Antibiotic prophylaxis in variceal hemorrhage:Timing,effectiveness and Clostridium difficile rates

AIM:To investigate if antibiotics administered within 8 h of endoscopy reduce mortality or increase the incidence of Clostridium difficile infection(CDI).METHODS:A 2-year retrospective analysis of all patients who presented with first variceal hemorrhage was undertaken.The primary outcome measure was 28-d mortality.Secondary outcome measures were 28-d rebleeding rates and 28-d incidence of CDI.All patients were admitted to a tertiary liver unit with a consultantled,24-h endoscopy service.Patients received standard care including terlipressin therapy.Data collection included:primary and secondary outcome measures,timing of first administration of intravenous antibiotics,eti-ology of liver disease,demographics,endoscopy details and complications.A prospective study was undertaken to determine the incidence of CDI in the study population and general medical inpatients admitted for antibiotic therapy of at least 5 d duration.Statistical analysis was undertaken using univariate,non-parametric tests and multivariate logistic regression analysis.RESULTS:There were 70 first presentations of variceal hemorrhage during the study period.Seventy percent of cases were male and 65.7% were due to chronic alcoholic liver disease.In total,64/70(91.4%) patients received antibiotics as prophylaxis during their admission.Specifically,53/70(75.7%) received antibiotics either before endoscopy or within 8 h of endoscopy [peri-endoscopy(8 h) group],whereas 17/70(24.3%) received antibiotics at > 8 h after endoscopy or not at all(non peri-endoscopy group).Overall mortality and rebleeding rates were 13/70(18.6%) and 14/70(20%),respectively.The periendoscopy(8 h) group was significantly less likely to die compared with the non peri-endoscopy group [13.2% vs 35.3%,P = 0.04,odds ratio(OR) = 0.28(0.078-0.997)] and showed a trend towards reduced rebleeding [17.0% vs 29.4%,P = 0.27,OR = 0.49(0.14-1.74)].On univariate analysis,the non peri-endoscopy group [P = 0.02,OR = 3.58(1.00-12.81)],higher model for end-stage liver disease(MELD) score(P = 0.02),presence of hepatorenal syndrome [P < 0.01,OR = 11.25(2.24-56.42)] and suffering a clinical episode of sepsis [P = 0.03,OR = 4.03(1.11-14.58)] were significant predictors of death at 28 d.On multivariate logistic regression analysis,lower MELD score [P = 0.01,OR = 1.16(1.04-1.28)] and periendoscopy(8 h) group [P = 0.01,OR = 0.15(0.03-0.68)] were independent predictors of survival at 28 d.The CDI incidence(5.7%) was comparable to that in the general medical population(5%).CONCLUSION:Antibiotics administered up to 8 h following endoscopy were associated with improved survival at 28 d.CDI incidence was comparable to that in other patient groups.

Risk factors for early rebleeding and mortality in acute variceal hemorrhage

AIM: To investigate the risk factors for 6-wk rebleeding and mortality in acute variceal hemorrhage (AVH) patients treated by percutaneous transhepatic variceal embolization (PTVE).

Prophylactic antibiotics for variceal hemorrhage: Clostridium difficile infection still can be a risk

Bron et al presented a retrospective study regarding the prophylactic use of antibiotics for variceal hemorrhage. Antibiotics appeared to improve the survival rate of patients without increasing clostridium difficile infection (CDI). We argue against the conclusion of the authors and consider that this result may be simply due to concurrent use of metronidazole, a therapeutic agent against CDI.

Prediction of Early Rebleeding and Mortality after Acute Esophageal Variceal Hemorrhage among Yemeni Patients in Major Hospitals—Sana’a

Background and aims: Acute variceal hemorrhage (AVH) is the most serious encountered complication of liver cirrhosis and carries high mortality rate. Several risk factors that predict early rebleeding and mortality have been studied and there is no similar study in our country, so the aim of this study was to identify the risk factors of early rebleeding and mortality after bleeding episode in cirrhotic patients in Yemen. Patients and Method: It was a prospective study of cirrhotic patients with AVH who were admitted to the main public hospitals in Sana’a between April 2014 and March 2015. Demographic information, medical histories, physical examination findings, and laboratory test results were collected. Endoscopic and pharmacologic treatment was performed. The patients were followed up since admission and up to 6 weeks for the occurrence of rebleeding and mortality after the acute attack. Univariate and multivariate analyses were performed to identify independent risk factors for rebleeding and mortality. Survival analysis was estimated using the Kaplan-Meier method. Result: A total of 102 patients were analyzed. 26 patients (25.5%) rebleeded within 6 weeks period. The predictive factors significantly associated with rebleeding within 6 weeks period in univariate analysis were clot on varix at index endoscope (P - 47.29, P = 0.001) and high serum bilirubin (- 1.19, P = 0.01). Sixteen patients died (15.7%) within 6 weeks period. Predictors of mortality with significant difference in univariate analysis were hypovolemic shock (P = 0.001), high WBCs count (P - 1.41, P - 1.40, P < 0.05) were independent risk factors for mortality within 6 weeks period. Conclusion: Early rebleeding in cirrhotic patients with AVH was associated with clot on varix at endoscope and high serum bilirubin more than 3 mg/dl. Early mortality rate was associated with high MELD score (≥19) and WBCs over 10.3 × 109/l.

