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

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.

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

2022 ◽  
Vol 12 (1) ◽  
Author(s):  
Voytek Slowik ◽  
Anissa Bernardez ◽  
Heather Wasserkrug ◽  
Ryan T. Fischer ◽  
James F. Daniel ◽  
...  
Keyword(s):  
Portal Hypertension ◽  
Survival Curve ◽  
Patient Characteristics ◽  
Primary Prophylaxis ◽  
Secondary Prophylaxis ◽  
Rural Children ◽  
Variceal Hemorrhage ◽  
Prophylaxis Group ◽  
Kaplan Meier ◽  
Surveillance Endoscopy

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.

scholarly journals Management of variceal hemorrhage: current concepts

2014 ◽  
Vol 27 (2) ◽  
pp. 138-144 ◽  
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.

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

2011 ◽  
Vol 52 (3) ◽  
pp. 254-261 ◽  
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

Secondary Prophylaxis in a Cohort of Adolescent and Adult Italian Hemophiliacs.

Blood ◽  
2007 ◽  
Vol 110 (11) ◽  
pp. 1148-1148
Author(s):  
Annarita Tagliaferri ◽  
Gianna Franca Rivolta ◽  
Antonio Coppola ◽  
Cristina Santoro ◽  
Gina Rossetti ◽  
...  
Keyword(s):  
Therapeutic Approach ◽  
Well Being ◽  
Primary Prophylaxis ◽  
Secondary Prophylaxis ◽  
Clinical Impact ◽  
Clotting Factor ◽  
Severe Hemophilia ◽  
Limited Data ◽  
On Demand

Abstract Although primary prophylaxis is a well-established and widely recommended practice for the management of patients with severe hemophilia, there are limited data in the literature documenting the benefit of secondary prophylaxis initiated in adolescence or adulthood. In order to address this issue we have conducted a retrospective study among the 10 Italian Hemophilia Centers on adolescent and adult patients with severe hemophilia switched from on-demand treatment to a long term secondary prophylaxis regimen. On the whole, we collected information on 73 consecutive patients with severe hemophilia (66 hemophilia A and 7 hemophilia B). Their median age started prophylaxis was 12 (range 10–17) for 23 adolescents and 30 (17.4–72) for the 50 adults and continued for a median of years 5.8 (2–14.7) in adolescents and 4 years (1.5–12) in adults. The clinical impact of secondary prophylaxis with respect to the last year on-demand regimen before switching is showed in the following table for each group of patients. Adolescents (n=23) Adults (n=50) On-Demand Prophylaxis On-Demand Prophylaxis Values are reported as mean (standard deviation) Bleedings 32.4(24.8) 2.8 (3.2) 42.7 (24.5) 5.5 (5.2) Joint bleedings 25.6 (22.1) 1.9 (2.3) 36.4 (24.5) 4.2 (4.1) Orthopaedic score 8.4 (7.5) 3.7 (2.4) 21.6 (12.2) 17.7 (12.2) Pettersson score 5.1 (3.4) 5.0 (3.3) 14.7 (13.8) 15.2 (14.3) Work/school days lost 35.1 (34.5) 1.0 (1.5) 33.8 (20.9) 2 (0–17) Concentrate consumption U/Kg/y 2449.8 (1761.9) 3508.3(803.1) 3222.6 (2241.8) 4058.5 (952.3) The decreased joint bleeding, better orthopaedic score, less work/school days lost, delayed progression of arthropathy and improved well-being observed with secondary prophylaxis show the benefit of this therapeutic approach and appear to counterbalance its higher clotting factor consumption. In conclusion large, prospective, long-term randomized studies are needed to definitevely assess the clinical impact of this strategy in adolescent and adult hemophiliacs and to identify those groups of patients who would benefit from this therapeutic approach.

scholarly journals Recent Advances in the Management of Acute Variceal Hemorrhage

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.

