Use and safety of prophylactic endoscopy from a single center serving urban and rural children with portal hypertension

AbstractProphylactic endoscopy is routine in adults with portal hypertension (PHTN), but there is limited data in pediatrics. We sought to describe our experience with prophylactic endoscopy in pediatric PHTN. This is a retrospective study of 87 children who began surveillance endoscopy prior to gastrointestinal bleeding (primary prophylaxis) and 52 who began after an episode of bleeding (secondary prophylaxis) from 01/01/1994 to 07/01/2019. Patients who underwent primary prophylaxis had a lower mean number of endoscopies (3.897 vs 6.269, p = 0.001). The primary prophylaxis group was less likely to require a portosystemic shunt (6% vs 15%, p < 0.001) with no difference in immediate complications (1% vs 2%, p = 0.173) or 2-week complications (1% vs 2%, p = 0.097). No deaths were related to variceal bleeding or endoscopy. Kaplan–Meier Survival Curve suggests improved transplant and shunt free survival in the primary prophylaxis group (log-rank p < 0.001). Primary and secondary endoscopic prophylaxis should be considered safe for the prevention of variceal hemorrhage in pediatric portal hypertension. There are differences in outcomes in primary and secondary prophylaxis, but unclear if this is due to patient characteristics versus treatment strategy. Further study is needed to compare safety and efficacy to watchful waiting.

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Use and Safety of Prophylactic Endoscopy From a Single Center Serving Urban and Rural Children With Portal Hypertension

10.21203/rs.3.rs-544137/v1 ◽

2021 ◽

Author(s):

Voytek Slowik ◽

Anissa Bernardez ◽

Heather Wasserkrug ◽

Ryan T. Fischer ◽

James F. Daniel ◽

...

Keyword(s):

Portal Hypertension ◽

Watchful Waiting ◽

Patient Characteristics ◽

Primary Prophylaxis ◽

Secondary Prophylaxis ◽

Rural Children ◽

Variceal Hemorrhage ◽

Limited Data ◽

Surveillance Endoscopy ◽

Versus Treatment

Abstract Background: Prophylactic endoscopy is routine in adults with portal hypertension (PHTN), but there is limited data in pediatrics. We sought to describe our experience with prophylactic endoscopy in pediatric PHTNMethods: Retrospective cohort study of 87 children who began surveillance endoscopy prior to gastrointestinal bleeding (primary prophylaxis) and 52 who began after an episode of bleeding (secondary prophylaxis) from 01/01/1994 – 07/01/2019. Results: Patients who underwent primary prophylaxis had a lower mean number of endoscopies (3.897 vs 6.269, p = 0.001). The primary prophylaxis group was less likely to require a portosystemic shunt (6% vs 15%, p < 0.001) with no difference in immediate complications (1% vs 2%, p = 0.173), 2-week complications (1% vs 2%, p = 0.097), need for transplant (24% vs 27%, p = 0.0819) or death (5% vs 13%, p = 0.061). No deaths were related to variceal bleeding or endoscopy. Conclusions: Primary and secondary endoscopic prophylaxis should be considered safe for the prevention of variceal hemorrhage in pediatric portal hypertension. There are differences in outcomes in primary and secondary prophylaxis, but unclear if this is due to patient characteristics versus treatment strategy. Further study is needed to compare safety and efficacy to watchful waiting.

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Management of variceal hemorrhage: current concepts

ABCD Arquivos Brasileiros de Cirurgia Digestiva (São Paulo) ◽

10.1590/s0102-67202014000200011 ◽

2014 ◽

Vol 27 (2) ◽

pp. 138-144 ◽

Cited By ~ 10

Author(s):

Fabricio Ferreira COELHO ◽

Marcos Vinícius PERINI ◽

Jaime Arthur Pirola KRUGER ◽

Gilton Marques FONSECA ◽

Raphael Leonardo Cunha de ARAÚJO ◽

...

Keyword(s):

