This editorial describes the contemporary concepts of prevention and management of gastroesophageal variceal bleeding in liver cirrhosis(LC)patients according to the current guidelines.Gastroesophageal variceal bleedi...This editorial describes the contemporary concepts of prevention and management of gastroesophageal variceal bleeding in liver cirrhosis(LC)patients according to the current guidelines.Gastroesophageal variceal bleeding is the most dangerous complication of portal hypertension in LC patients.Risk stratification and determination of an individual approach to the choice of therapeutic measures aimed at their prevention and management has emerged as one of the top concerns in modern hepatology.According to the current guidelines,in the absence of clinically significant portal hypertension,etiological and nonetiological therapies of LC is advisable for the primary preventing gastroesophageal variceal bleeding,whereas its presence serves as an indication for the administration of non-selectiveβ-blockers,among which carvedilol is the drug of choice.Non-selectiveβ-blockers,as well as endoscopic variceal ligation and transjugular intrahepatic portosystemic shunt can be used to prevent recurrence of gastroesophageal variceal bleeding.Pharmacotherapy with vasoactive drugs(terlipressin,somatostatin,octreotide),endoscopic variceal ligation,endovascular techniques and transjugular intrahepatic portosystemic shunt are recommended for the treatment of acute gastroesophageal variceal bleeding.Objective and accurate risk stratification of gastroesophageal variceal bleeding will allow developing individual strategies for their prevention and management,avoiding the first and further decompensation in LC,which will improve the prognosis and survival of patients suffering from it.展开更多
BACKGROUND Esophageal-gastric variceal bleeding(EGVB)represents a severe complication among patients with cirrhosis and often culminates in fatal outcomes.Interven-tional therapy,a rapidly developing treatment modalit...BACKGROUND Esophageal-gastric variceal bleeding(EGVB)represents a severe complication among patients with cirrhosis and often culminates in fatal outcomes.Interven-tional therapy,a rapidly developing treatment modality over the past few years,has found widespread application in clinical practice due to its minimally inva-sive characteristics.However,whether transjugular intrahepatic portosystemic shunt(TIPS)treatment has an impact on patient prognosis remains controversial.METHODS A retrospective study was conducted on ninety-two patients presenting with cirrhotic EGVB who were admitted to our hospital between September 2020 and September 2022.Based on the different modes of treatment,the patients were assigned to the study group(TIPS received,n=50)or the control group(per-cutaneous transhepatic varices embolization received,n=42).Comparative ana-lyses were performed between the two groups preoperatively and one month postoperatively for the following parameters:Varicosity status;hemodynamic parameters[portal vein flow velocity(PVV)and portal vein diameter(PVD);platelet count(PLT);red blood cell count;white blood cell count(WBC);and hepatic function[albumin(ALB),total bilirubin(TBIL),and aspartate transaminase(AST)].The Generic Quality of Life Inventory-74 was utilized to assess quality of life in the two groups,and the 1-year postoperative rebleeding and survival rates were compared.RESULTS Following surgical intervention,there was an improvement in the incidence of varicosity compared to the preoperative status in both cohorts.Notably,the study group exhibited more pronounced enhancements than did the control group(P<0.05).PVV increased,and PVD decreased compared to the preoperative values,with the study cohort achieving better outcomes(P<0.05).PLT and WBC counts were elevated postoperatively in the two groups,with the study cohort displaying higher PLT and WBC counts(P<0.05).No differences were detected between the two groups in terms of serum ALB,TBIL,or AST levels either preoperatively or postoperatively(P<0.05).Postoperative scores across all dimensions of life quality surpassed preoperative scores,with the study cohort achieving higher scores(P<0.05).At 22.00%,the one-year postoperative rebleeding rate in the study cohort was significantly lower than that in the control group(42.86%;P<0.05);conversely,no marked difference was obser-ved in the 1-year postoperative survival rate between the two cohorts(P>0.05).CONCLUSION TIPS,which has demonstrated robust efficacy in managing cirrhotic EGVB,remarkably alleviates varicosity and improves hemodynamics in patients.This intervention not only results in a safer profile but also contributes significantly to a more favorable prognosis.展开更多
BACKGROUND Esophagogastric variceal bleeding(EGVB)is a serious complication of patients with decompensated cirrhosis and is associated with high mortality and morbidity.Early diagnosis and screening of cirrhotic patie...BACKGROUND Esophagogastric variceal bleeding(EGVB)is a serious complication of patients with decompensated cirrhosis and is associated with high mortality and morbidity.Early diagnosis and screening of cirrhotic patients at risk for EGVB is crucial.Currently,there is a lack of noninvasive predictive models widely available in clinical practice.AIM To develop a nomogram based on clinical variables and radiomics to facilitate the noninvasive prediction of EGVB in cirrhotic patients.METHODS A total of 211 cirrhotic patients hospitalized between September 2017 and December 2021 were included in this retrospective study.Patients were divided into training(n=149)and validation(n=62)groups at a 7:3 ratio.Participants underwent three-phase computed tomography(CT)scans before endoscopy,and radiomic features were extracted from portal venous phase CT images.The independent sample t-test and least absolute shrinkage and selection operator logistic regression were used to screen out the best features and establish a radiomics signature(RadScore).Univariate and multivariate analyses were performed to determine the independent predictors of EGVB in clinical settings.A noninvasive predictive nomogram for the risk of EGVB was built using independent clinical predictors and RadScore.Receiver operating characteristic,calibration,clinical decision,and clinical impact curves were applied to evaluate the model’s performance.RESULTS Albumin(P=0.001),fibrinogen(P=0.001),portal vein thrombosis(P=0.002),aspartate aminotransferase(P=0.001),and spleen thickness(P=0.025)were selected as independent clinical predictors of EGVB.RadScore,constructed with five CT features of the liver region and three of the spleen regions,performed well in training(area under the receiver operating characteristic curve(AUC)=0.817)as well as in validation(AUC=0.741)cohorts.There was excellent predictive performance in both the training and validation cohorts for the clinical-radiomics model(AUC=0.925 and 0.912,respectively).Compared with the existing noninvasive models such as ratio of aspartate aminotransferase to platelets and Fibrosis-4 scores,our combined model had better predictive accuracy with the Delong's test less than 0.05.The Nomogram had a good fit in the calibration curve(P>0.05),and the clinical decision curve further supported its clinical utility.CONCLUSION We designed and validated a clinical-radiomics nomogram able to noninvasively predict whether cirrhotic patients will develop EGVB,thus facilitating early diagnosis and treatment.展开更多
