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
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
AIM:To determine the clinical value of a splenorenal shunt plus pericardial devascularization(PCVD)in portal hypertension(PHT)patients with variceal bleeding.METHODS:From January 2008 to November 2012,290 patients wit...AIM:To determine the clinical value of a splenorenal shunt plus pericardial devascularization(PCVD)in portal hypertension(PHT)patients with variceal bleeding.METHODS:From January 2008 to November 2012,290 patients with cirrhotic portal hypertension were treated surgically in our department for the prevention of gastroesophageal variceal bleeding:207 patients received a routine PCVD procedure(PCVD group),and83 patients received a PCVD plus a splenorenal shunt procedure(combined group).Changes in hemodynamic parameters,rebleeding,encephalopathy,portal vein thrombosis,and mortality were analyzed.RESULTS:The free portal pressure decreased to 21.43±4.35 mmHg in the combined group compared with24.61±5.42 mmHg in the PCVD group(P<0.05).The changes in hemodynamic parameters were more significant in the combined group(P<0.05).The long-term rebleeding rate was 7.22%in the combined group,which was lower than that in the PCVD group(14.93%),(P<0.05).CONCLUSION:Devascularization plus splenorenal shunt is an effective and safe strategy to control esophagogastric variceal bleeding in PHT.It should be recommended as a first-line treatment for preventing bleeding in PHT patients when surgical interventions are considered.展开更多
Purpose: To investigate the influence of meteorological factors on the esophagogastric variceal bleeding. The rhythmicity and variation mechanism of the onset of esophagogastric variceal bleeding were determined by la...Purpose: To investigate the influence of meteorological factors on the esophagogastric variceal bleeding. The rhythmicity and variation mechanism of the onset of esophagogastric variceal bleeding were determined by large sample study. Methods: 572 patients with esophagogastric variceal bleeding confirmed by endoscopy were enrolled in the study, and the gender, age, onset date and Child-Pugh grading of liver function were recorded, the meteorological data were provided by the Shiyan Meteorological Bureau, which included temperature, air pressure, air speed, precipitation, sunshine duration and so on. Results: The onset numbers in the four seasons were 130, 122, 144 and 176, respectively, and differences of the onset number in different seasons were significant (X2 = 11.888, p = 0.008), and the onset number in winter reached to maximum, while it decreased to minimum in summer. The results of Child-Pugh grading were as follows: Grade A 113 (19.8%), Grade B 234 (40.9%), and Grade C 225 (39.3%). There was no significance among the different grades by crosstabs analysis (X2 = 4.463, p = 0.107). The Spearman correlation analysis concluded the result of (r > 0 and p ?C accumulated temperature. The p value was more than0.01 inthe other factors. Conclusion: The onset of esophagogastric variceal bleeding was rhythmical, which rose to the maximum in winter and decreased to minimum in summer. The onset of the disease correlated positively with daily air pressure (mean, maximal, minimal), daily mean temperature, ten days’ air pressure (mean, daily difference, maximal, minimal and range) and ten days’ temperature range, and correlated negatively with daily maximal temperature, daily minimal temperature, ten days’ temperature (mean, maximal and minimal) and ten days’ ≥0°C accumulated temperature, and had no relationship with other factors. The mechanism of the onset may associate with the increase of portal venous flow through vasoconstriction induced by chill factors. It also may be the variation of air pressure which influenced the intraesophageal pressure and led to intraesophageal hemangiectasia that may increase the risk of bleeding.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
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
This letter to the editor relates to the study entitled“The role of computed tomography for the prediction of esophageal variceal bleeding:Current status and future perspectives”.Esophageal variceal bleeding(EVB)is ...This letter to the editor relates to the study entitled“The role of computed tomography for the prediction of esophageal variceal bleeding:Current status and future perspectives”.Esophageal variceal bleeding(EVB)is one of the most common and severe complications related to portal hypertension(PH).Despite marked advances in its management during the last three decades,EVB is still associated with significant morbidity and mortality.The risk of first EVB is related to the severity of both PH and liver disease,and to the size and endoscopic appearance of esophageal varices.Indeed,hepatic venous pressure gradient(HVPG)and esophagogastroduodenoscopy(EGD)are currently recognized as the“gold standard”and the diagnostic reference standard for the prediction of EVB,respectively.However,HVPG is an invasive,expensive,and technically complex procedure,not widely available in clinical practice,whereas EGD is mainly limited by its invasive nature.In this scenario,computed tomography(CT)has been recently proposed as a promising modality for the non-invasive prediction of EVB.While CT serves solely as a diagnostic tool and cannot replace EGD or HVPG for delivering therapeutic and physiological information,it has the potential to enhance the prediction of EVB more effectively when combined with liver disease scores,HVPG,and EGD.However,to date,evidence concerning the role of CT in this setting is still lacking,therefore we aim to summarize and discuss the current evidence concerning the role of CT in predicting the risk of EVB.展开更多
