Risk factors for predicting early variceal rebleeding after endoscopic variceal ligation

AIM: To analyze the clinical risk factors for early variceal rebleeding after endoscopic variceal ligation (EVL).METHODS: 342 cirrhotic patients with esophageal varices who received elective EVL to prevent bleeding or rebleeding at our endoscopy center between January 2005 and July 2010.were included in this study.The early rebleeding cases after EVL were confirmed by clinical signs or endoscopy.A case-control study was performed comparing the patients presenting with early rebleeding with those without this complication.RESULTS: The incidence of early rebleeding after EVL was 7.60%,and the morbidity of rebleeding was 26.9%.Stepwise multivariate logistic regression analysis showed that four variables were independent risk factors for early rebleeding: moderate to excessive ascites [odds ratio (OR) 62.83,95% CI: 9.39-420.56,P < 0.001],the number of bands placed (OR 17.36,95% CI: 4.00-75.34,P < 0.001),the extent of varices (OR 15.41,95% CI: 2.84-83.52,P = 0.002) and prothrombin time (PT) > 18 s (OR 11.35,95% CI: 1.93-66.70,P = 0.007).CONCLUSION: The early rebleeding rate after EVL is mainly affected by the volume of ascites,number of rubber bands used to ligate,severity of varices and prolonged PT.Effective measures for prevention and treatment should be adopted before and after EVL.

Evaluation of the effects of combined endoscopic variceal ligation and splenectomy with pericardial devascularization on esophageal varices

AIM: To detect the hemodynamic alterations in collateral circulation before and after combined endoscopic variceal ligation (EVL) and splenectomy with pericardial devascularization by ultrasonography, and to evaluate their effect using hemodynamic parameters. METHODS: Forty-three patients with esophageal varices received combined EVL and splenectomy with pericardial devascularization for variceal eradication. The esophageal vein structures and azygos blood flow (AZBF) were detected by endoscopic ultrasonography and color Doppler ultrasound. The recurrence and rebleeding of esophageal varices were followed up. RESULTS: Patients with moderate or severe varices in the esophageal wall and those with severe peri- esophageal collateral vein varices had improvements after treatment, while the percentage of patients with severe para-esophageal collateral vein varices decreased from 54.49% to 2.33%, and the percentage of patients with detectable perforating veins decreased from 79.07% to 4.65% (P < 0.01). Color Doppler flowmetry showed a significant decrease both in AZBF (43.00%, P < 0.05) and in diameter of the azygos vein (28.85%, P < 0.05), while the blood flow rate was unchanged. The recurrence rate of esophageal varices was 2.5% (1/40, mild), while no re-bleeding cases were recorded. CONCLUSION: EVL in combination with splenectomy with pericardial devascularization can block the collateral veins both inside and outside of the esophageal wall, and is more advantagious over splenectomy in combination with pericardial devascularization or EVL in preventing recurrence and re-bleeding of varices.

Comparative study for predictability of type 1 gastric variceal rebleeding after endoscopic variceal ligation:High-frequency intraluminal ultrasound study

BACKGROUND The efficacy of endoscopic ultrasonography for the follow-up of gastric varices treated with endoscopic variceal ligation(EVL)has not been established.AIM To evaluate the diagnostic correlation of esophagogastroduodenoscopy(EGD)and high-frequency intraluminal ultrasound(HFIUS)for type 1 gastric varices(GOV1)after EVL and to identify the predictability for rebleeding of EGD and HFIUS.METHODS In liver cirrhosis patients with GOV1,we performed endoscopic follow-up using EGD and HFIUS synchronously after EVL for hemorrhage from GOV1.Endoscopic grading and red color signs were analyzed using EGD,and the largest variceal cross-sectional areas were measured using HFIUS.In addition,1-year follow-up was performed.Variceal rebleeding was defined as the presence of hematemesis,hematochezia,or melena without other evidence of bleeding on endoscopic follow-up.RESULTS In 26 patients with GOV1,variceal cross-sectional areas on HFIUS of GOV1 was poorly correlated with EGD grading of GOV1(r=0.36).In 17 patients who completed the 1-year follow-up,variceal cross-sectional areas on HFIUS was a good predictor of subsequent rebleeding,whereas EGD grading was not a predictor of subsequent rebleeding.CONCLUSION HFIUS measurement is more predictive of GOV1 rebleeding than EGD grading,so HFIUS measurement may be necessary for endoscopic follow-up after EVL in patients with GOV1.