Portal Hypertension ◽

Surgical Treatment ◽

Variceal Bleeding ◽

Endoscopic Therapy ◽

Beta Blockers ◽

Primary Prophylaxis ◽

Underlying Disease ◽

Secondary Prophylaxis ◽

Variceal Hemorrhage ◽

Cirrhotic Patients

INTRODUCTION: The treatment of portal hypertension is complex and the the best strategy depends on the underlying disease (cirrhosis vs. schistosomiasis), patient's clinical condition and time on it is performed (during an acute episode of variceal bleeding or electively, as pre-primary, primary or secondary prophylaxis). With the advent of new pharmacological options and technical development of endoscopy and interventional radiology treatment of portal hypertension has changed in recent decades. AIM: To review the strategies employed in elective and emergency treatment of variceal bleeding in cirrhotic and schistosomotic patients. METHODS: Survey of publications in PubMed, Embase, Lilacs, SciELO and Cochrane databases through June 2013, using the headings: portal hypertension, esophageal and gastric varices, variceal bleeding, liver cirrhosis, schistosomiasis mansoni, surgical treatment, pharmacological treatment, secondary prophylaxis, primary prophylaxis, pre-primary prophylaxis. CONCLUSION: Pre-primary prophylaxis doesn't have specific treatment strategies; the best recommendation is treatment of the underlying disease. Primary prophylaxis should be performed in cirrhotic patients with beta-blockers or endoscopic variceal ligation. There is controversy regarding the effectiveness of primary prophylaxis in patients with schistosomiasis; when indicated, it is done with beta-blockers or endoscopic therapy in high-risk varices. Treatment of acute variceal bleeding is systematized in the literature, combination of vasoconstrictor drugs and endoscopic therapy, provided significant decline in mortality over the last decades. TIPS and surgical treatment are options as rescue therapy. Secondary prophylaxis plays a fundamental role in the reduction of recurrent bleeding, the best option in cirrhotic patients is the combination of pharmacological therapy with beta-blockers and endoscopic band ligation. TIPS or surgical treatment, are options for controlling rebleeding on failure of secondary prophylaxis. Despite the increasing evidence of the effectiveness of pharmacological and endoscopic treatment in schistosomotic patients, surgical therapy still plays an important role in secondary prophylaxis.

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Biosimilar medicines in oncology: Single-center experience with biosimilar G-CSF.

Journal of Clinical Oncology ◽

10.1200/jco.2012.30.15_suppl.e19501 ◽

2012 ◽

Vol 30 (15_suppl) ◽

pp. e19501-e19501

Author(s):

Nello Salesi ◽

Barbara Di Cocco ◽

Enzo Veltri

Keyword(s):

Febrile Neutropenia ◽

Locally Advanced ◽

Cost Savings ◽

Living Organism ◽

Primary Prophylaxis ◽

Prostate Adenocarcinoma ◽

Secondary Prophylaxis ◽

Prophylaxis Group ◽

Single Center Experience ◽

Platinum Based Chemotherapy

e19501 Background: A biosimilar medicine is one with proven similarity to a reference biological product for which the patent has expired and whose active ingredient is produced or derived from a living organism. Recombinant granulocyte colony-stimulating growth factors (G-CSF) are used for the prophylaxis of febrile neutropenia. Methods: In this observational study a total of 48 patients with solid tumours were treated with biosimilar Zarzio, a new biosimilar G-CSF for 4−14 days from the day following the end of chemotherapy. The primary prophylaxis group was composed of 10 patients with breast carcinoma receiving adjuvant chemotherapy (CEF: 5-fluorouracil 600 mg/m2, epirubicin 100 mg/m2 G1, cyclophosphamide 600 mg/m2 G1, q 21 for 4 cycles à docetaxel 100 mg/m2 G1, q 21); 17 patients with locally advanced or metastatic lung carcinoma (66% adenocarcinoma, 34% squamous) receiving 4–6 cycles of platinum-based chemotherapy; 6 patients with metastatic gastric adenocarcinoma treated with TCF (Taxotere 75 mg/m2, cisplatin 75 mg/m2, 5-fluorouracil 300 mg/m2 by continuous 24 hour infusion for 5 days, q 21) for 4–6 cycles; 4 patients with prostate adenocarcinoma treated with Docetaxel 75 mg/m2 G1, q 21 in 6 cycles. The secondary prophylaxis group was composed of 11 patients with colorectal adenocarcinoma (54.5% treated with adjuvant XELOX therapy: Xeloda 2000 mg/m2 G1à14, oxaliplatin 130 mg/m2 G1, q 21, and the remainder treated with first-line metastatic FOLFOXIRI therapy [CPT-11 165mg/m2 G1, 5-FU 3200 mg/m2 continuous infusion for 48 hours, oxaliplatin 85 mg/m2 G1, q 14]). Results: Three cases of febrile neutropenia were reported: two in patients with prostate adenocarcinoma and one case in a patient with pulmonary squamous cell carcinoma and multiple secondary skeletal lesions. These patients were treated with antibiotics with resolution of the clinical picture without hospitalization after 24 hours. Conclusions: Our experience indicates that the use of biosimilar G-CSF is safe and effective at reducing neutropenic complications in patients with mixed tumors and is associated with cost savings.