In this editorial we comment on the in-press article in the World Journal of Gastrointestinal endoscopy about the role of computed tomography(CT)for the prediction of esophageal variceal bleeding.The mortality and mor...In this editorial we comment on the in-press article in the World Journal of Gastrointestinal endoscopy about the role of computed tomography(CT)for the prediction of esophageal variceal bleeding.The mortality and morbidity are much increased in patients with chronic liver diseases when complicated with variceal bleeding.Predicting the patient at a risk of bleeding is extremely important and receives a great deal of attention,paving the way for primary prophylaxis either using medical treatment including carvedilol or propranolol,or endoscopic band ligation.Endoscopic examination and the hepatic venous pressure gradient are the gold standards in the diagnosis and prediction of variceal bleeding.Several non-invasive laboratory and radiological examinations are used for the prediction of variceal bleeding.The contrast-enhanced multislice CT is a widely used non-invasive,radiological examination that has many advantages.In this editorial we briefly comment on the current research regarding the use of CT as a non-invasive tool in predicting the variceal bleeding.展开更多
In this editorial,we comment on the minireview by Martino A,published in the recent issue of World Journal of Gastrointestinal Endoscopy 2023;15(12):681-689.We focused mainly on the possibility of replacing the hepati...In this editorial,we comment on the minireview by Martino A,published in the recent issue of World Journal of Gastrointestinal Endoscopy 2023;15(12):681-689.We focused mainly on the possibility of replacing the hepatic venous pressure gradient(HVPG)and endoscopy with noninvasive methods for predicting esophageal variceal bleeding.The risk factors for bleeding were the size of the varices,the red sign and the Child-Pugh score.The intrinsic core factor that drove these changes was the HVPG.Therefore,the present studies investigating noninvasive methods,including computed tomography,magnetic resonance imaging,elastography,and laboratory tests,are working on correlating imaging or serum marker data with intravenous pressure and clinical outcomes,such as bleeding.A single parameter is usually not enough to construct an efficient model.Therefore,multiple factors were used in most of the studies to construct predictive models.Encouraging results have been obtained,in which bleeding prediction was partly reached.However,these methods are not satisfactory enough to replace invasive methods,due to the many drawbacks of different studies.There is still plenty of room for future improvement.Prediction of the precise timing of bleeding using various models,and extracting the texture of variceal walls using high-definition imaging modalities to predict the red sign are interesting directions to lay investment on.展开更多
BACKGROUND Esophageal-gastro varices bleeding(EGVB)is the most widely known cause of mortality in individuals with cirrhosis,with an occurrence rate of 5%to 15%.Among them,gastric varices bleeding(GVB)is less frequent...BACKGROUND Esophageal-gastro varices bleeding(EGVB)is the most widely known cause of mortality in individuals with cirrhosis,with an occurrence rate of 5%to 15%.Among them,gastric varices bleeding(GVB)is less frequent than esophageal varices bleeding(EVB),but the former is a more critical illness and has a higher mortality rate.At present,endoscopic variceal histoacryl injection therapy(EVHT)is safe and effective,and it has been recommended by relevant guidelines as the primary method for the treatment of GVB.However,gastric varices after endoscopic treatment still have a high rate of early rebleeding,which is mainly related to complications of its treatment,such as bleeding from drained ulcers,rebleeding of varices etc.Therefore,preventing early postoperative rebleeding is very important to improve the quality of patient survival and outcomes.AIM To assess the efficacy of aluminium phosphate gel(APG)combined with proton pump inhibitor(PPI)in preventing early rebleeding after EVHT in individuals with GVB.METHODS Medical history of 196 individuals with GVB was obtained who were diagnosed using endoscopy and treated with EVHT in Shenzhen People's Hospital from January 2016 to December 2021.Based on the selection criteria,101 patients were sorted