scholarly journals Primary Prophylaxis of Variceal Haemorrhage in Patients with Cirrhosis: An Integrated Pharmacological and Endoscopic Approach.

2021 ◽  
Author(s):  
Veronica Pepe ◽  
Paolo Angeli ◽  
Marco Di Pascoli
Keyword(s):  
Liver Cirrhosis ◽  
Variceal Bleeding ◽  
Protective Factor ◽  
Bleeding Risk ◽  
Primary Prophylaxis ◽  
Pharmacological Therapy ◽  
Gastroesophageal Varices ◽  
Probability Of Survival ◽  
Increased Risk ◽  
Endoscopic Feature

Abstract Background: At the present time, in patients with liver cirrhosis and gastroesophageal varices, primary prophylaxis of variceal bleeding made with combination therapy with non-selective b-blockers (NSBBs) and endoscopic band ligation (EBL) is not recommended. The aim of this study was to evaluate if patients who develop an increased bleeding risk from varices while on NSBBs regimen benefit, in terms of bleeding and survival, from adding treatment with EBL. Methods: Patients with endoscopic finding of gastroesophageal varices with increased risk of bleeding (increased variceal size and/or development of red signs) during primary prophylaxis with NSBBs, followed at the Unit of Internal Medicine and Hepatology, University and General Hospital of Padova, Italy, from 2012 to 2019, were retrospectively evaluated. When an increased bleeding risk of the varices was confirmed, patients maintained the pharmacological therapy alone or underwent also EBL. The primary endpoint of the study was the rate of variceal bleeding, the secondary endpoint was mortality at 30 months. Results: Compared to patients treated only with NSBBs (n=56), in patients treated also with EBL (n=45), the 30‐month probability of variceal bleeding (29.1% vs 5.1%; P =0.036) was significantly reduced, while the probability of survival was similar (59.6% vs. 65.7%; P=0.61). On multivariate analysis, treatment with EBL was found to be a weak protective factor for mortality (HR 0.47, P=0.044). Conclusion: In patients with liver cirrhosis, when varices show endoscopic feature of increased haemorrhagic risk, adding EBL to NSBBs is effective in reducing the probability of first bleeding.

scholarly journals The Impact of Novel Anticoagulants on the Upper Gastrointestinal Tract Mucosa

Medicina ◽  
2020 ◽  
Vol 56 (7) ◽  
pp. 363
Author(s):  
Lubomir Mihalkanin ◽  
Branislav Stancak
Keyword(s):  
Gastrointestinal Tract ◽  
Protective Factor ◽  
Bleeding Risk ◽  
Endoscopic Biopsy ◽  
Upper Gastrointestinal Tract ◽  
Bleeding Detection ◽  
Increased Risk ◽  
Clinically Significant ◽  
The Impact ◽  
Upper Gastrointestinal

Background and objectives: Although treatment with novel oral non-vitamin K antagonist 3anticoagulants (NOACs) is associated with an overall decrease in hemorrhagic complications compared to warfarin, the incidence of gastrointestinal bleeding remains contradictory. Materials and Methods: After the exclusion of patients with pre-existing pathological lesions in the upper gastrointestinal tract (GIT) on esophageal-gastroduodenoscopy (EGD) at entry, a cohort of 80 patients (mean age of 74.8 ± 2.0 years) was randomly divided into four equivalent groups, treated with dabigatran, rivaroxaban, apixaban, or warfarin. Patients were prospectively followed up for three months of treatment, with a focus on anamnestic and endoscopic signs of bleeding. In addition, bleeding risk factors were evaluated. Results: In none of the patients treated with warfarin or NOACs was any serious or clinically significant bleeding recorded within the follow-up period. The incidence of clinical bleeding and endoscopically detected bleeding in the upper GT after three months of treatment was not statistically different among groups (χ2 = 2.8458; p = 0.41608). The presence of Helicobacter pylori (HP) was a risk factor for upper GIT bleeding (p < 0.05), while the use of proton pump inhibitors (PPIs) was a protective factor (p = 0.206; Spearman’s correlation coefficient = 0.205). We did not record any post-biopsy continued bleeding. Conclusions: No significant GIT bleeding was found in any of the treatment groups, so we consider it beneficial to perform routine EGD before the initiation of any anticoagulant therapy in patients with an increased risk of upper GIT bleeding. Detection and eradication of HP as well as preventive PPI treatment may mitigate the occurrence of endoscopic bleeding. Endoscopic biopsy during the NOAC treatment is safe.