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Primary Prophylaxis of Variceal Hemorrhage in Children With Portal Hypertension: A Framework for Future Research

Journal of Pediatric Gastroenterology and Nutrition ◽

10.1097/mpg.0b013e318205993a ◽

2011 ◽

Vol 52 (3) ◽

pp. 254-261 ◽

Cited By ~ 68

Author(s):

Simon C Ling ◽

Thomas Walters ◽

Patrick J McKiernan ◽

Kathleen B Schwarz ◽

Guadalupe Garcia-Tsao ◽

...

Keyword(s):

Portal Hypertension ◽

Primary Prophylaxis ◽

Future Research ◽

Variceal Hemorrhage

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Recent Advances in the Management of Acute Variceal Hemorrhage

Journal of Clinical Medicine ◽

10.3390/jcm10173818 ◽

2021 ◽

Vol 10 (17) ◽

pp. 3818

Author(s):

Alberto Zanetto ◽

Sarah Shalaby ◽

Paolo Feltracco ◽

Martina Gambato ◽

Giacomo Germani ◽

...

Keyword(s):

Portal Hypertension ◽

Portal Pressure ◽

Indirect Measurement ◽

Secondary Prophylaxis ◽

Variceal Hemorrhage ◽

Esophageal Variceal ◽

Gastroesophageal Varices ◽

Recent Advances ◽

Risk Patients ◽

Clinically Significant

Gastrointestinal bleeding is one of the most relevant causes of death in patients with cirrhosis and clinically significant portal hypertension, with gastroesophageal varices being the most frequent source of hemorrhage. Despite survival has improved thanks to the standardization on medical treatment aiming to decrease portal hypertension and prevent infections, mortality remains significant. In this review, our goal is to discuss the most recent advances in the management of esophageal variceal hemorrhage in cirrhosis with specific attention to the treatment algorithms involving the use of indirect measurement of portal pressure (HVPG) and transjugular intrahepatic portosystemic shunt (TIPS), which aim to further reduce mortality in high-risk patients after acute variceal hemorrhage and in the setting of secondary prophylaxis.

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Soluble CD163 for Prediction of High-Risk Esophageal Varices and Variceal Hemorrhage in Patients with Liver Cirrhosis

GE Portuguese Journal of Gastroenterology ◽

10.1159/000516913 ◽

2021 ◽

pp. 1-14

Author(s):

Mohamed Yousri Taher ◽

Abeer El-Hadidi ◽

Assem El-Shendidi ◽

Ahmed Sedky

Keyword(s):

High Risk ◽

Esophageal Varices ◽

Bleeding Risk ◽

Primary Prophylaxis ◽

Variceal Hemorrhage ◽

Cutoff Value ◽

Soluble Cd163 ◽

Acute Upper Gastrointestinal Bleeding ◽

Cirrhotic Patients ◽

Surveillance Endoscopy

Introduction: Activation of hepatic macrophages in liver disease is pathogenically related to portal hypertension (PH). Soluble CD163 (sCD163) is shed in blood by activated macrophages and may predict PH progression noninvasively. This study was designed to investigate the relation of serum sCD163 to the grade and bleeding risk of esophageal varices (EV) and its role for prediction of variceal hemorrhage (VH). Methods: The study included cirrhotic patients divided into 3 groups: patients who presented with acute upper gastrointestinal bleeding (UGIB) proved to originate from EV on endoscopy, patients without any history of UGIB but who revealed EV on surveillance endoscopy, and patients without endoscopic evidence of varices. Variceal grade and risk signs and bleeding stigmata were noted simultaneously with measurement of serum sCD163 concentration. Results: Serum sCD163 concentration showed a significant increase in cirrhotic patients compared to healthy subjects (p < 0.001) with a stepwise increase among the group without varices, nonbleeder group, and bleeder group sequentially. Serum sCD163 levels correlated positively with the variceal grade and risk signs in both the bleeder and nonbleeder groups (p = 0.002, p < 0.001 and p = 0.004, p < 0.001, respectively). Serum sCD163 at a cutoff value of 3.6 mg/L performed significantly for prediction of EV presence (AUC = 0.888). Serum sCD163 at a cutoff value >4 mg/L significantly predicted large-size and high-risk EV (AUC = 0.910 and AUC = 0.939, respectively) and the index bleed risk (AUC = 0.977). Serum sCD163 at a cutoff value >4.05 mg/L modestly discriminated bleeding EV from those that had never bled (AUC = 0.811). Conclusions: Serum sCD163 levels accurately predicted high-grade and high-risk EV and could help plan for primary prophylaxis. However, it modestly identified VH occurrence, and endoscopy would be required to make a definitive diagnosis.