BACKGROUND Portal hypertension combined with esophagogastric variceal bleeding(EGVB)is a serious complication in patients with hepatitis B virus(HBV)-related cirrhosis in China.Splenectomy plus pericardial devasculari...BACKGROUND Portal hypertension combined with esophagogastric variceal bleeding(EGVB)is a serious complication in patients with hepatitis B virus(HBV)-related cirrhosis in China.Splenectomy plus pericardial devascularization(SPD)and transjugular intrahepatic portosystemic shunt(TIPS)are effective treatments for EGVB.However,a comparison of the effectiveness and safety of those methods is lacking.AIM To compare the prognosis after SPD vs TIPS for acute EGVB after failure of endoscopic therapy or secondary prophylaxis of variceal rebleeding(VRB)in patients with HBV-related cirrhosis combined with portal hypertension.METHODS This retrospective cohort study included 318 patients with HBV-related cirrhosis and EGVB who underwent SPD or TIPS at West China Hospital of Sichuan University during 2009-2013.Propensity score-matched analysis(PSM),the Kaplan-Meier method,and multivariate Cox regression analysis were used to compare overall survival,VRB rate,liver function abnormality rate,and hepatocellular carcinoma(HCC)incidence between the two patient groups.RESULTS The median age was 45.0 years(n=318;226(71.1%)males).During a median follow-up duration of 43.0 mo,18(11.1%)and 33(21.2%)patients died in the SPD and TIPS groups,respectively.After PSM,SPD was significantly associated with better overall survival(OS)(P=0.01),lower rates of abnormal liver function(P<0.001),and a lower incidence of HCC(P=0.02)than TIPS.The VRB rate did not differ significantly between the two groups(P=0.09).CONCLUSION Compared with TIPS,SPD is associated with higher postoperative OS rates,lower rates of abnormal liver function and HCC,and better quality of survival as acute EGVB treatment after failed endoscopic therapy or as secondary prophylaxis of VRB in patients with HBV-related cirrhosis combined with portal hypertension.There is no significant between-group difference in VRB rates.展开更多
To assess “predictors” of esophageal varices (EV) and variceal bleeding using non-invasive markers in Albanian patients diagnosed with liver cirrhosis. METHODSOne hundred thirty-nine newly diagnosed cirrhotic patien...To assess “predictors” of esophageal varices (EV) and variceal bleeding using non-invasive markers in Albanian patients diagnosed with liver cirrhosis. METHODSOne hundred thirty-nine newly diagnosed cirrhotic patients without variceal bleeding were included in this analysis. Model for end-stage liver disease (MELD), aspartate aminotransferase (AST) to alanine aminotransferase (ALT) ratio (AST/ALT), AST to platelet ratio index (APRI), platelet count to spleen diameter (PC/SD), fibrosis-4-index (FIB-4), fibrosis index (FI) and King’s Score were measured for all participants. All patients underwent endoscopic assessment within two days of hospitalization. The major end point was the first esophageal variceal bleeding (EVB) event. The diagnostic performance of “predictors” for the presence of EV and EVB were assessed by sensitivity and specificity values obtained from the receiver operating characteristics procedure. RESULTSFIB-4 was the only strong and significant “predictor” of esophageal varices (multivariable-adjusted OR = 1.57 for one unit increment; 95%CI: 1.15-2.14). Furthermore, a cut-off value of 3.23 for FIB-4 was a significant predictor of esophageal varices, with a sensitivity of 72%, a specificity of 58% and a proportion of area under the curve (AUC) of 66% (P = 0.01). During the follow-up (median: 31.5 mo; interquartile range: 11-59 mo), 34 patients (24%) experienced a first EVB. FIB-4 was a poor predictor of EVB (the AUC was only 51%) for a cut-off value of 5.02. Furthermore, the AUC of AST/ALT, APRI, PC/SD, FI, MELD and King’s Score ranged from 45% to 55%. None of the non-invasive markers turned out to be a useful predictor of EVB. CONCLUSIONDespite the low diagnostic accuracy, FIB-4 appears the most efficient non-invasive liver fibrosis marker which can be used as an initial screening tool for cirrhotic patients.展开更多
AIM: To evaluate the clinical effects of transjugular intrahepatic portosystemic shunt (TIPS) vs endoscopic variceal sclerotherapy (EVS) in the management of gastric variceal (GV) bleeding in terms of variceal rebleed...AIM: To evaluate the clinical effects of transjugular intrahepatic portosystemic shunt (TIPS) vs endoscopic variceal sclerotherapy (EVS) in the management of gastric variceal (GV) bleeding in terms of variceal rebleeding, hepatic encephalopathy (HE), and survival by meta-analysis.METHODS: Medline, Embase, and CNKI were searched. Studies compared TIPS with EVS in treating GV bleeding were identified and included according to our predefined inclusion criteria. Data were extracted independently by two of our authors. Studies with prospective randomized design were considered to be of high quality. Hazard ratios (HRs) or odd ratios(ORs) were calculated using a fixed-effects model when there was no inter-trial heterogeneity. Oppositely, a random-effects model was employed.RESULTS: Three studies with 220 patients who had at least one episode of GV bleeding were included in the present meta-analysis. The proportions of patients with viral cirrhosis and alcoholic cirrhosis were 39% (range 0%-78%) and 36% (range 12% to 41%), respectively. The pooled incidence of variceal rebleeding in the TIPS group was significantly lower than that in the EVS group (HR = 0.3, 0.35, 95% CI: 0.17-0.71, P = 0.004). However, the risk of the development of any degree of HE was significantly increased in the TIPS group (OR = 15.97, 95% CI: 3.61-70.68). The pooled HR of survival was 1.26(95% CI: 0.76-2.09, P = 0.36). No inter-trial heterogeneity was observed among these analyses. CONCLUSION: The improved effect of TIPS in the prevention of GV rebleeding is associated with an increased risk of HE. There is no survival difference between the TIPS and EVS groups. Further studies are needed to evaluate the survival benefit of TIPS in cirrhotic patients with GV bleeding.展开更多
BACKGROUND Acute esophageal variceal hemorrhage(AEVH)is a common complication of cirrhosis and might precipitate multi-organ failure,causing acute-on-chronic liver failure(ACLF).AIM To analyze if the presence and grad...BACKGROUND Acute esophageal variceal hemorrhage(AEVH)is a common complication of cirrhosis and might precipitate multi-organ failure,causing acute-on-chronic liver failure(ACLF).AIM To analyze if the presence and grading of ACLF as defined by European Society for the Study of the Liver-Chronic Liver Failure(EASL-CLIF)is able to predict mortality in cirrhotic patients presenting AEVH.METHODS Retrospective cohort study executed in Hospital Geral de Caxias do Sul.Data from medical records from 2010 to 2016 were obtained by searching the hospital electronic database for patients who received terlipressin.Medical records were reviewed in order to determine the diagnosis of cirrhosis and AEVH,including 97 patients.Kaplan-Meier survival analysis was used for univariate analysis and a stepwise approach to the Cox regression for multivariate analysis.RESULTS All-cause mortality for AEVH patients was 36%,40.2%and 49.4%for 30-,90-and 365-day,respectively.The prevalence of ACLF was 41.3%.Of these,35%grade 1,50%grade 2 and 15%grade 3.In multivariate analysis,the non-use of non-selective beta-blockers,presence and higher grading of ACLF and higher Model for End-Stage Liver Disease scores were independently associated with higher mortality for 30-day with the addition of higher Child-Pugh scores for 90-day period.CONCLUSION Presence and grading of ACLF according to the EASL-CLIF criteria was independently associated with higher 30-and 90-day mortality in cirrhotic patients admitted due to AEVH.展开更多
