Can the Computed Tomographic Aspect of Porto-Systemic Circulation in Cirrhotic Patients Be Associated with the Presence of Variceal Hemorrhage?

Background and objectives: Variceal bleeding is a serious complication caused by portal hypertension, frequently encountered among cirrhotic patients. The purpose of this study was to determine whether the aspect of the collateral, porto-systemic circulation, as detected by CT are associated with the presence variceal hemorrhage (VH). Materials and Methods: 81 cirrhotic patients who underwent a contrast-enhanced CT examination were retrospectively included in the study. Patients were divided into two groups: Cirrhotic patients with variceal hemorrhage during the hospital admission concomitant, with the CT examination (n = 33) and group 2-cirrhotic patients, without any variceal hemorrhage in their medical history (n = 48). The diameter of the left gastric vein, the presence or absence and dimensions of oesophageal and gastric varices, paraumbilical veins and splenorenal shunts were the indicators assessed on CT. Results: The univariate analysis showed a significant association between the presence of upper GI bleeding and the diameters of paraoesophageal veins, paragastric veins and left gastric vein respectively, all of these CT parameters being higher in patients with variceal bleeding. In the multivariate logistic regression analysis, only the diameter of the left gastric vein was independently associated with the presence of variceal hemorrhage (OR = 1.6 (95% CI: 1.17–2.19), p = 0.003). We found an optimal cut-off value of 3 mm for the diameter of the left gastric vein useful to discriminate among patients with variceal hemorrhage from the ones without it, with a good diagnostic performance (AUC = 0.78, Se = 97%, Sp = 45.8%, PPV = 55.2%, NPV = 95.7%). Conclusions: Our observations point out that an objective CT quantification of porto-systemic circulation can be correlated with the presence of variceal hemorrhage and the diameter of the left gastric vein can be a reliable parameter associated with this condition.

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Efficacy of CTPV for Diagnostic and Therapeutic Assessment: Comparison with Endoscopy in Cirrhotic Patients with Gastroesophageal Varices

Gastroenterology Research and Practice ◽

10.1155/2020/6268570 ◽

2020 ◽

Vol 2020 ◽

pp. 1-10

Author(s):

Zijin Cui ◽

Haiqing Yang ◽

Xiaoxu Jin ◽

Huiqing Jiang ◽

Wei Qi ◽

...

Keyword(s):

Therapeutic Efficacy ◽

Statistical Significance ◽

Gastric Varices ◽

Variceal Hemorrhage ◽

Gastroesophageal Varices ◽

Exact Test ◽

Less Invasive ◽

Kappa Test ◽

Cirrhotic Patients

Background and Aims. Computed tomography portal venography (CTPV) shows potential in detecting varices that need treatment and their drainage pathways. However, its agreement with endoscopy requires further study. We investigated the feasibility of CTPV as an alternative tool to endoscopy in screening gastroesophageal varices (GEVs) and developed a CTPV-based model to provide a less invasive assessment of endotherapy for cirrhotic patients with GEVs. Methods. The study included 33 cirrhotic patients with a recent history of variceal hemorrhage. The presence, grade, and classification of GEVs on endoscopy and CTPV were compared (kappa test). Twenty-four patients were treated endoscopically, including 12 for esophageal varices (EVs), 8 for gastric varices (GVs), and 4 for GEVs. Treatment efficacies were assessed with the newly developed CTPV-based method at 1 week and 1 month after treatment. Efficiency evaluated by CTPV and endoscopy was compared by Fisher’s exact test to determine whether CTPV is efficient in the assessment of endotherapy efficacy. Results. For the screening and grading/classification of EVs and GVs, substantial agreement (EV kappa: 0.63 and 0.68; GV kappa: 0.62 and 0.75, respectively) was noted between endoscopy and CTPV. The therapeutic efficacy of EVs was higher when assessed by CTPV than when evaluated by endoscopy (37.50% vs. 12.50% at 1 week postoperation, P=0.22; 62.50% vs. 25.00% at 1 month postoperation, P=0.07), but without statistical significance. The same trend was also found in the assessment of therapeutic efficacy for GVs (25.00% vs. 16.67% at 1 week postoperation, P=1; 58.33% vs. 41.67% at 1 month postoperation, P=0.68). Conclusion. CTPV is comparable to endoscopy in the detection of GEVs and in the evaluation of endotherapy efficacy, which suggests that it could be a less invasive alternative for endoscopy in cirrhotic patients with GEVs needing treatment.