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Risk Factors for BreakthroughPneumocystis cariniiPneumonia on Aerosol Pentamidine Prophylaxis

Canadian Respiratory Journal ◽

10.1155/1995/948507 ◽

1995 ◽

Vol 2 (1) ◽

pp. 49-54

Author(s):

RA McIvor ◽

AR Rachlis ◽

P Berger ◽

LR Lee Pack ◽

Charles K Chan

Keyword(s):

Risk Factors ◽

Pulmonary Function Tests ◽

Pneumocystis Carinii ◽

Primary Prophylaxis ◽

Secondary Prophylaxis ◽

Cd4 Count ◽

Smoking History ◽

Control Group ◽

Prophylaxis Group ◽

Group Time

OBJECTIVE: To identify baseline characteristics of human immunodeficiency virus (HIV)-infected individuals on aerosol pentamidine forPneumocystis cariniiprophylaxis that are predictive of subsequent breakthroughPneumocystis cariniipneumonia (PCP).DESIGN: Nested case-control study assembled from a cohort of patients enrolled in the Toronto aerosol pentamidine program.METHODS: Subjects were selected from a cohort of HIV-infected individuals were enrolled in a community based aerosol pentamidine program between May 1989 and May 1992 in Toronto, Ontario. Cases - individuals who had breakthrough PCP - were matched with up to two controls enrolled in the same week. Risk factors examined for development of PCP for both primary and secondary prophylaxis included age, sex, smoking history, evidence of bronchospasm during aerosol pentamidine administration (fall of forced expiratory volume [FEV] 15% or more), administration of salbutamol before aerosol pentamidine, pulmonary function tests including lung volumes, flow rates and diffusing capacity for carbon monoxide. In the primary prophylaxis group, CD4 count at enrolment and in the secondary prophylaxis group, time from the most recent episode of PCP to enrolment for aerosol pentamidine and total time from the most recent episode of PCP to breakthrough PCP were examined as additional risk factors.RESULTS: A total or 1344 patients we re enrolled in the aerosol pentamidine program, 78% for primary prophylaxis and 22% for secondary prophylaxis. At the time of census at the end or 1992 there had been 96 episodes or breakthrough PCP, 5% on primary prophylaxis and 14.5% on secondary prophylaxis. In the primary prophylaxis group, enrolment CD4 count was significantly lower in the cases developing breakthrough PCP: 116±74 compared with 175±85 cells/mm3in the control group (P=0.001). There was no difference in any other variable. In the secondary prophylaxis group, time from the most recent episode of PCP to initiation of aerosol pentamidine therapy was longer in the cases developing breakthrough PCP: mean delay 6.1±6.6 months compared with 3.1±2.1 in controls (P=0.02). There was no difference in the other variables examined.CONCLUSIONS: The results of this study support immune augmentation for patients receiving aerosol pentamidine for primary prophylaxis, and aerosol pentamidine should be recommenced as soon as possible following an episode of PCP, for secondary prophylaxis.

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Ondansetron rapidly dissolving film for the prophylactic treatment of radiation-induced nausea and vomiting—a pilot study

Current Oncology ◽

10.3747/co.22.2395 ◽

2015 ◽

Vol 22 (3) ◽

pp. 199 ◽

Cited By ~ 5

Author(s):

E. Wong ◽

N. Pulenzas ◽

G. Bedard ◽

C. DeAngelis ◽

L. Zhang ◽

...

Keyword(s):

Acute Phase ◽

Palliative Radiotherapy ◽

Primary Prophylaxis ◽

Secondary Prophylaxis ◽

Nausea And Vomiting ◽

Life Questionnaire ◽

Maximum Increase ◽

Prophylaxis Group ◽

Radiation Induced ◽

Delayed Phase

Introduction The purpose of the present study was to investigate the efficacy of an ondansetron rapidly dissolving film (rdf) in the prophylaxis of radiation-induced nausea and vomiting (rinv). Rapidly dissolving film formulations facilitate drug delivery in circumstances in which swallowing the medication might be difficult for the patient.MethodsPatients undergoing palliative radiotherapy at risk for rinv were prescribed ondansetron rdf 8 mg twice daily while on treatment and were asked to complete a nausea and vomiting–specific daily diary, the Functional Living Index–Emesis (flie), and the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire–C15 Palliative (qlq-C15-pal). Patients were categorized as receiving primary or secondary prophylaxis based on whether they had already experienced emetic episodes. “Overall control” was defined as a maximum increase of 2 episodes of nausea or vomiting from baseline. “Acute phase” was defined as the days during radiation until the first day after radiation; “delayed phase” was defined as days 2–10 after radiation.Results The study accrued 30 patients. Rates of overall control for nausea and for vomiting during the acute phase in the primary prophylaxis group were 88% and 93% respectively; during the delayed phase, they were 73% and 75%. Rates of overall control for nausea and for vomiting during the acute phase in the secondary prophylaxis group were both 100%; during the delayed phase, they were 50%. The number of nausea and vomiting episodes was found to be significantly correlated with the flie and qlq-C15-pal questionnaires.Conclusions Ondansetron rdf is effective for the prophylaxis of rinv.