BACKGROUND: Transjugular intrahepatic portosystemic shunt(TIPS) and open splenectomy and esophagogastric devascularization(OSED) are widely used to treat patients with portal hypertension and recurrent variceal b...BACKGROUND: Transjugular intrahepatic portosystemic shunt(TIPS) and open splenectomy and esophagogastric devascularization(OSED) are widely used to treat patients with portal hypertension and recurrent variceal bleeding(PHRVB). This study aimed to compare the effectiveness between TIPS and OSED for the treatment of PHRVB.METHODS: The data were retrospectively retrieved from 479 cirrhotic patients(Child-Pugh A or B class) with PHRVB, who had undergone TIPS(TIPS group) or OSED(OSED group) between January 1, 2010 and October 31, 2014.RESULTS: A total of 196 patients received TIPS, whereas 283 underwent OSED. Within one month after TIPS and OSED, the rebleeding rates were 6.1% and 3.2%, respectively(P=0.122). Significantly lower incidence of pleural effusion,splenic vein thrombosis, and pulmonary infection, as well as higher hepatic encephalopathy rate, shorter postoperative length of hospital stay, and higher hospital costs were observed in the TIPS group than those in the OSED group. During the follow-up periods(29 months), significantly higher incidences of rebleeding(15.3% vs 4.6%, P=0.001) and hepatic encephalopathy(17.3% vs 3.9%, P=0.001) were observed in the TIPS group than in the OSED group. The incidence of instent stenosis was 18.9%. The survival rates were 91.3% in the TIPS group and 95.1% in the OSED group. The long-term liver function did not worsen after either TIPS or OSED.CONCLUSION: For the patients with liver function in the Child-Pugh A or B class, TIPS is not superior over OSED in terms of PHRVB treatment and rebleeding prevention.展开更多
BACKGROUND Endoscopic variceal treatment(EVT)is recommended as the mainstay choice for the management of high-risk gastroesophageal varices and acute variceal bleeding in liver cirrhosis.Proton pump inhibitors(PPIs)ar...BACKGROUND Endoscopic variceal treatment(EVT)is recommended as the mainstay choice for the management of high-risk gastroesophageal varices and acute variceal bleeding in liver cirrhosis.Proton pump inhibitors(PPIs)are widely used for various gastric acid-related diseases.However,the effects of PPIs on the development of post-EVT complications,especially gastrointestinal bleeding(GIB),remain controversial.AIM To evaluate the effects of postoperative use of PPIs on post-EVT complications in patients with liver cirrhosis during hospitalization.METHODS Patients with a diagnosis of liver cirrhosis who were admitted to the Department of Gastroenterology of the General Hospital of Northern Theater Command,treated by an attending physician between January 2016 and June 2020 and underwent EVT during their hospitalization were included.Logistic regression analyses were performed to explore the effects of postoperative use of PPIs on the development of post-EVT complications during hospitalization.Odds ratios(ORs)with 95%confidence intervals(CIs)were calculated.RESULTS A total of 143 patients were included.The incidence of post-EVT GIB and other post-EVT complications was 4.90%and 46.85%,respectively.In the overall analyses,postoperative use of PPIs did not significantly reduce the risk of post-EVT GIB(OR=0.525,95%CI=0.113-2.438,P=0.411)or other post-EVT complications(OR=0.804,95%CI=0.413-1.565,P=0.522).In the subgroup analyses according to the enrollment period,type and route of PPIs after the index EVT,use of PPIs before the index EVT,use of vasoactive drugs after the index EVT,indication of EVT(prophylactic and therapeutic),and presence of portal venous system thrombosis,ascites,and hepatocellular carcinoma,the effects of postoperative use of PPIs on the risk of post-EVT GIB or other post-EVT complications remain not statistically significant.CONCLUSION Routine use of PPIs after EVT should not be recommended in patients with liver cirrhosis for the prevention of post-EVT complications during hospitalization.展开更多
Several studies have indicated that the oral and gut microbiota may exhibit differences in patients with cirrhosis.Less is known about the microbiota in the stomach,which is located between the oral cavity and the int...Several studies have indicated that the oral and gut microbiota may exhibit differences in patients with cirrhosis.Less is known about the microbiota in the stomach,which is located between the oral cavity and the intestinal tract.In this study,the gastric mucosal microbiota of patients with liver cirrhosis and controls were analyzed with 16S ribosomal RNA(rRNA)pyrosequencing.Cirrhotic patients had significantly lower Helicobacter pylori(H.pylori)infection rates,as confirmed by both the histological method and the pyrosequencing method.In H.pylori-negative subjects,gastric bacterial communities of healthy and cirrhosis cohorts were clustered into four clusters based on bacterial compositions:Cluster_1 and Cluster_2(mostly cirrhosis),Cluster_3(mostly healthy),and Cluster_4(around half of each).Compositional and functional differences were observed among these different clusters.At the genus level,Cluster_1 and Cluster_2 showed enrichment of Neisseria and Streptococcus,respectively.Functionally,Cluster_2 was characterized as depleted of genetic information processing,as well as of modules related to glycan biosynthesis and metabolism.Patients in Cluster_2 had more severe gastrointestinal symptoms and a higher rate of previous endoscopic variceal ligation(EVL)therapy than patients in other clusters.Our findings suggest that the colonization of both H.pylori and non-H.pylori is influenced in liver cirrhosis.Although the H.pylori-negative gastric mucosal microbiota showed considerable heterogeneity,associations between specific gastric microbiota and clinical characteristics could be observed.Previous EVL therapy might lead to a distinct structure of the gastric mucosal microbiota,thus aggravating the gastrointestinal symptoms in H.pylori-negative cirrhotic patients.展开更多
AIM To summarize and critically examine the role of band ligation in secondary prophylaxis of variceal bleeding in patients with cirrhosis. METHODS A literature review was performed using the MEDLINE and PubM ed datab...AIM To summarize and critically examine the role of band ligation in secondary prophylaxis of variceal bleeding in patients with cirrhosis. METHODS A literature review was performed using the MEDLINE and PubM ed databases. The search terms consisted of the words "endoscopic band ligation" OR "variceal band ligation" OR "ligation" AND "secondary prophylaxis" OR "secondary prevention" AND "variceal bleeding" OR "variceal hemorrhage" AND "liver cirrhosis". The data collected from relevant meta-analyses and from the most recent randomized studies that were not included in these meta-analyses were used to evaluate the role of endoscopic band ligation in an effort to demonstrate the most recent advances in the treatment of esophageal varices. RESULTS This study included 11 meta-analyses published from 2002 to 2017 and 10 randomized trials published from 2010 to 2017 that evaluated the efficacy of band ligation in the secondary prophylaxis of variceal bleeding. Overall, the results proved that band ligation was superior to endoscopic sclerotherapy. Moreover, the use of β-blockers in combination with band ligation increased the treatment effectiveness, supporting the current recommendations for secondary prophylaxis of variceal bleeding. The use of transjugular intrahepatic portosystemic shunt was superior to combination therapy regarding rebleeding prophylaxis, with no difference in the survival rates; however, the results concerning the hepatic encephalopathy incidence were conflicting. Recent advances in the management of secondary prophylaxis of variceal bleeding have targeted a decrease in portal pressure based on the pathophysiological mechanisms of portal hypertension.CONCLUSION This review suggests that future research should be conducted to enhance current interventions and/or to develop innovative treatment options with improved clinical endpoints.展开更多