Splenectomy with endoscopic variceal ligation is superior to splenectomy with pericardial devascularization in treatment of portal hypertension

AIM: To investigate the therapeutic efficacy and complications of splenectomy with endoscopic variceal ligation (EVL) and splenectomy with pericardial devascularization (i.e. Hassab’s operation) in patients with portal hypertension. METHODS: A total of 103 patients with liver cirrhosis and portal hypertension were randomly selected to receive either splenectomy with EVL (n = 53, group A) or Hassab’s operation (n = 50, group B). RESULTS: The portal blood flow volume, the presence of portal vein thrombosis, gastric emptying time and free portal venous pressure (FPP) before and after the operation were determined. Patients were followed up for up to 64 mo with an average of 45 mo, and the Dagradi classification of variceal veins and the grading of portal hypertension gastropathy (PHG) were evaluated. It was found that all esophageal varices were occluded or decreased to grade Ⅱ or less in both groups. There was little difference in the recurrence rate of esophageal varices (11.9% vs 13.2%) and the re-bleeding rate (7.1% vs 5.3%) between groups A and B. The incidence of complications and the percentage of patients with severe PHG after the operation were significantly higher in group B (60.0% and 52.0%) than in group A (32.1% and 20.8%, P < 0.05). No patients died of operation-related complications. There was no significant difference in gastric emptying time, FPP and portal blood flow volume between the two groups. CONCLUSION: The results suggest that splenectomy with EVL achieves similar therapeutic efficacy to that of Hassab’s operation in terms of the recurrence rate of esophageal varices and the re-bleeding rate, but theformer results in fewer and milder complications.

Embolization combined with endoscopic variceal ligation for the treatment of esophagogastric variceal bleeding in patients with cirrhosis

Background Esophagogastric variceal bleeding caused by cirrhosis is a kind of emergent condition in the clinic. This study was conducted to explore the therapeutic effect and superiority of embolization of gastric fundus vadces combined with endoscopic variceal ligation （EVL） of esophageal varices for the treatment of patients with esophagogastric variceal bleeding caused by cirrhosis. Methods Totally 172 patients were diagnosed by endoscopic examination within 24 hours of hospitalization with active gastric fundus variceal bleeding and grade II above esophageal varices caused by cirrhosis. Other causes leading to upper digestive tract bleeding were excluded. Patients were randomly divided into a control group （n=82） and a therapy group （n=-90） following a random number table method. For the former, embolization for gastric fundus varices was performed, then an EVL for esophageal varices was performed 2 months later. For the therapy group, embolization for gastric fundus varices and EVL for esophageal varices were performed at the same time. Results The rate of emergency hemostasis in the therapy group was 100.0%, higher than that in the control group （87.8%, P〈0.05）. The rate of early rebleeding in the therapy group was 6.7% while the rate in the control group was 23.6% （P〈0.05）. No complications related to treatment occurred in both groups. Conclusion Embolization for gastric fundus varices combined with EVL for esophageal varices is a safe and effective method for the treatment of patients with esophagogastric variceal bleeding caused by cirrhosis.

Effect of aluminum phosphate gel on prevention of early rebleeding after ligation of esophageal variceal hemorrhage

BACKGROUND Liver cirrhosis is the main cause of portal hypertension.The leading cause of death in patients with liver cirrhosis is its most common complication,esophageal variceal bleeding(EVB).Endoscopic variceal ligation(EVL)is recommended by many guidelines to treat EVB and prevent rebleeding;however,esophageal ulcers occur after treatment.Delayed healing of ulcers and unhealed ulcers lead to high rebleeding and mortality rates.Thus,the prevention of early postoperative rebleeding is of great significance in improving the quality of life and prognosis of patients.AIM To evaluate the efficacy of aluminum phosphate gel(APG)plus a proton pump inhibitor(PPI)in the prevention of early rebleeding after EVL in patients with EVB.METHODS The medical records of 792 patients who were diagnosed with EVB and in whom bleeding was successfully stopped by EVL at Shenzhen People’s Hospital,Guangdong Province,China from January 2015 to December 2020 were collected.According to the study inclusion and exclusion criteria,401 cases were included in a PPI-monotherapy group(PPI group),and 377 cases were included in a PPI and APG combination therapy(PPI+APG)group.We compared the incidence rates of early rebleeding and other complications within 6 wk after treatment between the two groups.The two-sample t-test,Wilcoxon rank-sum test,and chisquared test were adopted for statistical analyses.RESULTS No significant differences in age,sex,model for end-stage liver disease score,coagulation function,serum albumin level,or hemoglobin level were found between the two groups.The incidence of early rebleeding in the PPI+APG group(9/337;2.39%)was significantly lower than that in the PPI group(30/401;7.48%)(P=0.001).Causes of early rebleeding in the PPI group were esophageal ulcer(3.99%,16/401)and esophageal varices(3.49%,14/401),while those in the PPI+APG group were also esophageal ulcers(5/377;1.33%)and esophageal varices(4/377;1.06%);such causes were significantly less frequent in the PPI+APG group than in the PPI group(P=0.022 and 0.024,respectively).The early mortality rate within 6 wk in both groups was 0%,which was correlated with the timely rehospitalization of all patients with rebleeding and the conduct of emergency endoscopic therapy.The incidence of adverse events other than early bleeding in the PPI+APG group(28/377;7.43%)was significantly lower than that in the PPI group(63/401;15.71%)(P<0.001).The incidence of chest pain in the PPI+APG group(9/377;2.39%)was significantly lower than that in the PPI group(56/401;13.97%)(P<0.001).The incidence of constipation in the PPI+APG group(16/377;4.24%)was significantly higher than that in the PPI group(3/401;0.75%)(P=0.002)but constipation was relieved after patients drank more water or took lactulose.In the PPI and PPI+APG groups,the incidence rates of spontaneous peritonitis within 6 wk after discharge were 0.50%(2/401)and 0.53%(2/377),respectively,and those of hepatic encephalopathy were 0.50%(2/401)and 0.27%(1/377),respectively,presenting no significant difference(P>0.999).CONCLUSION PPI+APG combination therapy significantly reduces the incidence of early rebleeding and chest pain in patients with EVB after EVL.