scholarly journals Pharmacotherapy of liver cirrhosis and its complications

2021 ◽  
pp. 23-27
Author(s):  
T. M. Bentsa
Keyword(s):  
Liver Cirrhosis ◽  
Spontaneous Bacterial Peritonitis ◽  
Hepatorenal Syndrome ◽  
Beta Blockers ◽  
Bleeding Risk ◽  
Refractory Ascites ◽  
Variceal Hemorrhage ◽  
Bacterial Peritonitis ◽  
Treatment And Prevention ◽  
Increased Risk

This article provides information about the pharmacotherapy of liver cirrhosis (LC) and its complications, such as variceal hemorrhage, ascites, increased risk of bacterial infection, spontaneous bacterial peritonitis, hepatic encephalopathy, hepatorenal syndrome LC is a major healthcare problem and is associated with an increased mortality due to the development of complications. LC is currently the 11th most common cause of death globally. Prognosis of LC is highly variable and influenced by several variables, such as etiology, severity of liver disease, presence of complications and comorbidities. In advanced cirrhosis, survival decreases to one or two years. Pharmacotherapy for LC should be implemented in accordance with up-to-date guidelines and in conjunction with aetiology management, nutritional optimisation and patient education. The main treatment of uncomplicated ascites is diuretics such as spironolactone in combination with a loop diuretic. For treatment refractory ascites vasoconstrictors and albumin are recommended. Antibiotics play a well-established role in the treatment and prevention of spontaneous bacterial peritonitis. For hepatorenal syndrome, the administration of vasopressor terlipressin and albumin is recommended. Endoscopic treatment is used for variceal bleeding (for example, ligation for esophageal varices and tissue glue for gastric varices). A shunt (TIPS) is used to treat severe or repeat variceal hemorrhage or refractory ascites. Non-selective beta-blockers effectively reduce variceal re-bleeding risk in LC patients with moderate/large varices. Thus, the treatment of LC as one of the most formidable multiorgan pathologies involves a comprehensive approach aimed at the correction of the main pathology and the treatment and prevention of its complications.

scholarly journals Perinatal Management of Haemophilia

2020 ◽  
Vol 40 (02) ◽  
pp. 226-232
Author(s):  
Werner Streif ◽  
Ralf Knöfler
Keyword(s):  
Screening Method ◽  
Age Groups ◽  
Bleeding Risk ◽  
Primary Prophylaxis ◽  
Cranial Ultrasound ◽  
Severe Haemophilia ◽  
Older Children ◽  
Increased Risk ◽  
Local Bleeding ◽  
Factor Concentrate

AbstractThe aim of this review is to provide practical guidance for the treatment of carriers of haemophilia and newborns presenting with haemophilia. Both mother and newborn have an increased risk for clinically relevant bleeding. An experienced team should manage genetic counselling, prenatal diagnosis, pregnancy, delivery and the newborn presenting with haemophilia. Published and regularly updated guidelines must guide this team. Vaginal and caesarean deliveries before labour entail a comparable bleeding risk. Haemophilia carriers should receive factor concentrate (FC) at the time of delivery if their factor level is below normal. Evidence remains insufficient to recommend systemic desmopressin and tranexamic acid for the prevention of peripartum haemorrhage. Primary prophylaxis with FC for all newborns with severe haemophilia is not justified. The pattern of bleeding seen in the affected newborns is essentially different from that seen in older children. Estimated frequency of intracranial haemorrhage (ICH) is 2 to 3%. Cranial ultrasound is a good screening method for ICH in newborns. Many neonatal bleeds are iatrogenic in origin. The most prominent concerns regarding neonatal factor replacement are the risk for inhibitor development, followed by local bleeding and issues related to poor vascular access. The preference for plasma-derived FC and recombinant FC differs widely between centres and countries. Replacement therapy should be monitored since newborns may require higher doses of FC. Emicizumab, licensed for all age groups since 2019, should not be used in newborns with severe haemophilia A and acute bleeding, although “non-factor” agents are expected to revolutionise haemophilia therapy.

