Efficacy of Octreotide Versus Terlipressin along with Endoscopic Variceal Ligation (EVL) in Preventing Re-bleeding and Mortality in Acute Bleeding Esophageal Varices in Cirrhosis: A Randomized Prospective Study

Background: Octreotide and terlipressin are two pharmacologic drugs used as an adjuvant therapy in the treatment of acute esophageal variceal bleeding. Large enough clinical trial data is not available, in comparing the efficacy of octreotide versus terlipressin as an adjunct to EVL for control of variceal bleed. Still, there is a scarcity of data on which is the better efficient drug amongst terlipress in and octreotide to control 5 days rebleeding. Aim: To compare efficacy of octreotide versus terlipressin in preventing the 6 weeks mortality (primary outcome) and 5 days rebleeding (secondary outcome) in cases of acute esophageal variceal bleeding. Method: All the patients of cirrhosis of liver presenting with upper gastrointestinal bleeding admitted in the Medicine Intensive Care Unit(MICU) at Acharya Vinoba Bhave Rural Hospital (AVBRH) will be enrolled. In this Randomized Prospective study ,patients presenting with acute esophageal variceal bleed, after diagnostic endoscopy during a period of one year (august 2020 to july 2021) will be randomised into two group by simple randomisation with chits: Group A will receive Terlipressin while Group B will receive Octreotide for 5 days combined with esophageal variceal ligation. These two groups will be compared in terms of hemodynamic effects, child pugh score, MELD (Model for End stage Liver Disease) score to predict 6 weeks mortality as primary outcome and 5 day treatment failure as secondary outcome according to Bavino VI consensus statement. Expected results: From our study we are anticipating that both octreotide and terlipressin will be equally efficacious in controlling the EVB when given along with EVL therapy and also there will be no difference in both the drugs in preventing 6 weeks mortality and 5 days rebleeding. Conclusion: There will be no significant difference between Terlipressin and Octreotide in preventing 6 week mortality and 5 day rebleeding in bleeding esophageal varices when given along with EVL therapy.

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Short-course vasoconstrictors are adequate for esophageal variceal bleeding after endoscopic variceal ligation: A systematic review and meta-analysis

Science Progress ◽

10.1177/00368504211031711 ◽

2021 ◽

Vol 104 (3) ◽

pp. 003685042110317

Author(s):

Jen-Hao Yeh ◽

Gin-Ho Lo ◽

Ru-Yi Huang ◽

Chih-Wen Lin ◽

Wen-Lun Wang ◽

...

Keyword(s):

Systematic Review ◽

Treatment Failure ◽

Variceal Bleeding ◽

Meta Analysis ◽

Cochrane Library ◽

Endoscopic Variceal Ligation ◽

Esophageal Variceal ◽

Esophageal Variceal Bleeding ◽

Short Course ◽

Significant Difference

Endoscopic variceal ligation (EVL) with vasoconstrictors has been recommended for acute esophageal variceal bleeding. However, the optimal duration of vasoconstrictors after EVL is controversial. This systematic review and meta-analysis was conducted to explore the efficacy of short-course vasoconstrictors (≤3 days) versus standard combination (3–5 days). A comprehensive literature review was conducted using the PubMed, Embase, and Cochrane library databases with subsequent meta-analysis. The primary outcomes were 5-day rebleeding, mortality, and treatment failure rates. A risk ratio (RR) with 95% confidence interval is used for outcome comparison. Nine randomized studies with 838 patients were included. The initial hemostasis (96.8% vs 97.4%, p = 0.919), 5-day rebleeding (11.2% vs 8.3%, RR = 1.05, 95% CI = 0.62–1.76), mortality (0 vs 1.3%, RR = 0.48, 95% CI = 0.10–2.39), and treatment failure (7.4% vs 5.9%, RR = 1.10, 95% CI = 0.48–2.49) were similar in both groups. Subgroup analysis suggested EVL alone had no significant difference of 5-day re-bleeding (15.9% vs 7.1%, RR = 2.25, 95% CI = 0.87–5.77), mortality (0 vs 0.7%, RR = 0.71, 95% CI = 0.08–6.03), treatment failure (9.6% vs 6.7%, RR = 1.43, 95% CI = 0.54–3.75) compared to standard combination. Clinical heterogeneity was found for the rebleeding rate for the subgroup during sensitivity analysis. EVL with short-course vasoconstrictors is highly efficacious for esophageal variceal bleeding. Further studies are required to determine the genuine need of subsequent vasoconstrictor after successful EVL.