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

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

<b><i>Introduction:</i></b> 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). <b><i>Methods:</i></b> 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. <b><i>Results:</i></b> Serum sCD163 concentration showed a significant increase in cirrhotic patients compared to healthy subjects (<i>p</i> &#x3c; 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 (<i>p</i> = 0.002, <i>p</i> &#x3c; 0.001 and <i>p</i> = 0.004, <i>p</i> &#x3c; 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 &#x3e;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 &#x3e;4.05 mg/L modestly discriminated bleeding EV from those that had never bled (AUC = 0.811). <b><i>Conclusions:</i></b> 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.

scholarly journals Splenic Artery Embolization: Endovascular and Percutaneous Trans-splenic Approach

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.

scholarly journals Pediatric Portal Hypertension

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.

Prophylaxis in people with haemophilia

2009 ◽  
Vol 101 (04) ◽  
pp. 674-681 ◽  
Author(s):  
Massimo Franchini ◽  
Annarita Tagliaferri ◽  
Antonio Coppola
Keyword(s):  
Quality Of Life ◽  
Cost Benefit ◽  
Primary Prophylaxis ◽  
Secondary Prophylaxis ◽  
Severe Haemophilia ◽  
Duration Of Treatment ◽  
First Choice ◽  
Long Term Treatment

SummaryA four-decade clinical experience and recent evidence from randomised controlled studies definitively recognised primary prophylaxis, i.e. the regular infusion of factor concentrates started after the first haemarthrosis and/or before the age of two years, as the first-choice treatment in children with severe haemophilia. The available data clearly show that preventing bleeding since an early age enables to avoid or reduce the clinical impact of muscle-skeletal impairment from haemophilic arthropathy and the related consequences in psycho-social development and quality of life of these patients. In this respect, the aim of secondary prophylaxis, defined as regular long-term treatment started after the age of two years or after two or more joint bleeds, is to avoid (or delay) the progression of arthropathy. The clinical benefits of secondary prophylaxis have been less extensively studied, especially in adolescents and adults; also in the latter better outcomes and quality of life for earlier treatment have been reported. This review summarises evidence from literature and current clinical strategies for prophylactic treatment in patients with severe haemophilia, also focusing on challenges and open issues (optimal regimen and implementation, duration of treatment, long-term adherence and outcomes, cost-benefit ratios) in this setting.

scholarly journals Pegfilgrastim for primary prophylaxis of febrile neutropenia in multiple myeloma

2021 ◽  
Author(s):  
Claudio Cerchione ◽  
Davide Nappi ◽  
Giovanni Martinelli
Keyword(s):  
Multiple Myeloma ◽  
Febrile Neutropenia ◽  
Supportive Care ◽  
Survival Rates ◽  
Primary Prophylaxis ◽  
Secondary Prophylaxis ◽  
Novel Agents ◽  
Severe Side Effect ◽  
Maximum Benefit ◽  
Long Acting

AbstractMultiple myeloma (MM) survival rates have been substantially increased thanks to novel agents that have improved survival outcomes and shown better tolerability than treatments of earlier years. These new agents include immunomodulating imide drugs (IMiD) thalidomide and lenalidomide, the proteasome inhibitor bortezomib (PI), recently followed by new generation IMID pomalidomide, monoclonal antibodies daratumumab and elotuzumab, and next generation PI carfilzomib and ixazomib. However, even in this more promising scenario, febrile neutropenia remains a severe side effect of antineoplastic therapies and can lead to a delay and/or dose reduction in subsequent cycles. Supportive care has thus become key in helping patients to obtain the maximum benefit from novel agents. Filgrastim is a human recombinant subcutaneous preparation of G-CSF, largely adopted in hematological supportive care as “on demand” (or secondary) prophylaxis to recovery from neutropenia and its infectious consequences during anti-myeloma treatment. On the contrary, pegfilgrastim is a pegylated long-acting recombinant form of granulocyte colony-stimulating factor (G-CSF) that, given its extended half-life, can be particularly useful when adopted as “primary prophylaxis,” therefore before the onset of neutropenia, along chemotherapy treatment in multiple myeloma patients. There is no direct comparison between the two G-CSF delivery modalities. In this review, we compare data on the two administrations’ modality, highlighting the efficacy of the secondary prophylaxis over multiple myeloma treatment. Advantage of pegfilgrastim could be as follows: the fixed administration rather than multiple injections, reduction in neutropenia and febrile neutropenia rates, and, finally, a cost-effectiveness advantage.

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