Diagnosis and management of variceal bleeding in the critically ill

2016 ◽  
Author(s):  
Deanna Blisard ◽  
Ali Al-Khafaji
Keyword(s):  
Venous Pressure ◽  
Portal Pressure ◽  
Primary Prophylaxis ◽  
Secondary Prophylaxis ◽  
Pharmacological Therapy ◽  
Variceal Haemorrhage ◽  
Gastroesophageal Varices ◽  
Endoscopic Intervention ◽  
Definitive Therapy ◽  
Haemorrhage Control

Cirrhosis is the most common cause of portal hypertension, which subsequently leads to development of gastroesophageal varices (GEV). Generally, presence of GEV correlates with the severity of cirrhosis and variceal haemorrhage can develop when hepatic venous pressure gradient exceeds 10–12 mmHg. The gold standard for diagnosis and often treatment of GEV is oesophagogastroduodenoscopy (OGD). Management of GEV is divided into primary prophylaxis, acute haemorrhage control, and secondary prophylaxis. Primary prophylaxis includes surveillance OGD and endoscopic intervention based on the size of the varices. Management of acute variceal haemorrhage includes resuscitation and endoscopic interventions. Basic resuscitative measures to maintain haemodynamic stability, vasoconstricting agents to decrease portal pressure, and the use of prophylactic antibiotics. Endoscopic intervention includes any of variceal band ligation, variceal sclerotherapy, and variceal obturation. Radiological or surgical portosystemic shunting markedly reduces portal pressure and are clinically effective therapy for patients who fail endoscopic or pharmacological therapy. Balloon tamponade is effective in temporarily controlling oesophageal variceal haemorrhage in over 80% of patients. Its use should be restricted to patients with uncontrollable bleeding, where more definitive therapy is planned within 24 hours. Secondary prophylaxis includes endoscopy plus pharmacological therapy of non-selective β‎−blockers.

Primary Prevention of Venous Thromboembolism in Long-Term Care: Identifying and Managing the Risk

2008 ◽  
Vol 14 (2) ◽  
pp. 149-158 ◽  
Author(s):  
Sylvia Haas ◽  
Alex C. Spyropoulos
Keyword(s):  
Venous Thromboembolism ◽  
Key Management ◽  
Long Term Care ◽  
Bleeding Risk ◽  
Primary Prophylaxis ◽  
Bleeding Complications ◽  
Term Care ◽  
Limited Mobility ◽  
Increased Risk

Venous thromboembolism (VTE) is a significant, but underestimated, cause of morbidity and mortality in long-term care settings. VTE risk increases significantly with age and is further increased by comorbidities common to this group; however, advancing age and limited mobility alone are insufficient to warrant pharmacological prophylaxis. Recognizing those at increased VTE risk during an acute illness is crucial for appropriate and timely prophylaxis. Warfarin is used for the long-term secondary prevention of VTE, whereas unfractionated and low-molecular-weight heparins are used for primary prophylaxis. The elderly are at increased risk for bleeding complications, because of the high frequency of comorbidities and comedications. Attention to dosing is recommended for those with severely impaired renal function, low body weight, or perceived to be at high bleeding risk. This review addresses the role of risk assessment in the decision of when to provide prophylaxis to an individual in long-term care and highlights key management issues for those prescribed prophylaxis.

Reduced stroke risk without increased bleeding risk in patients with atrial fibrillation and complicated liver cirrhosis treated with oral anticoagulation

2020 ◽  
Vol 41 (Supplement_2) ◽  
Author(s):  
K Steensig ◽  
M Pareek ◽  
A.L Krarup ◽  
P Sogaard ◽  
M Maeng ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Liver Cirrhosis ◽  
Anticoagulant Therapy ◽  
Oral Anticoagulation ◽  
Oral Anticoagulant ◽  
Vitamin K Antagonists ◽  
Oral Anticoagulants ◽  
Bleeding Risk ◽  
Increased Risk ◽  
First Time