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Seasonal variation in acute variceal upper gastrointestinal tract bleeding: Experience of one decade from Northern India

Asian Journal of Medical Sciences ◽

10.3126/ajms.v12i8.36803 ◽

2021 ◽

Vol 12 (8) ◽

pp. 76-80

Author(s):

Shabir Ahmad Shiekh ◽

Ali Imran ◽

Showkat Ahmad Kadla ◽

Mohammad Yasin ◽

Bilal Ahmad Khan ◽

...

Keyword(s):

Variceal Bleeding ◽

Demographic Data ◽

Esophageal Variceal ◽

Esophageal Variceal Bleeding ◽

Gastrointestinal Bleed ◽

Northern India ◽

Variceal Bleed ◽

Upper Gastrointestinal Bleed ◽

The World ◽

Upper Gastrointestinal

Background: There have been several reports of seasonal variations in the incidence of esophageal variceal bleeding but the data available from this part of the world is scanty. Aims and Objective: We aimed to study whether monthly and seasonal climatic changes during the year have an influence on the incidence of variceal bleeding in our setting and whether a particular time in the year can be defined as a high-risk period for variceal bleed. Materials and Methods: Data of all the patients with diagnosis of acute variceal upper gastrointestinal bleed who presented to our endoscopy centre from January 2010 to December 2019 was retrieved and analysed. The demographic data, clinical presentations and seasonal and monthly variation was analysed. Results: Out of a total of 10200 patients presenting with upper gastrointestinal bleed during the study time period, 530 patients had a diagnosis of variceal bleed after esophagogastroduodenoscopy (EGD). The majority of variceal bleed patients (48.5%) were seen between May to August months of the year. Conclusions: Contrary to the most of the literature which shows increased frequency of variceal bleed during winters, our patients bleed more during the months of May and August. This could be explained on the basis of unique socio-cultural and demographic pattern of this part of the world.

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Porto-Sinusoidal Vascular Disease as the Cause of Portal Hypertension in Felty’s Syndrome: A Case Report and Literature Review

BioMed Research International ◽

10.1155/2020/2618260 ◽

2020 ◽

Vol 2020 ◽

pp. 1-6

Author(s):

Song Yang ◽

Min Quan ◽

Yue Li ◽

Calvin Qian Pan ◽

Huichun Xing

Keyword(s):

Rheumatoid Arthritis ◽

Portal Hypertension ◽

Literature Review ◽

Esophageal Varices ◽

Variceal Bleeding ◽

Endoscopic Therapy ◽

Esophageal Variceal ◽

Esophageal Variceal Bleeding ◽

Felty's Syndrome ◽

Felty’S Syndrome

Felty’s syndrome (FS) is a disorder wherein patients with rheumatoid arthritis develop splenomegaly, neutropenia, and in some cases, portal hypertension without underlying cirrhosis. Esophageal variceal bleeding is a complication of FS in patients with portal hypertension. In contrast to splenectomy, few reports exist on the management of variceal bleeding with endoscopic therapy. Moreover, the long-term outcome has not been reported. We present a patient with esophageal variceal bleeding due to portal hypertension secondary to Felty’s syndrome. The patient was followed up for two years postendoscopy intervention. Literature review was performed and the histological features of portal hypertension in FS are discussed. The patient presented with a typical triad of rheumatoid arthritis (RA), splenomegaly, and neutropenia and was diagnosed as Felty’s syndrome in 2012. She was admitted to our hospital in September 2017 for esophageal variceal bleeding. At the time of admission, her liver function test was normal. Abdominal CT showed no signs of cirrhosis and portal vein obstruction. Liver biopsy further excluded diagnosis of cirrhosis and supported the diagnosis of porto-sinusoidal vascular disease (PSVD), which was previously named as noncirrhotic idiopathic portal hypertension (NCIPH). An upper abdominal endoscopy revealed gastric and esophageal varices. A series of endoscopies was performed to ligate the esophageal varices. The patient was followed up for two years and did not show rebleeding. In conclusion, comorbid PSVD might be a cause of portal hypertension in FS patients. The present case had excellent outcome in two years, which supported the use of endoscopic therapy for the management of variceal bleeding in FS patients. Further large prospective study is needed to confirm the findings.

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Sclerotherapy of esophageal varices in hemophilia patients with liver cirrhosis – a prospective, controlled clinical study

Polish Journal of Surgery ◽

10.5604/01.3001.0011.5957 ◽

2018 ◽

Vol 90 (1) ◽

pp. 29-34

Author(s):

Andrzej B. Szczepanik ◽

Konrad Pielaciński ◽

Anna M. Oses-Szczepanik ◽

Sławomir Huszcza ◽

Andrzej Misiak ◽

...