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Terlipressina: profilo farmacologico clinico, terapeutico e farmacoeconomico nel trattamento delle varici esofagee

Farmeconomia Health economics and therapeutic pathways ◽

10.7175/fe.v6i1.821 ◽

2005 ◽

Vol 6 (1) ◽

pp. 57-68

Author(s):

Lorenzo Pradelli

Keyword(s):

Medical Personnel ◽

Gastric Varices ◽

Endoscopic Sclerotherapy ◽

Variceal Hemorrhage ◽

Pharmacological Agents ◽

Endoscopic Techniques ◽

Drug Of Choice ◽

Cirrhotic Patients

The formation and rupture of esophageal and gastric varices are severe but common complications of hepatic cirrhosis. They represent the cause underlying more than one forth of all deaths in cirrhotic patients and exact an impressive burden in terms of survival, quality of life and health care resource consumption. Therapeutic options for the control of active variceal hemorrhage comprise pharmacological agents, endoscopic techniques and surgery. Of these, the only options immediately available in the absence of highly specialized medical personnel are vasoactive drugs, namely vasopressin and derivatives and somatostatin and derivatives. Despite this clear advantage, the role of pharmacological treatment is still debated; furthermore, there’s no consensus on the drug of choice for variceal bleeding control. In this paper the main pharmacological and clinical features of terlipressin, a synthetic vasopressin analog, are outlined, as well as a frame for its pharmacoeconomical evaluation. Terlipressin is the only vasoactive drug that demonstrated survival benefits in cirrhotic patients with active variceal hemorrhage, even in those treated with endoscopic sclerotherapy, and is characterized by a favorable risk/benefit ratio. The relative cost-effectiveness of the different drugs, nevertheless, is yet to be determined by methodologically rigorous studies, partly because at the present state of the research there still are clinical and economical uncertainties to be cleared.

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Characteristics of peptic ulcer bleeding in cirrhotic patients with esophageal and gastric varices

Scientific Reports ◽

10.1038/s41598-020-76530-3 ◽

2020 ◽

Vol 10 (1) ◽

Author(s):

Zheng Lu ◽

Xiaotian Sun ◽

Jingjing Han ◽

Bo Jin ◽

Wenhui Zhang ◽

...

Keyword(s):

Liver Cirrhosis ◽

Peptic Ulcer ◽

Prothrombin Time ◽

Variceal Bleeding ◽

Gastric Varices ◽

Ulcer Bleeding ◽

Peptic Ulcer Bleeding ◽

Ulcer Group ◽

Cirrhotic Patients ◽

Endoscopic Characteristics

AbstractUpper gastrointestinal bleeding (UGIB) is common in liver cirrhosis. Although esophageal and gastric varices (EGV) is the main bleeding source, there were still a proportion of patients with peptic ulcer bleeding. Thus, this study aimed to analyze the characteristic of variceal bleeding and peptic ulcer bleeding in liver cirrhosis. Cirrhotic patients with confirmed UGIB by urgent endoscopy from July 2012 to June 2018 were enrolled, and classified into peptic ulcer bleeding group (n = 248) and variceal bleeding group (n = 402). Clinical and endoscopic characteristics, therapeutic efficacy and prognosis were evaluated, and independent risk factors for 42-day morality were determined. The mean age and gender ratio of peptic ulcer bleeding group were higher than those in variceal bleeding group (55.58 ± 11.37 vs. 52.87 ± 11.57, P < 0.01; 4.51:1 vs. 2.87:1, P = 0.023). Variceal bleeding group most commonly presented as red blood emesis and coffee grounds (67.16%), while peptic ulcer group primarily manifested as melena (62.10%). Hepatocellular carcinoma was more prevalent in peptic ulcer group (141 vs. 119, P < 0.01). Albumin level in variceal bleeding group was lower higher (P < 0.01), but serum bilirubin, creatinine and prothrombin time were significantly higher (all P < 0.01). Success rate of endoscopic hemostasis for variceal bleeding and peptic ulcer bleeding was 89.05% and 94.35% (P = 0.021). Univariate and multivariate analysis identified prothrombin time (P = 0.041, OR [95% CI] 0.884 [0.786–0.995]), MELD score (P = 0.000, OR [95% CI] 1.153 [1.073–1.240]), emergency intervention (P = 0.002, OR [95% CI] 8.656 [2.219–33.764]), hepatic encephalopathy before bleeding (P = 0.003, OR [95% CI] 8.119 [2.084–31.637]) and hepatic renal syndrome before bleeding (P = 0.029, OR [95% CI] 3.877 [1.152–13.045]) as the independent predictors for 42-day mortality. Peptic ulcer bleeding should be distinguished from variceal bleeding by clinical and endoscopic characteristics.