BACKGROUND Proton pump inhibitors(PPIs)are widely prescribed,often without clear indications.There are conflicting data on its association with mortality risk and hepatic decompensation in cirrhotic patients.Furthermo...BACKGROUND Proton pump inhibitors(PPIs)are widely prescribed,often without clear indications.There are conflicting data on its association with mortality risk and hepatic decompensation in cirrhotic patients.Furthermore,PPI users and PPI exposure in some studies have been poorly defined with many confounding factors.AIM To examine if PPI use increases mortality and hepatic decompensation and the impact of cumulative PPI dose exposure.METHODS Data from patients with decompensated liver cirrhosis were extracted from a hospital database between 2013 to 2017.PPI users were defined as cumulative defined daily dose(cDDD)≥28 within a landmark period,after hospitalisation for hepatic decompensation.Cox regression analysis for comparison was done after propensity score adjustment.Further risk of hepatic decompensation was analysed by Poisson regression.RESULTS Among 295 decompensated cirrhosis patients,238 were PPI users and 57 were non-users.PPI users had higher mortality compared to non-users[adjusted HR=2.10,(1.20-3.67);P=0.009].Longer PPI use with cDDD>90 was associated with higher mortality,compared to non-users[aHR=2.27,(1.10-5.14);P=0.038].PPI users had a higher incidence of hospitalization for hepatic decompensation[aRR=1.61,(1.30-2.11);P<0.001].CONCLUSION PPI use in decompensated cirrhosis is associated with increased risk of mortality and hepatic decompensation.Longer PPI exposure with cDDD>90 increases the risk of mortality.展开更多
Spontaneous porto-systemic shunts(SPSS)are frequent in liver cirrhosis and their prevalence increases as liver function deteriorates,probably as a consequence of worsening portal hypertension,but without achieving an ...Spontaneous porto-systemic shunts(SPSS)are frequent in liver cirrhosis and their prevalence increases as liver function deteriorates,probably as a consequence of worsening portal hypertension,but without achieving an effective protection against cirrhosis'complications.Several types of SPSS have been described in the literature,each one associated with different clinical manifestations.In particular,recurrent or persistent hepatic encephalopathy is more frequent in patients with splenorenal shunt,while the presence of gastric varices and consequently the incidence of variceal bleeding is more common in gastrorenal shunt.In the advanced stage,the presence of large SPSS can lead to the so called“portosystemic shunt syndrome”,characterized by a progressive deterioration of hepatic function,hepatic encephalopathy and,sometimes,portal vein thrombosis.The detection of SPSS in patients with liver cirrhosis is recommended in order to prevent or treat recurrent hepatic encephalopathy or variceal bleeding.展开更多
Nowadays,transjugular intrahepatic portosystemic shunt(TIPS)has become a mainstay treatment option for the management of portal hypertension-related complications in liver cirrhosis.Accumulated evidence has shown that...Nowadays,transjugular intrahepatic portosystemic shunt(TIPS)has become a mainstay treatment option for the management of portal hypertension-related complications in liver cirrhosis.Accumulated evidence has shown that its indications are being gradually expanded.Notwithstanding,less attention has been paid for the selection of an appropriate stent during a TIPS procedure.Herein,we attempt to review the current evidence regarding the diameter,type,brand,and position of TIPS stents.Several following recommendations may be considered in the clinical practice:(1)a 10-mm stent may be more effective than an 8-mm stent for the management of portal hypertension,and may be superior to a 12-mm stent for the improvement of survival and shunt patency;(2)covered stents are superior to bare stents for reducing the development of shunt dysfunction;(3)if available,Viatorr stent-grafts may be recommended due to a higher rate of shunt patency;and(4)the placement of a TIPS stent in the left portal vein branch may be more reasonable for decreasingthe development of hepatic encephalopathy.However,given relatively low quality of evidence,prospective well-designed studies should be warranted to further confirm these recommendations.展开更多
Hepatic venous pressure gradient(HVPG)is an independent predictor of variceal rebleeding in patients with cirrhosis.After pharmacological and/or endoscopic therapy,the use of a transjugular intrahepatic portosystemic ...Hepatic venous pressure gradient(HVPG)is an independent predictor of variceal rebleeding in patients with cirrhosis.After pharmacological and/or endoscopic therapy,the use of a transjugular intrahepatic portosystemic shunt(TIPS)may be necessary in HVPG non-responders,but not in responders.Thus,HVPG measurement may be incorporated into the treatment algorithm for acute variceal bleeding,which further identifies the candidates that should undergo early insertion of TIPS or maintain the traditional pharmacological and/or endoscopic therapy.The potential benefits are to reduce the cost and prevent TIPS-related complications.展开更多
AIM: To develop a technique of combined endoscopic sclerotherapy and ligation (ESL) in which both techniques of endoscopic sclerotherapy (ES) and endoscopic variceal ligation (EVL) can be optimally used.METHODS: ESL w...AIM: To develop a technique of combined endoscopic sclerotherapy and ligation (ESL) in which both techniques of endoscopic sclerotherapy (ES) and endoscopic variceal ligation (EVL) can be optimally used.METHODS: ESL was performed in 10 patients (age 46.4±7.9;9 males, 1 female) with cirrhosis of liver using sclerotherapy needle and Speedband, Superview multiple band ligater (Boston Scientific, Microvasive, Watertown, MA). A single band was placed 5-10 cm proximal to the gastro-esophageal junction over each varix from proximal to distal margin,followed by intravariceal injection of 1.5 % ethoxysclerol (4 ml each) 2 to 3 cm proximal to the gastroesophageal junction on the ligated varices distal to deployed band. EVL was then performed at the injection site. Similarly other varices were also injected and ligated from distal to proximally. In the subsequent sessions, ES alone was performed to sclerose small varices at the gastroesophageal junction.RESULTS: ESL was successfully performed in all patients.A median of 3 (ESL 1, ES 2) sessions (ranged 1-4) were required to eradicate the varices in 9 (90 %) of 10 patients.Recurrence of varices without bleed was seen in 1 patient during a mean follow-up of 10.3 months (ranged 6-15).Two patients died of liver failure. None died of variceal bleeding. None of the patients had procedure related complications.CONCLUSION: ESL may be useful in the fast eradication of esophageal varices. However, randomised controlled trials are required to find out its relative efficacy and impact on variceal recurrence in comparison to ES or EVL.展开更多