Keyword(s):

Liver Cirrhosis ◽

Esophageal Varices ◽

Variceal Bleeding ◽

Hemophilia A ◽

Secondary Prophylaxis ◽

Severe Form ◽

Control Group ◽

Endoscopic Sclerotherapy ◽

Esophageal Variceal ◽

Esophageal Variceal Bleeding

Introduction: Bleeding from esophageal varices is a serious clinical condition in hemophilia patients due to congenital deficiency or lack of clotting factors VIII (in hemophilia A) and IX (in hemophilia B), decreased clotting factor II, VII, IX, X synthesis in the course of chronic liver disease and hipersplenic thrombocytopenia. The aim of this study was to assess the efficacy and safety of endoscopic sclerotherapy in acute esophageal variceal bleeding and in secondary prophylaxis of hemorrhage. The aim was also to investigate the optimal activity of deficiency factors VIII or IX and duration of replacement therapy required to ensure proper hemostasis after sclerotherapy procedures. Material and methods: 22 hemophilia patients (A-19, B-4) with coexistent liver cirrhosis and active esophageal variceal bleeding treated with endoscopic sclerotherapy were subjected to prospective analysis. The patients who survived were qualified to repeated sclerotherapy procedures every 3 weeks within secondary prophylaxis of bleeding (investigated group). A 3-day substitution therapy enhanced the infusion of the deficient or lacking factor in doses allowing to reach 80-100% of normal value activity of factor VIII on the 1st day and 60-80% in the next two days. The desired activity of factor IX was 60- 80% and 40-60% respectively. The control group consisted of 20 non-hemophiliac patients with liver cirrhosis comparable in terms of age, sex, stage of advancement of liver cirrhosis, who underwent the same medical proceedings as the investigated group. Results: Active esophageal bleeding was stopped in 21 of 22 (95%) hemophilia patients. Complications were observed in 3 patients; 2 patients died. The rate of hemostasis, complications and deaths in the control group were comparable and no statistical differences were found. In hemophilia patients subjected to secondary prophylaxis of hemorrhage, in 18 of 20 (80%), complete eradication of esophageal varices was achieved after 4 to 7 sclerotherapy procedures in 1 patient (average 5.4). Recurrent bleeding was observed in 15% of patients, complication in 20%; 1 patient died. Time lapse from bleeding to eradication was 12-21 weeks (average 15.2). In the control group the rate of variceal eradication, complication and deaths was comparable and no statistical differences were found. The usage of factor VIII concentrates was as follows: in hemophilia A, in a severe form - 80.9 U/kg b.w./day, in hemophilia A in a severe form with an inhibitor <5 BU – 95.2 U/kg b.w./day, in mild form – 64.2 U/kg b.w./day and in severe hemophilia B – 91.6 U/kg b.w./day. Conclusions: Sclerotherapy is an effective method in the management of esophageal variceal bleeding in hemophilia patients. It is also effective for total eradication of varices when applied as a secondary prophylaxis of hemorrhage. In our opinion, a 3-day replacement therapy at the applied doses is sufficient to ensure hemostasis and avoid bleeding complications.

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STUDY ON ENDOSCOPIC FEATURES OF GASTROESOPHAGEAL MUCOSA IN PATIENTS WITH CIRRHOSIS

Journal of Medicine and Pharmacy ◽

10.34071/jmp.2011.5.7 ◽

2011 ◽

pp. 45-51

Author(s):

Van Huy Tran ◽

Anh Hien Ho

Keyword(s):

