the first, second and third time of bc-EIS were 71.1% (27/38), 89.5% (34/38) and 100.0% (38/38), respectively. Among the 38 patients with EGV, no postoperation varices related rebleeding occurred. During the follow-up two patients had hematemesis and melena within one month after operation. The endoscopic diagnosis was gastric varices bleeding below the cardia, which was improved after tissue glue injection under endoscopy. No severe adverse reactions such as fever, spontaneous bacterial peritonitis, hepatic encephalopathy, ectopic embolism, or death occurred in all patients after bc-EIS treatment.Conclusions:The dosage of sclerosing medication in bc-EIS is reduced by half compared with the recommended amount in the guidelines, and the injection point bleeding is less, moreover, the rate of complete disappearance rate of esophageal varices is more than 70% after the first treatment.
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ObjectiveTo investigate the technical success rate and outcome of transjugular intrahepatic portosystemic shunt (TIPS) in preventing esophageal variceal rebleeding in patients with portal vein thrombosis (PVT) after splenectomy. MethodsA retrospective analysis was performed for the clinical data of 46 patients with PVT after splenectomy who were admitted to Shandong Provincial Hospital from December 2009 to January 2017 and underwent TIPS to prevent esophageal variceal rebleeding. According to the success or failure of TIPS, the patients were divided into TIPS success group with 38 patients and TIPS failure group with 8 patients. The two groups were compared in terms of postoperative variceal rebleeding, stent dysfunction, hepatic encephalopathy (HE), and survival. The paired t-test was used for comparison of continuous data between two groups, and the chi-square test was used for comparison of categorical data between two groups. The Kaplan-Meier curve was used to analyze variceal rebleeding-free rate, stent patency rate, HE-free rate, and survival rate, and the log-rank test was used for comparison of cumulative rebleeding-free rate and cumulative survival rate. ResultsThe technical success rate of TIPS was 82.6%. There were significant differences in 6-, 12-, and 24-month cumulative rebleeding-free rates between the TIPS success group and the TIPS failure group (94.3%/89.8%/89.8% vs 85.7%/85.7%/28.6%, χ2=4.563, P=0.033). In the TIPS success group, the 6-, 12-, and 24-month cumulative stent patency rates were 79.3%, 74.3%, and 69.0%, respectively, and the 6-, 12-, and 24-month cumulative HE-free rates after TIPS were 72.1%, 55.5%, and 55.5%, respectively. There were significant differences in 6-, 12-, and 24-month cumulative survival rates between the TIPS success group and the TIPS failure group (94.0%/94.0%/86.2% vs 714%/71.4%/71.4%, χ2=4.988, P=0.026). ConclusionTIPS is a safe and feasible method for preventing esophageal variceal rebleeding in patients with PVT after splenectomy, and TIPS combined with a percutaneous transhepatic approach may promote technical success.
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ObjectiveTo investigate the risk factors for rebleeding within 5 years and the influencing factors for 5-year survival in patients with liver cirrhosis and severe esophagogastric variceal bleeding (EVB). MethodsA retrospective analysis was performed for 129 patients with liver cirrhosis who attended Tianjin Third Central Hospital from May 2012 to May 2014 due to severe EVB for the first time, with a follow-up time of 5 years. Related clinical data were analyzed, including age, sex, cause of liver cirrhosis, presence or absence of infection at the first time of bleeding, liver stiffness measurement (LSM), splenic stiffness measurement (SSM), portal vein diameter, biochemical parameters, rebleeding time, and prognosis. Esophagogastric variceal rebleeding was defined as the primary endpoint and death was defined as the secondary endpoint. The t-test was used for comparison of continuous data between two groups, and the chi-square test was used for comparison of categorical data between two groups; a logistic regression analysis was used to investigate the independent risk factors for rebleeding, and a Cox regression analysis was used to analyze the predictive indicators for 5-year survival in EVB patients; the Kaplan-Meier curve was used to analyze the cumulative non-rebleeding rate. ResultsAmong the 129 patients, 87(67.4%) experienced rebleeding during follow-up. There were significant differences between the rebleeding group and the non-rebleeding group in the proportion of patients with alcoholic cirrhosis (χ2=4.896, P=0.027), portal vein diameter (t=2.203, P=0.030), LSM(Z=-2.771, P=0.006), and SSM(t=2.678, P=0.010). The patients with alcoholic cirrhosis had a significantly higher mean number of times of bleeding than those with non-alcoholic cirrhosis (all P＜0.05). The multivariate logistic regression analysis showed that alcoholic cirrhosis (odds ratio ［OR］=5.687, 95% confidence interval ［CI］: 1.230-26.129, P=0.025), LSM(OR=1.039, 95% CI: 1.010-1.070, P=0007), and SSM(OR=1.078, 95% CI: 1.028-1.129, P=0.001) were independent risk factors for rebleeding within 5 years after treatment in EVB patients. Among the 129 patients, 45 (34.9%) died. The univariate Cox regression analysis showed that there were significant differences between the death group and the survival group in age, times of bleeding, mean arterial pressure, portal vein diameter, aspartate aminotransferase, lymphocyte percentage, and presence or absence of infection at the first time of bleeding (all P＜005). Further multivariate analysis showed that 5-year survival rate was associated with portal vein diameter (OR=1.459, 95% CI: 1056-2.014, P=0.022), age (OR=1.053, 95% CI: 1.006-1.103, P=0.026), times of bleeding (OR=1.286, 95% CI: 1.040-1.591, P=0.020), and presence or absence of infection at the first time of bleeding (OR=5.239, 95% CI: 1.750-15.641, P=0.003). ConclusionAlcoholic cirrhosis, LSM, and SSM are independent risk factors for rebleeding within 5 years in EVB patients, and age, times of bleeding, portal vein diameter, and presence or absence of infection at the first time of bleeding are associated with 5-year survival.