文摘This editorial describes the contemporary concepts of prevention and management of gastroesophageal variceal bleeding in liver cirrhosis(LC)patients according to the current guidelines.Gastroesophageal variceal bleeding is the most dangerous complication of portal hypertension in LC patients.Risk stratification and determination of an individual approach to the choice of therapeutic measures aimed at their prevention and management has emerged as one of the top concerns in modern hepatology.According to the current guidelines,in the absence of clinically significant portal hypertension,etiological and nonetiological therapies of LC is advisable for the primary preventing gastroesophageal variceal bleeding,whereas its presence serves as an indication for the administration of non-selectiveβ-blockers,among which carvedilol is the drug of choice.Non-selectiveβ-blockers,as well as endoscopic variceal ligation and transjugular intrahepatic portosystemic shunt can be used to prevent recurrence of gastroesophageal variceal bleeding.Pharmacotherapy with vasoactive drugs(terlipressin,somatostatin,octreotide),endoscopic variceal ligation,endovascular techniques and transjugular intrahepatic portosystemic shunt are recommended for the treatment of acute gastroesophageal variceal bleeding.Objective and accurate risk stratification of gastroesophageal variceal bleeding will allow developing individual strategies for their prevention and management,avoiding the first and further decompensation in LC,which will improve the prognosis and survival of patients suffering from it.
文摘BACKGROUND Esophageal-gastric variceal bleeding(EGVB)represents a severe complication among patients with cirrhosis and often culminates in fatal outcomes.Interven-tional therapy,a rapidly developing treatment modality over the past few years,has found widespread application in clinical practice due to its minimally inva-sive characteristics.However,whether transjugular intrahepatic portosystemic shunt(TIPS)treatment has an impact on patient prognosis remains controversial.METHODS A retrospective study was conducted on ninety-two patients presenting with cirrhotic EGVB who were admitted to our hospital between September 2020 and September 2022.Based on the different modes of treatment,the patients were assigned to the study group(TIPS received,n=50)or the control group(per-cutaneous transhepatic varices embolization received,n=42).Comparative ana-lyses were performed between the two groups preoperatively and one month postoperatively for the following parameters:Varicosity status;hemodynamic parameters[portal vein flow velocity(PVV)and portal vein diameter(PVD);platelet count(PLT);red blood cell count;white blood cell count(WBC);and hepatic function[albumin(ALB),total bilirubin(TBIL),and aspartate transaminase(AST)].The Generic Quality of Life Inventory-74 was utilized to assess quality of life in the two groups,and the 1-year postoperative rebleeding and survival rates were compared.RESULTS Following surgical intervention,there was an improvement in the incidence of varicosity compared to the preoperative status in both cohorts.Notably,the study group exhibited more pronounced enhancements than did the control group(P<0.05).PVV increased,and PVD decreased compared to the preoperative values,with the study cohort achieving better outcomes(P<0.05).PLT and WBC counts were elevated postoperatively in the two groups,with the study cohort displaying higher PLT and WBC counts(P<0.05).No differences were detected between the two groups in terms of serum ALB,TBIL,or AST levels either preoperatively or postoperatively(P<0.05).Postoperative scores across all dimensions of life quality surpassed preoperative scores,with the study cohort achieving higher scores(P<0.05).At 22.00%,the one-year postoperative rebleeding rate in the study cohort was significantly lower than that in the control group(42.86%;P<0.05);conversely,no marked difference was obser-ved in the 1-year postoperative survival rate between the two cohorts(P>0.05).CONCLUSION TIPS,which has demonstrated robust efficacy in managing cirrhotic EGVB,remarkably alleviates varicosity and improves hemodynamics in patients.This intervention not only results in a safer profile but also contributes significantly to a more favorable prognosis.
基金The study was reviewed and approved by the Ethics Committee of the Second Affiliated Hospital of Chongqing Medical University(No.2022-149).
文摘BACKGROUND Esophagogastric variceal bleeding(EGVB)is a serious complication of patients with decompensated cirrhosis and is associated with high mortality and morbidity.Early diagnosis and screening of cirrhotic patients at risk for EGVB is crucial.Currently,there is a lack of noninvasive predictive models widely available in clinical practice.AIM To develop a nomogram based on clinical variables and radiomics to facilitate the noninvasive prediction of EGVB in cirrhotic patients.METHODS A total of 211 cirrhotic patients hospitalized between September 2017 and December 2021 were included in this retrospective study.Patients were divided into training(n=149)and validation(n=62)groups at a 7:3 ratio.Participants underwent three-phase computed tomography(CT)scans before endoscopy,and radiomic features were extracted from portal venous phase CT images.The independent sample t-test and least absolute shrinkage and selection operator logistic regression were used to screen out the best features and establish a radiomics signature(RadScore).Univariate and multivariate analyses were performed to determine the independent predictors of EGVB in clinical settings.A noninvasive predictive nomogram for the risk of EGVB was built using independent clinical predictors and RadScore.Receiver operating characteristic,calibration,clinical decision,and clinical impact curves were applied to evaluate the model’s performance.RESULTS Albumin(P=0.001),fibrinogen(P=0.001),portal vein thrombosis(P=0.002),aspartate aminotransferase(P=0.001),and spleen thickness(P=0.025)were selected as independent clinical predictors of EGVB.RadScore,constructed with five CT features of the liver region and three of the spleen regions,performed well in training(area under the receiver operating characteristic curve(AUC)=0.817)as well as in validation(AUC=0.741)cohorts.There was excellent predictive performance in both the training and validation cohorts for the clinical-radiomics model(AUC=0.925 and 0.912,respectively).Compared with the existing noninvasive models such as ratio of aspartate aminotransferase to platelets and Fibrosis-4 scores,our combined model had better predictive accuracy with the Delong's test less than 0.05.The Nomogram had a good fit in the calibration curve(P>0.05),and the clinical decision curve further supported its clinical utility.CONCLUSION We designed and validated a clinical-radiomics nomogram able to noninvasively predict whether cirrhotic patients will develop EGVB,thus facilitating early diagnosis and treatment.
