ABSTRACT
BACKGROUND: Bleeding esophageal varices (BEV) in cirrhosis has been considered an indication for liver transplantation (LT). This issue was examined in a randomized controlled trial (RCT) of unselected, consecutive patients with advanced cirrhosis and BEV that compared endoscopic sclerotherapy (EST; n = 106) to emergency direct portacaval shunt (EPCS; n = 105). METHODS: Diagnostic work-up and treatment were initiated within 8 hours. Patients were evaluated for LT on admission and repeatedly thereafter; 96% underwent over 10 years of regular follow-up. The analysis was supplemented by 1300 unrandomized cirrhotic patients who previously underwent portacaval shunt (PCS) with 100% follow-up. RESULTS: In the RCT long-term bleeding control was 100% following EPCS, only 20% following EST. Also, 3-, 5-, 10-, and 15-year survival rates were 75%, 73%, 46%, and 46%, respectively, following EPCS compared with 44%, 21%, 9%, and 9% following EST, respectively (P < .001). Only 13 RCT patients (6%) were ultimately referred for LT mainly because of progressive liver failure; only 7 (3%) were approved for LT and only 4 (2%) underwent LT. The 1- and 5-year LT survival rates were 0.68% and 0, respectively, compared with 81% and 73%, respectively, after EPCS. In the 1300 unrandomized PCS patients, 50 (3.8%) were referred and 19 (1.5%) underwent LT. The 5-year survival rate was 53% compared with 72% for all 1300 patients. CONCLUSIONS: If bleeding is permanently controlled, as occurred invariably following EPCS, cirrhotic patients with BEV seldom require LT. PCS is effective first-line and long-term treatment. Should LT be required in patients with PCS, although technically more demanding, numerous studies have shown that PCS does not increase mortality or complications. EST is not effective emergency or long-term therapy.
Subject(s)
Emergency Treatment , Esophageal and Gastric Varices/surgery , Liver Cirrhosis/surgery , Liver Transplantation , Acute Disease , Humans , Survival Rate , Treatment OutcomeABSTRACT
The name "Inflammatory Bowel Disease", of Anglo-Saxon origin, has been worked wide used in the medical language to name two nosologic entities: "Ulcerative colitis" (CU) and "Crohn's Disease" (EC). Both affect primarily young people, with approximately equal male to female ratio, although there is slight preponderance of females. In early as 90's, the development of ulcerative colitis during pregnancy had been described as potentially fatal complication, based on this observation therapeutic abortion was frequently recommended; now a days five questions in these patients with Inflammatory Bowel Disease (EII) that want to become pregnant have to be made: 1. Will the patient have more trouble getting pregnant? 2. Will the same (EC) affect the prognosis of pregnancy? 3. Will pregnancy affect the disease? 4. Which will be the treatment of the (EC) in pregnant women? 5. Will the treatment affect the fetus of the pregnancy? The authors present a case of Crohn's disease of the colon, in a patient of 24 years old with her first pregnancy. This case offered the opportunity to discuss problems and questions that took place in this kind of circumstances as mentioned earlier.