into the PPI alone treatment group,and 95 patients were sorted into the PPI combined with the APG treatment group.The incidences of early rebleeding and corresponding complications within 6 wk after treatment were compared between both groups.Statistical methods were performed by two-sample t-test,Wilcoxon rank sum test andχ2 test.RESULTS No major variations were noted between the individuals of the two groups in terms of age,gender,Model for End-Stage Liver Disease score,coagulation function,serum albumin,hemoglobin,type of gastric varices,the dose of tissue glue injection and EV that needed to be treated simultaneously.The early rebleeding rate in PPI+APG group was 3.16%(3/95),which was much lower than that in the PPI group(12.87%,13/101)(P=0.013).Causes of early rebleeding:the incidence of gastric ulcer bleeding in the PPI+APG group was 2.11%(2/95),which was reduced in comparison to that in the PPI group(11.88%,12/101)(P=0.008);the incidence of venous bleeding in PPI+APG group and PPI group was 1.05%(1/95)and 0.99%(1/101),respectively,and there was no significant difference between them(0.999).The early mortality rate was 0 in both groups within 6 wk after the operation,and the low mortality rate was related to the timely hospitalization and active treatment of all patients with rebleeding.The overall incidence of complications in the PPI+APG group was 12.63%(12/95),which was not significantly different from 13.86%(14/101)in the PPI group(P=0.800).of abdominal pain in the PPI+APG group was 3.16%(3/95),which was lower than that in the PPI group(11.88%,12/101)(P=0.022).However,due to aluminum phosphate gel usage,the incidence of constipation in the PPI+APG group was 9.47%(9/95),which was higher than that in the PPI group(1.98%,2/101)(P=0.023),but the health of the patients could be improved by increasing drinking water or oral lactulose.No patients in either group developed spontaneous peritonitis after taking PPI,and none developed hepatic encephalopathy and ectopic embolism within 6 wk of EVHT treatment.CONCLUSION PPI combined with APG can significantly reduce the incidence of early rebleeding and postoperative abdominal pain in cirrhotic patients with GVB after taking EVHT.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 bleedi...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
Esophageal variceal bleeding(EVB)is one of the most common and severe complications related to portal hypertension(PH).Despite marked advances in its management during the last three decades,EVB is still associated wi...Esophageal variceal bleeding(EVB)is one of the most common and severe complications related to portal hypertension(PH).Despite marked advances in its management during the last three decades,EVB is still associated with significant morbidity and mortality.The risk of first EVB is related to the severity of both PH and liver disease,and to the size and endoscopic appearance of esophageal varices.Indeed,hepatic venous pressure gradient(HVPG)and esophagogastroduodenoscopy(EGD)are currently recognized as the“gold standard”and the diagnostic reference standard for the prediction of EVB,respectively.However,HVPG is an invasive,expensive,and technically complex procedure,not widely available in clinical practice,whereas EGD is mainly limited by its invasive nature.In this scenario,computed tomography(CT)has been recently proposed as a promising modality for the non-invasive prediction of EVB.Although CT is only a diagnostic modality,thus being not capable of supplanting EGD or HVPG in providing therapeutic and physiological data,it could potentially assist liver disease scores,HVPG,and EGD in a more effective prediction of EVB.However,to date,evidence concerning the role of CT in this setting is still lacking.Our review aimed to summarize and discuss the current evidence concerning the role of CT in predicting the risk of EVB.展开更多
BACKGROUND Upper gastrointestinal bleeding(UGIB)is defined as bleeding that occurs proximal to the ligament of Treitz and can sometimes lead to potentially serious and life-threatening clinical situations in children....BACKGROUND Upper gastrointestinal bleeding(UGIB)is defined as bleeding that occurs proximal to the ligament of Treitz and can sometimes lead to potentially serious and life-threatening clinical situations in children.Globally,the cause of UGIB differs significantly depending on the geographic location,patient population and presence of comorbid conditions.AIM To observe endoscopic findings of UGIB in children at a tertiary care center of Bangladesh.METHODS This retrospective study was carried out in the department of Pediatric Gastroenterology and Nutrition of Bangabandhu Shiekh Mujib Medical University,a tertiary care hospital of Bangladesh,between January 2017 and January 2019.Data collected from hospital records of 100 children who were 16 years of age or younger,came with hematemesis,melena or both hematemesis and melena.All patients underwent upper gastrointestinal endoscopy(Olympus CV 1000 upper gastrointestinal video endoscope)after initial stabilization.Necessary investigations to diagnose portal hypertension and chronic liver disease with underlying causes for management purposes were also done.RESULTS A total of 100 patients were studied.UGIB was common in the age group 5-10 years(42%),followed by above 10 years(37%).Hematemesis was the most common presenting symptom(75%)followed by both hematemesis and melena(25%).UGIB from ruptured esophageal varices was the most common cause(65%)on UGI endoscopy followed by gastric erosion(5%)and prolapsed gastropathy(2%).We observed that 23%of children were normal after endoscopic examination.CONCLUSION Ruptured esophageal varices were the most common cause of UGIB in children in Bangladesh.Other causes included gastric erosions and prolapsed gastropathy syndrome.展开更多