基金the National Key R&D Program of China,No.2022YFC2503701the Science and Technological Supports Project of Sichuan Province,No.2022YFS0255the National Natural Science Foundation of China,No.81800449.
文摘BACKGROUND Portal hypertension combined with esophagogastric variceal bleeding(EGVB)is a serious complication in patients with hepatitis B virus(HBV)-related cirrhosis in China.Splenectomy plus pericardial devascularization(SPD)and transjugular intrahepatic portosystemic shunt(TIPS)are effective treatments for EGVB.However,a comparison of the effectiveness and safety of those methods is lacking.AIM To compare the prognosis after SPD vs TIPS for acute EGVB after failure of endoscopic therapy or secondary prophylaxis of variceal rebleeding(VRB)in patients with HBV-related cirrhosis combined with portal hypertension.METHODS This retrospective cohort study included 318 patients with HBV-related cirrhosis and EGVB who underwent SPD or TIPS at West China Hospital of Sichuan University during 2009-2013.Propensity score-matched analysis(PSM),the Kaplan-Meier method,and multivariate Cox regression analysis were used to compare overall survival,VRB rate,liver function abnormality rate,and hepatocellular carcinoma(HCC)incidence between the two patient groups.RESULTS The median age was 45.0 years(n=318;226(71.1%)males).During a median follow-up duration of 43.0 mo,18(11.1%)and 33(21.2%)patients died in the SPD and TIPS groups,respectively.After PSM,SPD was significantly associated with better overall survival(OS)(P=0.01),lower rates of abnormal liver function(P<0.001),and a lower incidence of HCC(P=0.02)than TIPS.The VRB rate did not differ significantly between the two groups(P=0.09).CONCLUSION Compared with TIPS,SPD is associated with higher postoperative OS rates,lower rates of abnormal liver function and HCC,and better quality of survival as acute EGVB treatment after failed endoscopic therapy or as secondary prophylaxis of VRB in patients with HBV-related cirrhosis combined with portal hypertension.There is no significant between-group difference in VRB rates.
文摘To assess “predictors” of esophageal varices (EV) and variceal bleeding using non-invasive markers in Albanian patients diagnosed with liver cirrhosis. METHODSOne hundred thirty-nine newly diagnosed cirrhotic patients without variceal bleeding were included in this analysis. Model for end-stage liver disease (MELD), aspartate aminotransferase (AST) to alanine aminotransferase (ALT) ratio (AST/ALT), AST to platelet ratio index (APRI), platelet count to spleen diameter (PC/SD), fibrosis-4-index (FIB-4), fibrosis index (FI) and King’s Score were measured for all participants. All patients underwent endoscopic assessment within two days of hospitalization. The major end point was the first esophageal variceal bleeding (EVB) event. The diagnostic performance of “predictors” for the presence of EV and EVB were assessed by sensitivity and specificity values obtained from the receiver operating characteristics procedure. RESULTSFIB-4 was the only strong and significant “predictor” of esophageal varices (multivariable-adjusted OR = 1.57 for one unit increment; 95%CI: 1.15-2.14). Furthermore, a cut-off value of 3.23 for FIB-4 was a significant predictor of esophageal varices, with a sensitivity of 72%, a specificity of 58% and a proportion of area under the curve (AUC) of 66% (P = 0.01). During the follow-up (median: 31.5 mo; interquartile range: 11-59 mo), 34 patients (24%) experienced a first EVB. FIB-4 was a poor predictor of EVB (the AUC was only 51%) for a cut-off value of 5.02. Furthermore, the AUC of AST/ALT, APRI, PC/SD, FI, MELD and King’s Score ranged from 45% to 55%. None of the non-invasive markers turned out to be a useful predictor of EVB. CONCLUSIONDespite the low diagnostic accuracy, FIB-4 appears the most efficient non-invasive liver fibrosis marker which can be used as an initial screening tool for cirrhotic patients.
文摘AIM: To evaluate the clinical effects of transjugular intrahepatic portosystemic shunt (TIPS) vs endoscopic variceal sclerotherapy (EVS) in the management of gastric variceal (GV) bleeding in terms of variceal rebleeding, hepatic encephalopathy (HE), and survival by meta-analysis.METHODS: Medline, Embase, and CNKI were searched. Studies compared TIPS with EVS in treating GV bleeding were identified and included according to our predefined inclusion criteria. Data were extracted independently by two of our authors. Studies with prospective randomized design were considered to be of high quality. Hazard ratios (HRs) or odd ratios(ORs) were calculated using a fixed-effects model when there was no inter-trial heterogeneity. Oppositely, a random-effects model was employed.RESULTS: Three studies with 220 patients who had at least one episode of GV bleeding were included in the present meta-analysis. The proportions of patients with viral cirrhosis and alcoholic cirrhosis were 39% (range 0%-78%) and 36% (range 12% to 41%), respectively. The pooled incidence of variceal rebleeding in the TIPS group was significantly lower than that in the EVS group (HR = 0.3, 0.35, 95% CI: 0.17-0.71, P = 0.004). However, the risk of the development of any degree of HE was significantly increased in the TIPS group (OR = 15.97, 95% CI: 3.61-70.68). The pooled HR of survival was 1.26(95% CI: 0.76-2.09, P = 0.36). No inter-trial heterogeneity was observed among these analyses. CONCLUSION: The improved effect of TIPS in the prevention of GV rebleeding is associated with an increased risk of HE. There is no survival difference between the TIPS and EVS groups. Further studies are needed to evaluate the survival benefit of TIPS in cirrhotic patients with GV bleeding.
基金This study was approved by the Research ethics committee of Universidade de Caxias do Sul on June 20,2017,under protocol no.66646617.3.0000.5341.
