Sclerotherapy with or without octreotide for acute variceal bleeding.

BACKGROUND: Sclerotherapy is considered the most effective way to stop bleeding from esophageal varices, but acute variceal bleeding is still associated with a high risk of rebleeding and death. We compared sclerotherapy alone with sclerotherapy and octreotide to control acute variceal bleeding and prevent early rebleeding in patients with cirrhosis. METHODS: In a double-blind, prospective trial, 199 patients with cirrhosis and acute variceal bleeding who underwent emergency sclerotherapy were randomly assigned to receive a continuous infusion of octreotide (25 micrograms per hour) or placebo for five days. The primary outcome measure was survival without rebleeding five days after sclerotherapy. RESULTS: After five days, the proportion of patients who had survived without rebleeding was higher in the octreotide group (85 of 98 patients, or 87 percent) than in the placebo group (72 of 101, or 71 percent; 95 percent confidence interval for the difference, 4 to 27 percent; P = 0.009). The mean number of units of blood transfused within the first 24 hours after sclerotherapy was lower in the octreotide group (1.2 units; range, 0 to 7) than in the placebo group (2.0 units; range, 0 to 10; P = 0.006). A logistic-regression analysis showed that the treatment assignment (P = 0.003) and the number of blood units transfused before any other treatment was undertaken (P = 0.002) were the only two variables independently associated with survival without rebleeding. After adjustment for base-line differences between the two groups, the odds ratio for treatment failure in the placebo group, as compared with the octreotide group, was 3.3 (95 percent confidence interval, 1.5 to 7.3). The mean (+/- SD) 15-day cumulative survival rate (estimated by the Kaplan-Meier method) was 88 +/- 12 percent in both groups. Side effects were minor, and their incidence was similar in the two groups. CONCLUSIONS: In patients with cirrhosis, the combination of sclerotherapy and octreotide is more effective than sclerotherapy alone in controlling acute variceal bleeding, but there is no difference between the overall mortality rates associated with the two approaches to treatment.

[Is the identification of acute biliary and alcoholic pancreatitis by early pancreatic enzyme assay possible?]. / L'identification des pancréatites aiguës biliaires et alcooliques par le dosage précoce des enzymes pancréatiques est-elle possible?

Early and appropriate treatment of acute pancreatitis (AP) depends on early causal diagnosis. Published studies have shown favourable results following sphincterotomy performed within the 72 hours of onset of severe gallstone-associated AP. Among the various bio-clinical indices, the lipase/amylase (L/A) ratio, computed within 72 hours after onset, has been shown to discriminate between alcoholic and non alcoholic AP. Our study evaluates the data of biochemical disorders in 51 patients presenting with an episode of AP; these patients were divided into 3 groups: A: alcoholic AP, n = 15; B: biliary AP, n = 25; and C: post-ERCP AP, n = 11. These 3 groups were similar with respect to clinical severity of AP and CT scan. The time delays between onset of the symptoms and the biochemical assay were 1.9 +/- 0.3, 1.9 +/- 0.2 and 0.6 +/- 0.3 d (P < 0.01). AST, ALT, bilirubin, GGT and alkaline phosphatase were significantly (P < 0.05) greater in group B. Blamey's score was 0.5 +/- 0.2, 2.8 +/- 0.2 and 2.5 +/- 0.4 in groups A, B and C respectively. Serum amylase, serum lipase and L/A ratio were identical in groups A and B. The decrease in serum amylase after 48 hours was more important only in group B (56 +/- 8, 80 +/- 4, 47 +/- 3% respectively in groups A, B and C). L/A ratio was significantly greater in group C when compared with group A and B (1.7 +/- 0.4, 1.5 +/- 0.2 and 2.2 +/- 0.3 in groups A, B and C respectively).(ABSTRACT TRUNCATED AT 250 WORDS)