AIM:To compare the efficacy of modified percutaneous transhepatic variceal embolization(PTVE)with 2-octyl-cyanoacrylate(2-OCA)and endoscopic variceal obturation(EVO)with an injection of 2-OCA for prophylaxis of gastri...AIM:To compare the efficacy of modified percutaneous transhepatic variceal embolization(PTVE)with 2-octyl-cyanoacrylate(2-OCA)and endoscopic variceal obturation(EVO)with an injection of 2-OCA for prophylaxis of gastric variceal rebleeding. METHODS:In this retrospective study,the medical records of liver cirrhosis patients with gastric variceal bleeding who underwent either endoscopic 2-OCA(EVO) or modified PTVE using 2-OCA at Shandong Provincial Hospital from January 2006 to December 2008 were reviewed.Patient demographics,rebleeding rate,survival rate,and complications were compared between the two groups(PTVE and EVO).All results were expressed as mean±SD,or as a percentage.Quantitative variables were compared by two sample Student t tests, and qualitative variables were compared by the Fisher exact test or theχ 2 test(with Yates correction)where appropriate.A P value less than 0.05 was considered significant.Statistical computation was performed using SPSS 13.0 software. RESULTS:A total of 77 patients were included;45 patients who underwent EVO and 32 patients who received PTVE.During the follow-up(19.78±7.70 mo in the EVO group,vs 21.53±8.56 mo in the PTVE group) rebleeding occurred in 17 patients in the EVO group and in 4 patients in the PTVE group(37.78%vs 12.5%, P=0.028).The cumulative rebleeding-free rate was 75%,59%,and 49%in 1,2,and 3 years respectively for EVO,and 93%,84%,and 84%for PTVE(P=0.011). Cox analysis was used to identify independent factors that predicted rebleeding after treatment.Variables including age,gender,cause,Child-Pugh classification, size of gastric varices(GV),location of GV,and treatment methods were analyzed.It was revealed that Child-Pugh classification[risk ratio(RR)2.10,95%CI:1.03-4.28,P=0.040],choice of treatment(RR 0.25, 95%CI:0.08-0.80,P=0.019),and size of GV(RR 2.14, 95%CI:1.07-4.28,P=0.032)were the independent factors for predicting rebleeding.Follow-up computed tomography revealed that cyanoacrylate was retained in the varices and in the feeding veins of PTVE patients. During the follow-up,eight patients in the EVO group and four patients in the PTVE group died.The cumulative survival rates at 1,2,and 3 years were 93%,84%, and 67%respectively in the EVO group,and 97%, 88%,and 74%respectively in the PTVE group.The survival rates were not significantly different between the two groups(P=0.432).Cox analysis showed that the Child-Pugh classification was the most significant prognostic factor of survival(RR 2.77,95%CI:1.12-6.80,P=0.027).The incidence of complications was similar in both groups. CONCLUSION:With extensive and permanent obliteration of gastric varices and its feeding veins,PTVE with 2-OCA is superior to endoscopic 2-OCA injection for preventing gastric variceal rebleeding.展开更多
Management of acute variceal bleeding has greatly improved over recent years. Available data indicates that general management of the bleeding cirrhotic patient by an experienced multidisciplinary team plays a major r...Management of acute variceal bleeding has greatly improved over recent years. Available data indicates that general management of the bleeding cirrhotic patient by an experienced multidisciplinary team plays a major role in the f inal outcome of this complication. It is currently recommended to combine pharmacological and endoscopic therapies for the initial treatment of the acute bleeding. Vasoactive drugs (preferable somatostatin or terlipressin) should be started as soon as a variceal bleeding is suspected (ideally during transfer to hospital) and maintained afterwards for 2-5 d. After stabilizing the patient with cautious fluid and blood support, an emergency diagnostic endoscopy should be done and, as soon as a skilled endoscopist is available, an endoscopic variceal treatment (ligation as f irst choice, sclerotherapy if endoscopic variceal ligation not feasible) should be performed. Antibiotic prophylaxis must be regarded as an integral part of the treatment of acute variceal bleeding and should be started at admission and maintained for at least 7 d. In case of failure to control the acute bleeding, rescue therapies should be immediately started. Shunt therapies (especially tran sjugular intrahepatic portosystemic shunt) are very effective at controlling treatment failures after an acute variceal bleeding. Therapeutic developments and increasing knowledge in the prognosis of this complication may allow optimization of the management strategy by adapting the different treatments to the expected risk of complications for each patient in the near future. Theoretically, this approach would allow the initiation of early aggressive treatments in high-risk patients and spare low-risk individuals unnecessary proce dures. Current research efforts will hopefully clarify this hypothesis and help to further improve the outcomes of the severe complication of cirrhosis.展开更多