文摘BACKGROUND Acute esophageal variceal hemorrhage(AEVH)is a common complication of cirrhosis and might precipitate multi-organ failure,causing acute-on-chronic liver failure(ACLF).AIM To analyze if the presence and grading of ACLF as defined by European Society for the Study of the Liver-Chronic Liver Failure(EASL-CLIF)is able to predict mortality in cirrhotic patients presenting AEVH.METHODS Retrospective cohort study executed in Hospital Geral de Caxias do Sul.Data from medical records from 2010 to 2016 were obtained by searching the hospital electronic database for patients who received terlipressin.Medical records were reviewed in order to determine the diagnosis of cirrhosis and AEVH,including 97 patients.Kaplan-Meier survival analysis was used for univariate analysis and a stepwise approach to the Cox regression for multivariate analysis.RESULTS All-cause mortality for AEVH patients was 36%,40.2%and 49.4%for 30-,90-and 365-day,respectively.The prevalence of ACLF was 41.3%.Of these,35%grade 1,50%grade 2 and 15%grade 3.In multivariate analysis,the non-use of non-selective beta-blockers,presence and higher grading of ACLF and higher Model for End-Stage Liver Disease scores were independently associated with higher mortality for 30-day with the addition of higher Child-Pugh scores for 90-day period.CONCLUSION Presence and grading of ACLF according to the EASL-CLIF criteria was independently associated with higher 30-and 90-day mortality in cirrhotic patients admitted due to AEVH.
文摘BACKGROUND: Transjugular intrahepatic portosystemic shunt(TIPS) and open splenectomy and esophagogastric devascularization(OSED) are widely used to treat patients with portal hypertension and recurrent variceal bleeding(PHRVB). This study aimed to compare the effectiveness between TIPS and OSED for the treatment of PHRVB.METHODS: The data were retrospectively retrieved from 479 cirrhotic patients(Child-Pugh A or B class) with PHRVB, who had undergone TIPS(TIPS group) or OSED(OSED group) between January 1, 2010 and October 31, 2014.RESULTS: A total of 196 patients received TIPS, whereas 283 underwent OSED. Within one month after TIPS and OSED, the rebleeding rates were 6.1% and 3.2%, respectively(P=0.122). Significantly lower incidence of pleural effusion,splenic vein thrombosis, and pulmonary infection, as well as higher hepatic encephalopathy rate, shorter postoperative length of hospital stay, and higher hospital costs were observed in the TIPS group than those in the OSED group. During the follow-up periods(29 months), significantly higher incidences of rebleeding(15.3% vs 4.6%, P=0.001) and hepatic encephalopathy(17.3% vs 3.9%, P=0.001) were observed in the TIPS group than in the OSED group. The incidence of instent stenosis was 18.9%. The survival rates were 91.3% in the TIPS group and 95.1% in the OSED group. The long-term liver function did not worsen after either TIPS or OSED.CONCLUSION: For the patients with liver function in the Child-Pugh A or B class, TIPS is not superior over OSED in terms of PHRVB treatment and rebleeding prevention.
文摘BACKGROUND Endoscopic variceal treatment(EVT)is recommended as the mainstay choice for the management of high-risk gastroesophageal varices and acute variceal bleeding in liver cirrhosis.Proton pump inhibitors(PPIs)are widely used for various gastric acid-related diseases.However,the effects of PPIs on the development of post-EVT complications,especially gastrointestinal bleeding(GIB),remain controversial.AIM To evaluate the effects of postoperative use of PPIs on post-EVT complications in patients with liver cirrhosis during hospitalization.METHODS Patients with a diagnosis of liver cirrhosis who were admitted to the Department of Gastroenterology of the General Hospital of Northern Theater Command,treated by an attending physician between January 2016 and June 2020 and underwent EVT during their hospitalization were included.Logistic regression analyses were performed to explore the effects of postoperative use of PPIs on the development of post-EVT complications during hospitalization.Odds ratios(ORs)with 95%confidence intervals(CIs)were calculated.RESULTS A total of 143 patients were included.The incidence of post-EVT GIB and other post-EVT complications was 4.90%and 46.85%,respectively.In the overall analyses,postoperative use of PPIs did not significantly reduce the risk of post-EVT GIB(OR=0.525,95%CI=0.113-2.438,P=0.411)or other post-EVT complications(OR=0.804,95%CI=0.413-1.565,P=0.522).In the subgroup analyses according to the enrollment period,type and route of PPIs after the index EVT,use of PPIs before the index EVT,use of vasoactive drugs after the index EVT,indication of EVT(prophylactic and therapeutic),and presence of portal venous system thrombosis,ascites,and hepatocellular carcinoma,the effects of postoperative use of PPIs on the risk of post-EVT GIB or other post-EVT complications remain not statistically significant.CONCLUSION Routine use of PPIs after EVT should not be recommended in patients with liver cirrhosis for the prevention of post-EVT complications during hospitalization.
基金This work was supported by the National Natural Science Foun-dation of China(81790631)Zhejiang Provincial Natural Science Foundation of China(LY15H030012).
文摘Several studies have indicated that the oral and gut microbiota may exhibit differences in patients with cirrhosis.Less is known about the microbiota in the stomach,which is located between the oral cavity and the intestinal tract.In this study,the gastric mucosal microbiota of patients with liver cirrhosis and controls were analyzed with 16S ribosomal RNA(rRNA)pyrosequencing.Cirrhotic patients had significantly lower Helicobacter pylori(H.pylori)infection rates,as confirmed by both the histological method and the pyrosequencing method.In H.pylori-negative subjects,gastric bacterial communities of healthy and cirrhosis cohorts were clustered into four clusters based on bacterial compositions:Cluster_1 and Cluster_2(mostly cirrhosis),Cluster_3(mostly healthy),and Cluster_4(around half of each).Compositional and functional differences were observed among these different clusters.At the genus level,Cluster_1 and Cluster_2 showed enrichment of Neisseria and Streptococcus,respectively.Functionally,Cluster_2 was characterized as depleted of genetic information processing,as well as of modules related to glycan biosynthesis and metabolism.Patients in Cluster_2 had more severe gastrointestinal symptoms and a higher rate of previous endoscopic variceal ligation(EVL)therapy than patients in other clusters.Our findings suggest that the colonization of both H.pylori and non-H.pylori is influenced in liver cirrhosis.Although the H.pylori-negative gastric mucosal microbiota showed considerable heterogeneity,associations between specific gastric microbiota and clinical characteristics could be observed.Previous EVL therapy might lead to a distinct structure of the gastric mucosal microbiota,thus aggravating the gastrointestinal symptoms in H.pylori-negative cirrhotic patients.