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Outcome of the Pediatric Patients with Portal Cavernoma: The Retrospective Study for 10 Years Focusing on Recurrent Variceal Bleeding

Gastroenterology Research and Practice ◽

10.1155/2016/7953870 ◽

2016 ◽

Vol 2016 ◽

pp. 1-8 ◽

Cited By ~ 1

Author(s):

Hongjie Guo ◽

Fabao Hao ◽

Chunbao Guo ◽

Yang Yu

Keyword(s):

Logistic Regression ◽

Variceal Bleeding ◽

Collateral Circulation ◽

Pediatric Patients ◽

Venous Pressure ◽

Multivariate Logistic Regression Analysis ◽

Portal Venous Pressure ◽

Endoscopic Sclerotherapy ◽

Variceal Hemorrhage ◽

Portal Cavernoma

Background. Portal cavernoma (PC) is the most critical condition with risk or variceal hemorrhage in pediatric patients. We retrospectively investigated the patients with PC focusing on the predictors for recurrent variceal bleeding.Methods. Between July 2003 and June 2013, we retrospectively enrolled all consecutive patients admitted to our department with a diagnosis of PC without abdominal malignancy or liver cirrhosis. The primary endpoint of this observational study was recurrent variceal bleeding. Independent predictors of recurrent variceal bleeding were identified using the logistic regression model.Results. A total of 157 patients were enrolled in the study. During the follow-up period, 24 patients exhibited onset of recurrent variceal bleeding. Acute variceal bleeding was subjected to conservative symptomatic treatment and emergency endoscopic sclerotherapy. Surgical procedure selection was based on the severity of vascular dilation and collateral circulation. Multivariate logistic regression analysis demonstrated that the presence of ascites, collateral circulation, and portal venous pressure were independent prognostic factors of recurrent variceal bleeding for patients with portal cavernoma.Conclusions. The presence of ascites, collateral circulation, and portal venous pressure evaluation are important and could predict the postsurgical recurrent variceal bleeding in patients with portal cavernoma.

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TIPS in the Treatment of Variceal Bleeding

Digestive Disease Interventions ◽

10.1055/s-0038-1629915 ◽

2017 ◽

Vol 01 (04) ◽

pp. 265-271

Author(s):

Joseph Morrison ◽

Andrew Lipnik ◽

Ron Gaba

Keyword(s):

Variceal Bleeding ◽

Selection Criteria ◽

Gastric Varices ◽

Portosystemic Shunt ◽

Variceal Hemorrhage ◽

Life Threatening ◽

Intrahepatic Portosystemic Shunt ◽

Patient Selection Criteria ◽

Early Tips

AbstractVariceal bleeding is a life-threatening complication of portal hypertension. In recent years, transjugular intrahepatic portosystemic shunt (TIPS) creation has cemented a role in the management of acute refractory bleeding and recurrent variceal hemorrhage. This article aims to review the use of TIPS in patients with variceal bleeding, with a focus on accepted procedure indications, patient selection criteria, TIPS technique, clinical outcomes, and contemporary issues, such as early TIPS in acute variceal hemorrhage, the role of adjuvant embolotherapy, and TIPS utility for gastric varices.

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Clinical Features and Outcomes of Repeated Endoscopic Therapy for Esophagogastric Variceal Hemorrhage in Cirrhotic Patients: Ten-Year Real-World Analysis

Gastroenterology Research and Practice ◽

10.1155/2020/5747563 ◽

2020 ◽

Vol 2020 ◽

pp. 1-10

Author(s):

Jia-li Ma ◽

Ling-ling He ◽

Ping Li ◽

Yu Jiang ◽

Ju-long Hu ◽

...