AIM:To investigate the effect of antiviral therapy with nucleoside analogs in hepatitis B virus(HBV)-related cirrhosis and esophageal varices.METHODS:Eligible patients with HBV-related cirrhosis and esophageal varices...AIM:To investigate the effect of antiviral therapy with nucleoside analogs in hepatitis B virus(HBV)-related cirrhosis and esophageal varices.METHODS:Eligible patients with HBV-related cirrhosis and esophageal varices who consulted two tertiary hospitals in Beijing,China,the Chinese Second Artillery General Hospital and Chinese PLA General Hospital,were enrolled in the study from January 2005 to December 2009. Of 117 patients,79 received treatment with different nucleoside analogs and 38 served as controls. Bleeding rate,change in variceal grade and non-bleeding duration were analyzed. Multivariate Cox proportional hazard regression was used to identify factors related to esophageal variceal bleeding.antiviral group compared to the control group(29.1%vs 65.8%,P < 0.001). Antiviral therapy was an independent factor related to esophageal bleeding in multivariate analysis(HR = 11.3,P < 0.001). The mean increase in variceal grade per year was lower in the antiviral group(1.0 ± 1.3 vs 1.7 ± 1.2,P = 0.003). Nonbleeding duration in the antiviral group was prolonged in the Kaplan-Meier model. Viral load rebound was observed in 3 cases in the lamivudine group and in 1 case in the adefovir group,all of whom experienced bleeding. Entecavir and adefovir resulted in lower bleeding rates(17.2% and 28.6%,respectively) than the control(P < 0.001 and P = 0.006,respectively),whereas lamivudine(53.3%) did not(P = 0.531).CONCLUSION:Antiviral therapy delays the progression of esophageal varices and reduces bleeding risk in HBV-related cirrhosis,however,high-resistance agents tend to be ineffective for long-term treatment.展开更多
BACKGROUND Acute variceal bleeding is one of the deadliest complications of cirrhosis,with a high risk of in-hospital rebleeding and mortality.Some risk scoring systems to predict clinical outcomes in patients with up...BACKGROUND Acute variceal bleeding is one of the deadliest complications of cirrhosis,with a high risk of in-hospital rebleeding and mortality.Some risk scoring systems to predict clinical outcomes in patients with upper gastrointestinal bleeding have been developed.However,for cirrhotic patients with variceal bleeding,data regarding the predictive value of these prognostic scores in predicting in-hospital outcomes are limited and controversial.AIM To validate and compare the overall performance of selected prognostic scoring systems for predicting in-hospital outcomes in cirrhotic patients with variceal bleeding.METHODS From March 2017 to June 2019,cirrhotic patients with acute variceal bleeding were retrospectively enrolled at the Second Affiliated Hospital of Xi’an Jiaotong University.The clinical Rockall score(CRS),AIMS65 score(AIMS65),Glasgow-Blatchford score(GBS),modified GBS(mGBS),Canada-United Kingdom-Australia score(CANUKA),Child-Turcotte-Pugh score(CTP),model for endstage liver disease(MELD)and MELD-Na were calculated.The overall performance of these prognostic scoring systems was evaluated.RESULTS A total of 330 cirrhotic patients with variceal bleeding were enrolled;the rates of in-hospital rebleeding and mortality were 20.3%and 10.6%,respectively.For inhospital rebleeding,the discriminative ability of the CTP and CRS were clinically acceptable,with area under the receiver operating characteristic curves(AUROCs)of 0.717(0.648-0.787)and 0.716(0.638-0.793),respectively.The other tested scoring systems had poor discriminative ability(AUROCs<0.7).For inhospital mortality,the CRS,CTP,AIMS65,MELD-Na and MELD showed excellent discriminative ability(AUROCs>0.8).The AUROCs of the mGBS,CANUKA and GBS were relatively small,but clinically acceptable(AUROCs>0.7).Furthermore,the calibration of all scoring systems was good for either inhospital rebleeding or death.CONCLUSION For cirrhotic patients with variceal bleeding,in-hospital rebleeding and mortality rates remain high.The CTP and CRS can be used clinically to predict in-hospital rebleeding.The performances of the CRS,CTP,AIMS65,MELD-Na and MELD are excellent at predicting in-hospital mortality.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
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.