文摘AIM To summarize and critically examine the role of band ligation in secondary prophylaxis of variceal bleeding in patients with cirrhosis. METHODS A literature review was performed using the MEDLINE and PubM ed databases. The search terms consisted of the words "endoscopic band ligation" OR "variceal band ligation" OR "ligation" AND "secondary prophylaxis" OR "secondary prevention" AND "variceal bleeding" OR "variceal hemorrhage" AND "liver cirrhosis". The data collected from relevant meta-analyses and from the most recent randomized studies that were not included in these meta-analyses were used to evaluate the role of endoscopic band ligation in an effort to demonstrate the most recent advances in the treatment of esophageal varices. RESULTS This study included 11 meta-analyses published from 2002 to 2017 and 10 randomized trials published from 2010 to 2017 that evaluated the efficacy of band ligation in the secondary prophylaxis of variceal bleeding. Overall, the results proved that band ligation was superior to endoscopic sclerotherapy. Moreover, the use of β-blockers in combination with band ligation increased the treatment effectiveness, supporting the current recommendations for secondary prophylaxis of variceal bleeding. The use of transjugular intrahepatic portosystemic shunt was superior to combination therapy regarding rebleeding prophylaxis, with no difference in the survival rates; however, the results concerning the hepatic encephalopathy incidence were conflicting. Recent advances in the management of secondary prophylaxis of variceal bleeding have targeted a decrease in portal pressure based on the pathophysiological mechanisms of portal hypertension.CONCLUSION This review suggests that future research should be conducted to enhance current interventions and/or to develop innovative treatment options with improved clinical endpoints.
文摘BACKGROUND Proton pump inhibitors(PPIs)are widely prescribed,often without clear indications.There are conflicting data on its association with mortality risk and hepatic decompensation in cirrhotic patients.Furthermore,PPI users and PPI exposure in some studies have been poorly defined with many confounding factors.AIM To examine if PPI use increases mortality and hepatic decompensation and the impact of cumulative PPI dose exposure.METHODS Data from patients with decompensated liver cirrhosis were extracted from a hospital database between 2013 to 2017.PPI users were defined as cumulative defined daily dose(cDDD)≥28 within a landmark period,after hospitalisation for hepatic decompensation.Cox regression analysis for comparison was done after propensity score adjustment.Further risk of hepatic decompensation was analysed by Poisson regression.RESULTS Among 295 decompensated cirrhosis patients,238 were PPI users and 57 were non-users.PPI users had higher mortality compared to non-users[adjusted HR=2.10,(1.20-3.67);P=0.009].Longer PPI use with cDDD>90 was associated with higher mortality,compared to non-users[aHR=2.27,(1.10-5.14);P=0.038].PPI users had a higher incidence of hospitalization for hepatic decompensation[aRR=1.61,(1.30-2.11);P<0.001].CONCLUSION PPI use in decompensated cirrhosis is associated with increased risk of mortality and hepatic decompensation.Longer PPI exposure with cDDD>90 increases the risk of mortality.
文摘Spontaneous porto-systemic shunts(SPSS)are frequent in liver cirrhosis and their prevalence increases as liver function deteriorates,probably as a consequence of worsening portal hypertension,but without achieving an effective protection against cirrhosis'complications.Several types of SPSS have been described in the literature,each one associated with different clinical manifestations.In particular,recurrent or persistent hepatic encephalopathy is more frequent in patients with splenorenal shunt,while the presence of gastric varices and consequently the incidence of variceal bleeding is more common in gastrorenal shunt.In the advanced stage,the presence of large SPSS can lead to the so called“portosystemic shunt syndrome”,characterized by a progressive deterioration of hepatic function,hepatic encephalopathy and,sometimes,portal vein thrombosis.The detection of SPSS in patients with liver cirrhosis is recommended in order to prevent or treat recurrent hepatic encephalopathy or variceal bleeding.
文摘Nowadays,transjugular intrahepatic portosystemic shunt(TIPS)has become a mainstay treatment option for the management of portal hypertension-related complications in liver cirrhosis.Accumulated evidence has shown that its indications are being gradually expanded.Notwithstanding,less attention has been paid for the selection of an appropriate stent during a TIPS procedure.Herein,we attempt to review the current evidence regarding the diameter,type,brand,and position of TIPS stents.Several following recommendations may be considered in the clinical practice:(1)a 10-mm stent may be more effective than an 8-mm stent for the management of portal hypertension,and may be superior to a 12-mm stent for the improvement of survival and shunt patency;(2)covered stents are superior to bare stents for reducing the development of shunt dysfunction;(3)if available,Viatorr stent-grafts may be recommended due to a higher rate of shunt patency;and(4)the placement of a TIPS stent in the left portal vein branch may be more reasonable for decreasingthe development of hepatic encephalopathy.However,given relatively low quality of evidence,prospective well-designed studies should be warranted to further confirm these recommendations.
文摘Hepatic venous pressure gradient(HVPG)is an independent predictor of variceal rebleeding in patients with cirrhosis.After pharmacological and/or endoscopic therapy,the use of a transjugular intrahepatic portosystemic shunt(TIPS)may be necessary in HVPG non-responders,but not in responders.Thus,HVPG measurement may be incorporated into the treatment algorithm for acute variceal bleeding,which further identifies the candidates that should undergo early insertion of TIPS or maintain the traditional pharmacological and/or endoscopic therapy.The potential benefits are to reduce the cost and prevent TIPS-related complications.
文摘AIM: To develop a technique of combined endoscopic sclerotherapy and ligation (ESL) in which both techniques of endoscopic sclerotherapy (ES) and endoscopic variceal ligation (EVL) can be optimally used.METHODS: ESL was performed in 10 patients (age 46.4±7.9;9 males, 1 female) with cirrhosis of liver using sclerotherapy needle and Speedband, Superview multiple band ligater (Boston Scientific, Microvasive, Watertown, MA). A single band was placed 5-10 cm proximal to the gastro-esophageal junction over each varix from proximal to distal margin,followed by intravariceal injection of 1.5 % ethoxysclerol (4 ml each) 2 to 3 cm proximal to the gastroesophageal junction on the ligated varices distal to deployed band. EVL was then performed at the injection site. Similarly other varices were also injected and ligated from distal to proximally. In the subsequent sessions, ES alone was performed to sclerose small varices at the gastroesophageal junction.RESULTS: ESL was successfully performed in all patients.A median of 3 (ESL 1, ES 2) sessions (ranged 1-4) were required to eradicate the varices in 9 (90 %) of 10 patients.Recurrence of varices without bleed was seen in 1 patient during a mean follow-up of 10.3 months (ranged 6-15).Two patients died of liver failure. None died of variceal bleeding. None of the patients had procedure related complications.CONCLUSION: ESL may be useful in the fast eradication of esophageal varices. However, randomised controlled trials are required to find out its relative efficacy and impact on variceal recurrence in comparison to ES or EVL.