Esophageal Varices ◽

Variceal Bleeding ◽

Varicose Veins ◽

University Hospital ◽

Esophageal Variceal ◽

Cross Sectional ◽

Esophageal Variceal Bleeding ◽

Endoscopic Images ◽

Red Color ◽

Grade 3

Background: 1. To evaluate endoscopic images of gastroesophageal mucosa in patients with cirrhosis. 2. To evaluate the relationship between endoscopic images of the gastroesophageal and some clinical, subclinical features. Subjects and Methods: A cross- sectional descriptive study. From May 2010 to April 2011, the study sample includes 88 cirrhotic patients hospitalized at Hue Central Hospital and at Hue University Hospital. Results 1. 95.5% of patients with cirrhosis have esophageal varices. The presence of red color signs on esophageal varices accounts for 48.8% of the cases. The esophageal varices with bleeding accounts for 39.3%. The most common images of gastric mucosa in patients with cirrhosis observed was gastritis (58.0%), mucosal mosiac-like pattern (52.3%) and the lesser common signs seen were gastric ulcer (19.3%) and fundal varices (12.5%). 2. Among the esophageal varices cases at grade 3, 58.3% patients had moderate and large ascites. Among the esophageal variceal bleeding cases at grade 3, the rate of esophageal variceal bleeding is 84.9%, and among the grade 2 cases, the rate is 15.1%. The prevalence of platelet counts <100 Kμ / L in patients with varicose veins in the esophagus accounts for 75% among the grade 3. Among the grade 3 cases, The prevalence of major spleen with width>13 cm accounted for 66.7%. The rate of bleeding from esophageal varices in patients with red color signs is 84.9%. Conclusion: 1. The common endoscopic images of gastroesophageal mucosa in patients with cirrhosis is esophageal varices, gastritis and mucosal mosiac-like pattern. 2. Esophageal varices is related with ascites, bleeding, low platelet count and spleen diameter >13cm. Bleeding from esophageal varices is related with red color signs and is not related to mucosal mosaic-like pattern. Key words: esophageal varices, gastric endoscopy, cirrhosis

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Treatment of Acute Hemorrhage from Esophageal Varices in Cirrhotic Patients.

Albanian Journal of Trauma and Emergency Surgery ◽

10.32391/ajtes.v3i1.22 ◽

2019 ◽

Vol 3 (1) ◽

Author(s):

Judah Morgan ◽

Berti Shagla ◽

Ryan M. Kwok

Keyword(s):

Esophageal Varices ◽

Variceal Bleeding ◽

Venous Hypertension ◽

High Rate ◽

Variceal Hemorrhage ◽

Esophageal Variceal ◽

Acute Hemorrhage ◽

Esophageal Variceal Bleeding ◽

Portal Venous Hypertension ◽

High Index Of Suspicion

Cirrhosis describes the end stages of chronic inflammation and progressive scarring of the liver and may lead to hepatocellular dysfunction and portal venous hypertension. Liver cirrhosis in itself is a major cause of mortality worldwide, accounting from more than 1 million deaths in 2010. Esophageal varices are common in cirrhosis such that Christensen et al. documented their occurrence in 90% of patients with cirrhosis within 10 years of follow up, 40% experiencing variceal bleeding. Acute hemorrhage from esophageal varices will classically appear as hematemesis and/or melena in patients with a history of cirrhosis. It is most often diagnosed by performance of an EGD which will reveal actively bleeding varices. Because of the high rate of morbidity and mortality associated with esophageal variceal bleeding, one must have a high index of suspicion in any patient with chronic liver disease or cirrhosis. As such, empiric management for variceal hemorrhage should be initiated any time this diagnosis is considered.

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Outcome of Endoscopic Variceal Band Ligation

Journal of Nepal Medical Association ◽

10.31729/jnma.3131 ◽

2017 ◽

Vol 56 (206) ◽

Cited By ~ 1

Author(s):

Barun Shrestha ◽

Sudhamshu KC ◽

Sita Ram Chaudhary ◽

Bhupendra Kumar Basnet ◽

Amrendra Kumar Mandal ◽

...

Keyword(s):

Liver Cirrhosis ◽

Esophageal Varices ◽

Variceal Bleeding ◽

Endoscopic Examination ◽

Endoscopic Variceal Ligation ◽

Esophageal Variceal ◽

Esophageal Variceal Bleeding ◽

Acute Variceal Bleeding ◽

Red Color ◽

Pugh Class

Introduction: Bleeding from esophageal varices in cirrhosis is an emergent condition with high mortality. One of the preferred modality of treating esophageal varices is EVL. We aimed to find out the outcome of EVL in controlling acute esophageal variceal bleeding, prophylactic banding to prevent future bleeding and the number of sessions required for complete eradication of varices.Methods: This descriptive observational study was carried out in Gastroenterology and Hepatology unit of Bir Hospital, NAMS from June 2016 to May 2017. Consecutive cases who presented in emergency room with acute variceal bleeding due to liver cirrhosis and cases of liver cirrhosis with large varices and red color signs on endoscopic examination were enrolled. They underwent EVL and subsequent re-endoscope at one month interval till the eradication of varices was achieved. Results: Among 83 patients, 15 (18.1%) were of Child Pugh class A, 29 (34.9%) B and 39 (47%) were of C. In 20 (24.1%) cases varices could be eradicated in one session of EVL while 57 (68.7%) required two sessions and in 6 (7.2%) cases it took three sessions. Total average EVL session required for obliteration of esophageal varices was 1.84±0.53. There was only one (1.2%) of early re-bleeding post EVL.Conclusions: EVL is an effective modality of treatment in controlling acute esophageal variceal bleeding, in preventing future variceal bleeding as well as in eradicating esophageal varices, with very few complications.Keywords: acute variceal bleeding; cirrhosis; endoscopic variceal ligation; large varices; red color sign. [PubMed]

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Causes of Upper GI Bleed: Variceal or non-variceal.