Keyword(s):

Clinical Features ◽

Variceal Bleeding ◽

Endoscopic Therapy ◽

Survival Rates ◽

Variceal Hemorrhage ◽

Term Survival ◽

Long Term Survival ◽

Cirrhotic Patients ◽

One Year

Objective. This study is aimed at evaluating the survival of cirrhotic patients with different etiologies after endoscopic therapy for acute variceal bleeding and the effect of repeated endotherapy on patients’ prognosis. Methods. We retrospectively evaluated the clinical features and outcomes between cirrhotic patients with chronic HBV or HCV infections and other etiologies. The 3-year and 5-year survival rates and rehemorrhage rate in one year between the viral and nonviral cirrhosis patients were compared by Kaplan-Meier curves and log-rank test. Cox analysis was used to identify the impact factors that affect the long-term survival of patients with cirrhosis and variceal bleeding after endotherapy. Results. Out of 2665 patients with liver cirrhosis and variceal hemorrhage selected from our medical center between September 2008 and December 2017, a total of 1342 patients were included for analysis. The median follow-up duration was 32.9 months (range 0.16-111.4 months), the 3- and 5-year cumulative survival rates were 75.3% and 52.8%, respectively. The median survival time was significantly longer in viral cirrhosis patients (47.1 months [95% CI: 24.9-69.1]) compared with nonviral cirrhosis patients (37.0 months [95% CI: 25.0-56.0], p=0.001). The 3-year and 5-year survival rates of the viral group were higher than the nonviral group. The rehemorrhage rate at one year was higher in nonviral patients than in viral patients (p<0.001). Conclusion. Repeated endotherapy combined with effective antiviral therapy is helpful for long-term survival of cirrhotic population with variceal hemorrhage and HBV or HCV infection.

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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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Impact of Helicobacter pylori Infection on Gastric Variceal Bleeding among Patients with Liver Cirrhosis

Gastroenterology Research and Practice ◽

10.1155/2019/6529420 ◽

2019 ◽

Vol 2019 ◽

pp. 1-6 ◽

Cited By ~ 1

Author(s):

Mohamed A. Elsebaey ◽

Mohamed A. Tawfik ◽

Samah A. Elshweikh ◽

Manal Saad Negm ◽

Mohammed H. Elnaggar ◽

...

Keyword(s):

Helicobacter Pylori ◽

Variceal Bleeding ◽

Serum Gastrin ◽

Gastrin Level ◽

Gastric Varices ◽

Serum Gastrin Level ◽

Red Color ◽

Cirrhotic Patients ◽

H Pylori ◽

Follicular Gastritis

Background and Aims. Currently, it is well known that Helicobacter pylori- (H. pylori-) related peptic ulcer is one of the main causes of nonvariceal bleeding in cirrhotic patients. However, there is a lack of data to identify the exact effect ofH. pyloriinfection on variceal bleeding. This study was conducted to identify the impact ofH. pyloriinfection on gastric variceal bleeding in cirrhotic patients.Patients and Methods. 76 cirrhotic patients with gastric varices were included in this prospective study and divided into 2 groups: nonbleeding gastric varices (32 patients) and bleeding gastric varices (44 patients). The fasting serum gastrin level was measured. Mucosal biopsies from the gastric body and antrum were examined to determine the patterns of gastritis and the presence ofH. pylori.Results. The frequency ofH. pyloriinfection in the studied patients was 59.2%. There were significant differences between both groups regarding liver decompensation (P=0.001), red color sign over gastric varices (P=0.0011), prevalence ofH. pyloriinfection (P=0.0049), histological patterns of gastritis (P=0.0069), and serum gastrin level (P=0.0200). By multivariate analysis, Child C cirrhosis, red color sign over gastric varices, andH. pylori-induced follicular gastritis were independent risk factors for bleeding from gastric varices.Conclusion.H. pylori-induced follicular gastritis is considered as an additional risk factor for bleeding from gastric varices.

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Endoscopic variceal ligation combined with sclerotherapy for management of gastroesophageal variceal bleeding in pediatric patients

10.21203/rs.3.rs-855914/v1 ◽

2021 ◽

Author(s):

Ming-Ming Li ◽

Fang Sun ◽

Man-Xiu Huai ◽

Chun-Ying Qu ◽

Feng Shen ◽

...