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.
文摘AIM:To determine the clinical value of a splenorenal shunt plus pericardial devascularization(PCVD)in portal hypertension(PHT)patients with variceal bleeding.METHODS:From January 2008 to November 2012,290 patients with cirrhotic portal hypertension were treated surgically in our department for the prevention of gastroesophageal variceal bleeding:207 patients received a routine PCVD procedure(PCVD group),and83 patients received a PCVD plus a splenorenal shunt procedure(combined group).Changes in hemodynamic parameters,rebleeding,encephalopathy,portal vein thrombosis,and mortality were analyzed.RESULTS:The free portal pressure decreased to 21.43±4.35 mmHg in the combined group compared with24.61±5.42 mmHg in the PCVD group(P<0.05).The changes in hemodynamic parameters were more significant in the combined group(P<0.05).The long-term rebleeding rate was 7.22%in the combined group,which was lower than that in the PCVD group(14.93%),(P<0.05).CONCLUSION:Devascularization plus splenorenal shunt is an effective and safe strategy to control esophagogastric variceal bleeding in PHT.It should be recommended as a first-line treatment for preventing bleeding in PHT patients when surgical interventions are considered.
文摘Purpose: To investigate the influence of meteorological factors on the esophagogastric variceal bleeding. The rhythmicity and variation mechanism of the onset of esophagogastric variceal bleeding were determined by large sample study. Methods: 572 patients with esophagogastric variceal bleeding confirmed by endoscopy were enrolled in the study, and the gender, age, onset date and Child-Pugh grading of liver function were recorded, the meteorological data were provided by the Shiyan Meteorological Bureau, which included temperature, air pressure, air speed, precipitation, sunshine duration and so on. Results: The onset numbers in the four seasons were 130, 122, 144 and 176, respectively, and differences of the onset number in different seasons were significant (X2 = 11.888, p = 0.008), and the onset number in winter reached to maximum, while it decreased to minimum in summer. The results of Child-Pugh grading were as follows: Grade A 113 (19.8%), Grade B 234 (40.9%), and Grade C 225 (39.3%). There was no significance among the different grades by crosstabs analysis (X2 = 4.463, p = 0.107). The Spearman correlation analysis concluded the result of (r > 0 and p ?C accumulated temperature. The p value was more than0.01 inthe other factors. Conclusion: The onset of esophagogastric variceal bleeding was rhythmical, which rose to the maximum in winter and decreased to minimum in summer. The onset of the disease correlated positively with daily air pressure (mean, maximal, minimal), daily mean temperature, ten days’ air pressure (mean, daily difference, maximal, minimal and range) and ten days’ temperature range, and correlated negatively with daily maximal temperature, daily minimal temperature, ten days’ temperature (mean, maximal and minimal) and ten days’ ≥0°C accumulated temperature, and had no relationship with other factors. The mechanism of the onset may associate with the increase of portal venous flow through vasoconstriction induced by chill factors. It also may be the variation of air pressure which influenced the intraesophageal pressure and led to intraesophageal hemangiectasia that may increase the risk of bleeding.
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.
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This letter to the editor relates to the study entitled“The role of computed tomography for the prediction of esophageal variceal bleeding:Current status and future perspectives”.Esophageal variceal bleeding(EVB)is one of the most common and severe complications related to portal hypertension(PH).Despite marked advances in its management during the last three decades,EVB is still associated with significant morbidity and mortality.The risk of first EVB is related to the severity of both PH and liver disease,and to the size and endoscopic appearance of esophageal varices.Indeed,hepatic venous pressure gradient(HVPG)and esophagogastroduodenoscopy(EGD)are currently recognized as the“gold standard”and the diagnostic reference standard for the prediction of EVB,respectively.However,HVPG is an invasive,expensive,and technically complex procedure,not widely available in clinical practice,whereas EGD is mainly limited by its invasive nature.In this scenario,computed tomography(CT)has been recently proposed as a promising modality for the non-invasive prediction of EVB.While CT serves solely as a diagnostic tool and cannot replace EGD or HVPG for delivering therapeutic and physiological information,it has the potential to enhance the prediction of EVB more effectively when combined with liver disease scores,HVPG,and EGD.However,to date,evidence concerning the role of CT in this setting is still lacking,therefore we aim to summarize and discuss the current evidence concerning the role of CT in predicting the risk of EVB.