Evaluation of the efficacy and safety of endoscopic band ligation in the treatment of bleeding from mild to moderate gastric varices type 1

BACKGROUND According to practice guidelines,endoscopic band ligation(EBL)and endoscopic tissue adhesive injection(TAI)are recommended for treating bleeding from esophagogastric varices.However,EBL and TAI are known to cause serious complications,such as hemorrhage from dislodged ligature rings caused by EBL and hemorrhage from operation-related ulcers resulting from TAI.However,the optimal therapy for mild to moderate type 1 gastric variceal hemorrhage(GOV1)has not been determined.Therefore,the aim of this study was to discover an individualized treatment for mild to moderate GOV1.AIM To compare the efficacy,safety and costs of EBL and TAI for the treatment of mild and moderate GOV1.METHODS A clinical analysis of the data retrieved from patients with mild or moderate GOV1 gastric varices who were treated under endoscopy was also conducted.Patients were allocated to an EBL group or an endoscopic TAI group.The differences in the incidence of varicose relief,operative time,operation success rate,mortality rate within 6 wk,rebleeding rate,6-wk operation-related ulcer healing rate,complication rate and average operation cost were compared between the two groups of patients.RESULTS The total effective rate of the two treatments was similar,but the efficacy of EBL(66.7%)was markedly better than that of TAI(39.2%)(P<0.05).The operation success rate in both groups was 100%,and the 6-wk mortality rate in both groups was 0%.The average operative time(26 min)in the EBL group was significantly shorter than that in the TAI group(46 min)(P<0.01).The rate of delayed postoperative rebleeding in the EBL group was significantly lower than that in the TAI group(11.8%vs 45.1%)(P<0.01).At 6 wk after the operation,the healing rate of operation-related ulcers in the EBL group was 80.4%,which was significantly greater than that in the TAI group(35.3%)(P<0.01).The incidence of postoperative complications in the two groups was similar.The average cost and other related economic factors were greater for the EBL than for the TAI(P<0.01).CONCLUSION For mild to moderate GOV1,patients with EBL had a greater one-time varix eradication rate,a greater 6-wk operation-related ulcer healing rate,a lower delayed rebleeding rate and a lower cost than patients with TAI.

MELD score can predict early mortality in patients with rebleeding after band ligation for variceal bleeding

AIM:To investigate the outcomes,as well as risk factors for 6-wk mortality,in patients with early rebleeding after endoscopic variceal band ligation (EVL) for esophageal variceal hemorrhage (EVH).METHODS:Among 817 EVL procedures performed for EVH between January 2007 and December 2008,128 patients with early rebleeding,defined as rebleeding within 6 wk after EVL,were enrolled for analysis.RESULT:The rate of early rebleeding after EVL for acute EVH was 15.6% (128/817).The 5-d,6-wk,3-mo,and 6-mo mortality rates were 7.8%,38.3%,55.5%,and 58.6%,respectively,in these early rebleeding patients.The use of beta-blockers,occurrence of hypovolemic shock,and higher model for end-stage liver disease (MELD) score at the time of rebleeding were independent predictors for 6-wk mortality.A cut-off value of 21.5 for the MELD score was found with an area under ROC curve of 0.862 (P < 0.001).The sensitivity,specificity,positive predictive value,and negative predictive value were 77.6%,81%,71.7%,and 85.3%,respectively.As for the 6-mo survival rate,patients with a MELD score ≥ 21.5 had a significantly lower survival rate than patients with a MELD score < 21.5 (P < 0.001).CONCLUSION:This study demonstrated that the MELD score is an easy and powerful predictor for 6-wk mortality and outcomes of patients with early rebleeding after EVL for EVH.

Determination of correlation of Adjusted Blood Requirement Index with outcome in patients presenting with acute variceal bleeding

AIM： To determine the correlation of Adjusted Blood Requirement Index （ABRI） with the 7th day outcome in patients presenting with acute variceal bleeding.METHODS： All patients presenting with acute variceal hemorrhage （AVH） were included. Patients with previous band ligation, sclerotherapy, gastrointestinal or hepatic malignancies were excluded. Patients were managed as per standard protocol for AVH with terlipressin and band ligation. ABRI scores were calculated using the formula outcome of alive or expired up to the 7th day after treatment. The correlation between ABRI and mortality was estimated and a receiver operative characteristic （ROC） curve was plotted.RESULTS： A total of 113 patients （76 male; 37 female） were included. On assessment, 18 were in Child＇s Pugh Class A, 82 in Class B and 13 were in Class C. The median number of blood units transfused ± inter-quartile range was 3.0 ± 2.0. The median ± inter-quartile range for ABRI was 1.3 ± 1.1. The ROC curve of ABRI for expiry showed a significantly large area of 0.848 （P 〈 0.0001; 95% CI： 0.75-0.95）. A significant correlation of log transformation of ABRI with an outcome of mortality was present （P 〈 0.0001）.