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Splenic Artery Embolization: Endovascular and Percutaneous Trans-splenic Approach

International Journal of Recent Surgical and Medical Sciences ◽

10.1055/s-0038-1676559 ◽

2018 ◽

Vol 4 (02) ◽

pp. 047-053

Author(s):

Pankaj Banode ◽

Gaurav Sharma

Keyword(s):

Portal Hypertension ◽

Splenic Artery ◽

Outcome Measurement ◽

Splenic Abscess ◽

Secondary Prophylaxis ◽

Variceal Hemorrhage ◽

Artery Embolization ◽

Splenic Artery Embolization ◽

Vascular Abnormality ◽

Splenic Embolization

Abstract Background Splenic artery embolization is becoming a widely acceptable procedure for nonsurgical management in many clinical settings such as pseudoaneurysms or to salvage splenic functions in portal hypertension, hypersplenism, and secondary prophylaxis in variceal hemorrhage. Various published meta-analyses of splenic artery embolization found an overall success rate of 90% in vascular abnormality. Methods Retrospective study of all splenic artery embolization procedures in 1 year (January 2017–2018) to analyze various indications, procedure technique, and its modification as well as outcome measurement and complications. Results Total 16 splenic artery embolization procedures were performed including one case of percutaneous trans-splenic glue embolization in 1-year duration. Procedure Indication It included pseudoaneurysm (n = 7, 44%); trauma (n = 1, 6%); adjuvant to surgical splenectomy in hypersplenism (n = 3, 18%); secondary prophylaxis in portal hypertension, portosystemic varices with/without reduced platelet counts, or ascites (n = 4, 25%); and Budd-Chiari syndrome (n = 1, 6%). Total 13 (81%) procedures were elective, whereas emergency embolization was performed in 3 (18.7%). Endovascular technical success was 93.7% (n = 15) cases. Percutaneous trans-splenic embolization was performed in one (6%) case in which access to bleeding point was not possible. The embolic agents included combination of metallic coils (n = 14, 87.5%), Gelfoam (n = 6, 37.5%), polyvinyl alcohol (PVA) particles (n = 5, 31%), and cyanoacrylate glue (n = 3, 18.7%). Complication rate was low with development of splenic abscess with infected pyothorax in one (6%) case of hypersplenism requiring pigtail drainage with uneventful full recovery. Conclusion Splenic artery embolization provides safer nonsurgical options in management of cases such as trauma, hypersplenism, portal hypertension for control of hemorrhage and preservation of splenic function. Endovascular embolization facilitates complete exclusion of pseudoaneurysms in majority with percutaneous splenic embolization using glue or coils as a safer alternative where endovascular access to bleeding vessels is difficult.

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Pediatric Portal Hypertension

10.5772/intechopen.95243 ◽

2021 ◽

Author(s):

Reda A. Zbaida

Keyword(s):

Portal Hypertension ◽

Variceal Bleeding ◽

Age Groups ◽

Primary Prophylaxis ◽

Secondary Prophylaxis ◽

Age Group ◽

Pediatric Age ◽

Pediatric Age Group ◽

Rex Shunt ◽

Hepatic Portal

Portal hypertension is increased intravascular pressure of the portal vein. The prevalence of causes in children is different from adults ones. The commonest cause of pediatric portal hypertension is the extra-hepatic portal hypertension, comparing with an adult where liver cirrhosis is the comments cause. Also, taking into consideration, the fundamental physiological differences between the two age groups. These elements are making the attempt to extrapolate the adult guidelines to the pediatric age group unpractical. On the other hand, the limitation of well-designed studies in the pediatric age group makes reaching a consensus about the safety and efficiency of primary prophylaxis of variceal bleeding difficult. In contrast, there were enough data to recommend the secondary prophylaxis of variceal bleeding and the safety and efficiency of Meso-Rex shunt for portal hypertension have been confirmed. These indicate the necessity of further studies to reach a complete algorithm of guidelines for pediatric portal hypertension.

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