The Professional Medical Journal ◽

10.29309/tpmj/2020.27.04.3920 ◽

2020 ◽

Vol 27 (04) ◽

pp. 820-824

Author(s):

Talha Munir ◽

Muhammad Naeem Safdar ◽

Salman Azhar ◽

Rizwan Rasool Khan ◽

Samara Siddique ◽

...

Keyword(s):

Variceal Bleeding ◽

Tertiary Care ◽

Care Hospital ◽

Gi Bleeding ◽

Esophageal Variceal ◽

Esophageal Variceal Bleeding ◽

Upper Gi Bleeding ◽

Upper Gi ◽

Variceal Bleed ◽

Gi Bleed

Objectives: To determine the frequency of esophageal variceal bleed in patients with upper GI bleed presenting in a tertiary care hospital. Study Design: Cross sectional survey. Setting: Department of Medicine, Mayo Hospital, Lahore and Madinah Teaching Hospital, Faisalabad. Period: 6 months from 01-06-2018 to 31-12-2018. Material & Methods: Two hundred patients with upper GI bleed were included in the study. All the patients had upper GI endoscopy to determine the esophageal variceal bleeding which was documented as frequency distribution table. Results: Esophageal variceal bleed was seen among 108 (54%) patients while it was not present among 92 (46%) patients. Conclusion: Esophageal variceal bleeding is frequently present among patients with upper GI bleeding and should be suspected in every patient with upper GI bleeding.

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Prospective study of bacteremia rate after elective band ligation and sclerotherapy with cyanoacrylate for esophageal varices in patients with advanced liver disease

Arquivos de Gastroenterologia ◽

10.1590/s0004-28032011000400006 ◽

2011 ◽

Vol 48 (4) ◽

pp. 248-251 ◽

Cited By ~ 5

Author(s):

Danielle Queiroz Bonilha ◽

Lucianna Motta Correia ◽

Marie Monaghan ◽

Luciano Lenz ◽

Marcus Santos ◽

...

Keyword(s):

Liver Disease ◽

Prospective Study ◽

Esophageal Varices ◽

Endoscopic Treatment ◽

Advanced Liver Disease ◽

Esophageal Variceal ◽

Band Ligation ◽

Diagnostic Endoscopy ◽

Significant Difference ◽

Cirrhotic Patients

CONTEXT: Band ligation (BL) is the most appropriate endoscopic treatment for acute bleeding or prophylaxis of esophageal variceal bleeding. Sclerotherapy with N-butyl-2-cyanoacrylate (CY) can be an alternative for patients with advanced liver disease. Bacteremia is an infrequent complication after BL while the bacteremia rate following treatment with CY for esophageal varices remains unknown. OBJECTIVES: To evaluate and compare the incidence of transient bacteremia between cirrhotic patients submitted to diagnostic endoscopy, CY and BL for treatment of esophageal varices. METHODS: A prospective study comprising the period from 2004 to 2007 was conducted at Hospital of Universidade Federal de São Paulo, UNIFESP, SP, Brazil. Cirrhotic patients with advanced liver disease (Child-Pugh B or C) were enrolled. The patients were divided into two groups according treatment: BL Group (patients undergoing band ligation, n = 20) and CY Group (patients receiving cyanoacrylate injection for esophageal variceal, n = 18). Cirrhotic patients with no esophageal varices or without indication for endoscopic treatment were recruited as control (diagnostic group n = 20). Bacteremia was evaluated by blood culture at baseline and 30 minutes after the procedure. RESULTS: After 137 scheduled endoscopic procedures, none of the 58 patients had fever or any sign suggestive of infection. All baseline cultures were negative. No positive cultures were observed after CY or in the control group - diagnostic endoscopy. Three (4.6 %) positive cultures were found out of the 65 sessions of band ligation (P = 0.187). Two of these samples were positive for coagulase-negative staphylococcus, which could be regarded as a contaminant. The isolated microorganism in the other case was Klebsiella oxytoca. The patient in this case presented no evidence of immunodeficiency except liver disease. CONCLUSIONS: There was no significant difference in bacteremia rate between these three groups. BL or CY injection for non-bleeding esophageal varices may be considered as low-risk procedures regarding bacteremia even when performed on patients with advanced liver disease.

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