Serum levels of soluble Fas, nitric oxide and cytokines in acute decompensated cirrhotic patients

AIM： To evaluate plasma levels of nitrite/nitrate （NOx）, soluble Pas （spas） antigen, tumor necrosis factor alpha （TNF-α） and interleukin-6 （IL-6） in patients with compensated and acute decompensated cirrhosis and to evaluate mediators causing acute decompensation in liver cirrhosis, METHODS： This prospective study was conducted in the medical intensive care unit of an academic tertiary center, Fifty-five patients with acute decompensation （gastrointestinal hemorrhage, encephalopathy, hydropic decompensation） and twenty-five patients with compensated liver drrhosis were included, Blood samples were taken for analyses of spas, Nox, IL-6, TNF-α, Liver enzymes and kidney functions were also tested, RESULTS： In patients with acute decompensation, plasma spas levels were higher than in non-decompensated patients （15305 ± 4646 vs 12458± 4322 pg/mL, P 〈 0.05）. This was also true for the subgroup of patients with alcoholic liver cirrhosis （P 〈 0.05）. The other mediators were not different and none of the parameters predicted survival, except for ALT （alanine-aminotransferase）. In patients with portal-hypertension-induced acute hemorrhage, NOx levels were significantly lower than in patients with other forms of decompensation （70.8 ± 48.3 vs 112.9 ± 74.9 pg/mL, P 〈 0.05）. When NOx levels were normalized to creatinine levels, the difference disappeared. IL-6, TNF-α and spas were not different between bleeders and non-bleeders. In decompensated patients spas, IL-6 and NOx levels correlated positively with creatinine levels, while IL-6 levels were dependent on Child class. CONCLUSION： In acute decompensated cirrhotic patients sPas is increased, suggesting a role of apoptosis in this process and patients with acute bleeding have lower NOx levels, However, in this acute complex clinical situation, kidney function seems to have a predominant influence on mediator levels,

Passive expansion of sub-maximally dilated transjugular intrahepatic portosystemic shunts and assessment of clinical outcomes

AIM To assess for passive expansion of sub-maximally dilated transjugular intrahepatic portosystemic shunts(TIPS) and compare outcomes with maximally dilated TIPS.METHODS Polytetrafluoroethylene covered TIPS(Viatorr) from July 2002 to December 2013 were retrospectively reviewed at two hospitals in a single institution. Two hundred and thirty patients had TIPS maximally dilated to 10 mm(m TIPS), while 43 patients who were at increased risk for hepatic encephalopathy(HE), based on clinical evaluation or low pre-TIPS portosystemic gradient(PSG), had 10 mm TIPS sub-maximally dilated to 8 mm(sm TIPS). Group characteristics(age, gender, Model for End-Stage Liver Disease score, post-TIPS PSG and clinical outcomes were compared between groups, including clinical success(ascites or varices), primary patency,primary assisted patency, and severe post-TIPS HE. A subset of fourteen patients with sm TIPS underwent follow-up computed tomography imaging after TIPS creation, and were grouped based on time of imaging(< 6 mo and > 6 mo). Change in diameter and crosssectional area were measured with 3D imaging software to evaluate for passive expansion.RESULTS Patient characteristics were similar between the sm TIPS and m TIPS groups, except for pre-TIPS portosystemic gradient, which was lower in the sm TIPS group(19.4 mm Hg ± 6.8 vs 22.4 mm Hg ± 7.1, P = 0.01). Primary patency and primary assisted patency between sm TIPS and m TIPS was not significantly different(P = 0.64 and 0.55, respectively). Four of the 55 patients(7%) with sm TIPS required TIPS reduction for severe refractory HE, while this occurred in 6 of the 218 patients(3%) with m TIPS(P = 0.12). For the 14 patients with follow-up computed tomography(CT) imaging, the median imaging follow-up was 373 d. There was an increase in median TIPS diameter, median percent diameter change, median area, and median percent area change in patients with CT follow-up greater than 6 mo after TIPS placement compared to follow-up within 6 mo(8.45 mm, 5.58%, 56.04 mm^2, and 11.48%, respectively, P = 0.01).CONCLUSION Passive expansion of sm TIPS does occur but clinical outcomes of sm TIPS and m TIPS were similar. Sub-maximal dilation can prevent complications related to overshunting in select patients.

Management of portal hypertension in children

Portal hypertension can be caused by a wide variety of conditions.It frequently presents with bleeding from esophageal varices.The approach to acute variceal hemorrhage in children is a stepwise progression from least invasive to most invasive.Management of acute variceal bleeding is straightforward.But data on primary prophylaxis and long term management prevention of recurrent variceal bleeding in children is scarce,therefore prospective multicenter trials are needed to establish best practices.