Abstract Introduction Patients with atrial fibrillation (AF) have an increased risk of thromboembolic events (TE), while patients with complicated liver cirrhosis have an increased risk of both TE and bleeding. Oral anticoagulation reduces the risk of TE in the general group of patients with AF but its use in patients with liver cirrhosis is obscured by their imbalance between endogenous procoagulants and anticoagulants, as well as the lack of data from randomized controlled trials. Purpose To examine the risks of TE and bleeding in patients with AF and complicated liver cirrhosis according to whether oral anticoagulation is initiated. Methods We conducted a nationwide registry-based study of anticoagulant-naive patients with complicated liver cirrhosis and first-time AF diagnosed between 2010–2017. Complicated liver cirrhosis was defined as liver cirrhosis plus one of the following: alcoholism, esophageal varices, ascites or hepatorenal syndrome. Patients were followed for a maximum of 5 years. TE was defined as a composite of ischemic stroke, transient ischemic attack or systemic thromboembolism; and the bleeding endpoint was defined as gastrointestinal, cerebral or urogenital bleeding requiring hospitalization, or any hospital contact with epistaxis. TE risk was estimated by use of the CHA2DS2-VASc score, while bleeding risk was estimated by use of the HAS-BLED score. Outcomes were stratified according to whether an oral anticoagulant (vitamin K antagonists [VKA] or direct oral anticoagulants [DOAC]) was initiated. Results We identified 770 patients with complicated liver cirrhosis and first-time AF. TE events occurred in 7.0% (n=25/359) of patients with a CHA2DS2-VASc score ≤2 versus 20.7% (n=85/411) of patients with a CHA2DS2-VASc score &gt;2. Among 411 patients with a high CHA2DS2-VASc score, 111 (27.0%) were prescribed an oral anticoagulant (OAC+; VKA, n=53 [47.7%], DOAC, n=58 [52.3%]), while 300 (73.0%) were not treated with oral anticoagulation (OAC−). These two groups had comparable baseline data, including HAS-BLED (OAC+ 3.0 [2.5–4.0] versus OAC− 3.0 [2.0–4.0]) and CHA2DS2-VASc (OAC+ 4.0 [3.0–5.0] versus OAC− 4.0 [3.0–5.0]) scores. The 5-year TE risk among patients receiving anticoagulant therapy was 14.4% (n=16/111) versus 23.0% (n=69/300) in patients not treated with anticoagulant therapy (hazard ratio (HR) 0.55 [0.32–0.95]). The difference in bleeding risk was insignificant between the two groups (HR 0.67 [0.35–1.30]). Adjusting for CHA2DS2-VASc, HAS-BLED and prior bleeding requiring hospitalization did not significantly change the HR estimate, and no significant interactions were found. Conclusion TE risk was significantly lower in AF patients with complicated liver cirrhosis treated with oral anticoagulation, without a significantly increased bleeding risk. However, the majority of AF patients with complicated liver cirrhosis are not treated with anticoagulant therapy, indicating a potential for reducing the TE burden in this population. Funding Acknowledgement Type of funding source: None

scholarly journals Effects of Proton Pump Inhibitor on Gastroesophageal Varices of Cirrhosis: A Randomized Controlled Trial

2021 ◽  
Author(s):  
Xiaoning Chen ◽  
Tao Zhou ◽  
Ting Zhou ◽  
Yueyue Li ◽  
Xin Sun ◽  
...  
Keyword(s):  
Proton Pump Inhibitor ◽  
Adverse Events ◽  
Proton Pump ◽  
Variceal Bleeding ◽  
Endoscopic Therapy ◽  
Controlled Trial ◽  
Primary Prophylaxis ◽  
Secondary Prophylaxis ◽  
Gastroesophageal Varices ◽  
Acute Bleeding

Abstract BackgroundThe use of proton pump inhibitor (PPI) for gastroesophageal varices in patients with cirrhosis after endoscopic therapy remains controversial. This study aimed to evaluate the effect of PPI on gastroesophageal varices in patients with cirrhosis after endoscopic therapy, including variceal bleeding and adverse events.MethodsBetween May 2017 and June 2019, cirrhotic patients with gastroesophageal varices confirmed by endoscopy were considered for enrollment in this study. Eligible subjects were randomized into two groups: one group received PPI for 14 days and the other group did not undergo PPI treatment. Patients were followed up for 8 weeks.ResultsDuring the follow-up period, three patients (3/53, 5.66%) in the PPI group experienced variceal bleeding on day 9, 16, and 25 after endoscopic therapy, including one patient with primary prophylaxis and two with acute bleeding. In the non-PPI group, three patients (3/56, 5.66%) suffered from variceal bleeding on day 7, 42, and 56 after endoscopic therapy, including two patients with secondary prophylaxis and one with acute bleeding (P>0.99). The rate of adverse events was similar between the two groups (38% vs. 28%, P=0.30). Furthermore, the average hospitalization expense of patients in the PPI group was higher than that of patients in the non-PPI group ($2305 vs. $3096, P<0.001).ConclusionsPPI does not appear to reduce variceal bleeding and adverse events in patients with cirrhosis after endoscopic therapy.Trial registration: This trial was registered with ClinicalTrials.gov (NCT 03175731, 05/06/2017).

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