文摘In this editorial we comment on the in-press article in the World Journal of Gastrointestinal endoscopy about the role of computed tomography(CT)for the prediction of esophageal variceal bleeding.The mortality and morbidity are much increased in patients with chronic liver diseases when complicated with variceal bleeding.Predicting the patient at a risk of bleeding is extremely important and receives a great deal of attention,paving the way for primary prophylaxis either using medical treatment including carvedilol or propranolol,or endoscopic band ligation.Endoscopic examination and the hepatic venous pressure gradient are the gold standards in the diagnosis and prediction of variceal bleeding.Several non-invasive laboratory and radiological examinations are used for the prediction of variceal bleeding.The contrast-enhanced multislice CT is a widely used non-invasive,radiological examination that has many advantages.In this editorial we briefly comment on the current research regarding the use of CT as a non-invasive tool in predicting the variceal bleeding.
文摘In this editorial,we comment on the minireview by Martino A,published in the recent issue of World Journal of Gastrointestinal Endoscopy 2023;15(12):681-689.We focused mainly on the possibility of replacing the hepatic venous pressure gradient(HVPG)and endoscopy with noninvasive methods for predicting esophageal variceal bleeding.The risk factors for bleeding were the size of the varices,the red sign and the Child-Pugh score.The intrinsic core factor that drove these changes was the HVPG.Therefore,the present studies investigating noninvasive methods,including computed tomography,magnetic resonance imaging,elastography,and laboratory tests,are working on correlating imaging or serum marker data with intravenous pressure and clinical outcomes,such as bleeding.A single parameter is usually not enough to construct an efficient model.Therefore,multiple factors were used in most of the studies to construct predictive models.Encouraging results have been obtained,in which bleeding prediction was partly reached.However,these methods are not satisfactory enough to replace invasive methods,due to the many drawbacks of different studies.There is still plenty of room for future improvement.Prediction of the precise timing of bleeding using various models,and extracting the texture of variceal walls using high-definition imaging modalities to predict the red sign are interesting directions to lay investment on.
基金Supported by Clinical Research and Cultivation Project of Shenzhen People's Hospital,No.SYLCYJ202116.
文摘BACKGROUND Esophageal-gastro varices bleeding(EGVB)is the most widely known cause of mortality in individuals with cirrhosis,with an occurrence rate of 5%to 15%.Among them,gastric varices bleeding(GVB)is less frequent than esophageal varices bleeding(EVB),but the former is a more critical illness and has a higher mortality rate.At present,endoscopic variceal histoacryl injection therapy(EVHT)is safe and effective,and it has been recommended by relevant guidelines as the primary method for the treatment of GVB.However,gastric varices after endoscopic treatment still have a high rate of early rebleeding,which is mainly related to complications of its treatment,such as bleeding from drained ulcers,rebleeding of varices etc.Therefore,preventing early postoperative rebleeding is very important to improve the quality of patient survival and outcomes.AIM To assess the efficacy of aluminium phosphate gel(APG)combined with proton pump inhibitor(PPI)in preventing early rebleeding after EVHT in individuals with GVB.METHODS Medical history of 196 individuals with GVB was obtained who were diagnosed using endoscopy and treated with EVHT in Shenzhen People's Hospital from January 2016 to December 2021.Based on the selection criteria,101 patients were sorted into the PPI alone treatment group,and 95 patients were sorted into the PPI combined with the APG treatment group.The incidences of early rebleeding and corresponding complications within 6 wk after treatment were compared between both groups.Statistical methods were performed by two-sample t-test,Wilcoxon rank sum test andχ2 test.RESULTS No major variations were noted between the individuals of the two groups in terms of age,gender,Model for End-Stage Liver Disease score,coagulation function,serum albumin,hemoglobin,type of gastric varices,the dose of tissue glue injection and EV that needed to be treated simultaneously.The early rebleeding rate in PPI+APG group was 3.16%(3/95),which was much lower than that in the PPI group(12.87%,13/101)(P=0.013).Causes of early rebleeding:the incidence of gastric ulcer bleeding in the PPI+APG group was 2.11%(2/95),which was reduced in comparison to that in the PPI group(11.88%,12/101)(P=0.008);the incidence of venous bleeding in PPI+APG group and PPI group was 1.05%(1/95)and 0.99%(1/101),respectively,and there was no significant difference between them(0.999).The early mortality rate was 0 in both groups within 6 wk after the operation,and the low mortality rate was related to the timely hospitalization and active treatment of all patients with rebleeding.The overall incidence of complications in the PPI+APG group was 12.63%(12/95),which was not significantly different from 13.86%(14/101)in the PPI group(P=0.800).of abdominal pain in the PPI+APG group was 3.16%(3/95),which was lower than that in the PPI group(11.88%,12/101)(P=0.022).However,due to aluminum phosphate gel usage,the incidence of constipation in the PPI+APG group was 9.47%(9/95),which was higher than that in the PPI group(1.98%,2/101)(P=0.023),but the health of the patients could be improved by increasing drinking water or oral lactulose.No patients in either group developed spontaneous peritonitis after taking PPI,and none developed hepatic encephalopathy and ectopic embolism within 6 wk of EVHT treatment.CONCLUSION PPI combined with APG can significantly reduce the incidence of early rebleeding and postoperative abdominal pain in cirrhotic patients with GVB after taking EVHT.