Keyword(s):

Variceal Bleeding ◽

Pediatric Patients ◽

Median Number ◽

Gastric Varices ◽

Secondary Prophylaxis ◽

Endoscopic Management ◽

Endoscopic Variceal Ligation ◽

Variceal Hemorrhage ◽

Clinical Center ◽

The Mean

Abstract Background Portal hypertension (PH) frequently gives rise to severe and life-threatening complications, including hemorrhage accompanied by the rupture of esophageal and gastric varices. In contrast to the widely studied guidelines for the management of PH in adults, there remains controversial about the optimal endoscopic management of variceal bleeding in children for secondary prophylaxis. The study aims to determine the efficacy and safety of endoscopic variceal ligation (EVL) and sclerotherapy (EST) to control bleeding in children in our clinical center. Methods The retrospective study included 21 children with gastroesophageal variceal bleeding who were treated by endoscopic variceal ligation or sclerotherapy at Xinhua Hospital, Shanghai Jiaotong University School of Medicine between January 2007 and July 2020. The treatment outcome involving short-term hemostatic rate and long-term rebleeding rate were investigated. Adverse events related to the procedures, such as esophageal ulcer, esophageal stricture, abnormal embolization, pneumonia and perforation were also observed. Results The 21 pediatric patients who were diagnosed as moderate to severe esophageal varices concurrent with gastric varices experienced EVL or EST successfully. Hemostasis was achieved in 45 of 47 (95.7%) episodes of upper gastrointestinal bleeding. The mean volume of each single aliquot of cyanoacrylate injected was 0.3 ± 0.1 mL (range: 0.1–0.5 mL). Twenty-four patients (75%) reach varices eradication in the EVL group with a median number of procedures before eradication of 2 (1–4) and a median time to eradication of 3.40 months (1.10-13.33). Eleven patients (52.4%) developed rebleeding events, with the mean duration of hemostasis being 11.1 ± 11.6 mo (range: 1.0-39.2 mo). No treatment-related complications, for example, distal embolism, were noted with the exception of abdominal pain in one patient (4.8%). Conclusions Endoscopic variceal sclerotherapy or in combination with EVL turns out to be an effective and safe approach to treat variceal hemorrhage in children for secondary prophylaxis.

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Results of a Modified Sugiura's Devascularisation in the Management of “Unshuntable” Portal Hypertension

HPB Surgery ◽

10.1155/1999/59087 ◽

1999 ◽

Vol 11 (4) ◽

pp. 235-239 ◽

Cited By ~ 10

Author(s):

S. R. Shah ◽

S. S. Nagral ◽

S. K. Mathur

Keyword(s):

Portal Hypertension ◽

Variceal Bleeding ◽

Splenic Vein ◽

Gastric Varices ◽

Recurrent Bleeding ◽

Variceal Hemorrhage ◽

Medium Term ◽

Venous Anatomy ◽

Esophageal Variceal

The results of a modified Sugiura devascularisation procedure were assessed in 14 patients with thrombosis of the portal and splenic vein requiring surgery for variceal hemorrhage, with no vein suitable for orthodox shunt surgery. The venous anatomy was determined by ultrasonography with Doppler studies and portovenography. Liver biochemistry as well as liver architecture on histopathology was normal in all. The surgery was elective in 9 cases for documented bleed from diffuse fundal gastric varices (FGV) and emergency in 5 cases, 3 having bleeding FGV and 2 for failure of emergency esophageal variceal sclerotherapy. All were subjected to a transabdominal extensive devascularisation of the upper two third of the stomach and lower 7–10cm of the esophagus. Stapled esophageal transection (n=11) or esophageal variceal under-running (n=1) was performed in all with esophageal varices. FGV were underrun. Follow up endoscopies were done six monthly. There were 9 males and 5 females with a mean age of 17.2 years (SD 12.8). There was no operative mortality. Acute variceal bleeding was controlled in all patients. Over a mean follow up of 38 months, all but one remain free of recurrent bleeding. We conclude that a modified Sugiura devascularisation procedure is effective in the immediate and medium term control of variceal bleeding in patients with “unshuntable” portal hypertension.

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