Reinforcing the management of type 1 gastric esophageal varices

Variceal bleed represents an important complication of cirrhosis,with its presence reflecting the severity of liver disease.Gastric varices,though less frequently seen than esophageal varices,present a distinct clinical challenge due to its higher intensity of bleeding and associated mortality.Based upon the Sarin classification,GOV1 is the most common subtype of gastric varices seen in clinical practice.

Primary prophylaxis of variceal bleeding in patients with cirrhosis:A comparison of different strategies

Patients with cirrhosis and esophageal varices bleed at a yearly rate of 5%-15%,and,when variceal hemorrhage develops,mortality reaches 20%.Patients are deemed at high risk of bleeding when they present with medium or large-sized varices,when they have red signs on varices of any size and when they are classified as Child-Pugh C and have varices of any size.In order to avoid variceal bleeding and death,individuals with cirrhosis at high risk of bleeding must undergo primary prophylaxis,for which currently recommended strategies are the use of traditional non-selective beta-blockers(NSBBs)(i.e.,propranolol or nadolol),carvedilol(a NSBB with additional alpha-adrenergic blocking effect)or endoscopic variceal ligation(EVL).The superiority of one of these alternatives over the others is controversial.While EVL might be superior to pharmacological therapy regarding the prevention of the first bleeding episode,either traditional NSBBs or carvedilol seem to play a more prominent role in mortality reduction,probably due to their capacity of preventing other complications of cirrhosis through the decrease in portal hypertension.A sequential strategy,in which patients unresponsive to pharmacological therapy would be submitted to endoscopic treatment,or the combination of pharmacological and endoscopic strategies might be beneficial and deserve further investigation.

Gastroesophageal varices in a patient presenting with essential thrombocythemia:A case report

BACKGROUND Gastroesophageal varices are a rare complication of essential thrombocythemia(ET).ET is a chronic myeloproliferative neoplasm(MPN)characterized by an increased number of blood platelets.CASE SUMMARY A 46-year-old woman,who denied a history of liver disease,was admitted to our hospital on presentation of hematemesis.Laboratory examination revealed a hemoglobin level of 83 g/L,and a platelet count of 397×109/L.The appearance of gastric and esophageal varices with red colored signs as displayed by an urgent endoscopy was followed by endoscopic variceal ligation and endoscopic tissue adhesive.Abdominal computed tomography revealed cirrhosis,marked splenomegaly,portal vein thrombosis and portal hypertension.In addition,bone marrow biopsy and evidence of mutated Janus kinase 2,substantiated the onset of ET.The patient was asymptomatic with regular routine blood testing during the 6-mo follow-up period.Therefore,in this case,gastroesophageal varices were induced by ET.CONCLUSION MPN should be given considerable attention when performing differential diagnoses in patients with gastroesophageal varices.An integrated approach such as laboratory tests,radiological examination,and pathological biopsy,should be included to allow optimal decisions and management.

Sequential therapy for patients with cirrhosis complicated by common bile duct stones and moderate to severe gastroesophageal varices

Cirrhosis complicated by common bile duct stones is a common clinical finding.1 Currently, good therapeutic results occur in patients with cirrhosis complicated by moderate to severe gastroesophageal varices and common bile duct stones using endoscopic variceal ligation （EVL） and/or embolization followed two weeks later by calculus removal with endoscopic retrograde cholangiopancreatography （ERCP）.