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.
文摘Esophageal variceal bleeding(EVB)is one of the most common and severe complications related to portal hypertension(PH).Despite marked advances in its management during the last three decades,EVB is still associated with significant morbidity and mortality.The risk of first EVB is related to the severity of both PH and liver disease,and to the size and endoscopic appearance of esophageal varices.Indeed,hepatic venous pressure gradient(HVPG)and esophagogastroduodenoscopy(EGD)are currently recognized as the“gold standard”and the diagnostic reference standard for the prediction of EVB,respectively.However,HVPG is an invasive,expensive,and technically complex procedure,not widely available in clinical practice,whereas EGD is mainly limited by its invasive nature.In this scenario,computed tomography(CT)has been recently proposed as a promising modality for the non-invasive prediction of EVB.Although CT is only a diagnostic modality,thus being not capable of supplanting EGD or HVPG in providing therapeutic and physiological data,it could potentially assist liver disease scores,HVPG,and EGD in a more effective prediction of EVB.However,to date,evidence concerning the role of CT in this setting is still lacking.Our review aimed to summarize and discuss the current evidence concerning the role of CT in predicting the risk of EVB.
基金The study was reviewed and approved by the departmental Ethics Committee of the Department of Pediatric Gastroenterology and Nutrition of Bangabandhu Shiekh Mujib Medical University(Approval No.BSMMU/Ped.Gastro/2023/122).
文摘BACKGROUND Upper gastrointestinal bleeding(UGIB)is defined as bleeding that occurs proximal to the ligament of Treitz and can sometimes lead to potentially serious and life-threatening clinical situations in children.Globally,the cause of UGIB differs significantly depending on the geographic location,patient population and presence of comorbid conditions.AIM To observe endoscopic findings of UGIB in children at a tertiary care center of Bangladesh.METHODS This retrospective study was carried out in the department of Pediatric Gastroenterology and Nutrition of Bangabandhu Shiekh Mujib Medical University,a tertiary care hospital of Bangladesh,between January 2017 and January 2019.Data collected from hospital records of 100 children who were 16 years of age or younger,came with hematemesis,melena or both hematemesis and melena.All patients underwent upper gastrointestinal endoscopy(Olympus CV 1000 upper gastrointestinal video endoscope)after initial stabilization.Necessary investigations to diagnose portal hypertension and chronic liver disease with underlying causes for management purposes were also done.RESULTS A total of 100 patients were studied.UGIB was common in the age group 5-10 years(42%),followed by above 10 years(37%).Hematemesis was the most common presenting symptom(75%)followed by both hematemesis and melena(25%).UGIB from ruptured esophageal varices was the most common cause(65%)on UGI endoscopy followed by gastric erosion(5%)and prolapsed gastropathy(2%).We observed that 23%of children were normal after endoscopic examination.CONCLUSION Ruptured esophageal varices were the most common cause of UGIB in children in Bangladesh.Other causes included gastric erosions and prolapsed gastropathy syndrome.
文摘AIM:To compare the efficacy of modified percutaneous transhepatic variceal embolization(PTVE)with 2-octyl-cyanoacrylate(2-OCA)and endoscopic variceal obturation(EVO)with an injection of 2-OCA for prophylaxis of gastric variceal rebleeding. METHODS:In this retrospective study,the medical records of liver cirrhosis patients with gastric variceal bleeding who underwent either endoscopic 2-OCA(EVO) or modified PTVE using 2-OCA at Shandong Provincial Hospital from January 2006 to December 2008 were reviewed.Patient demographics,rebleeding rate,survival rate,and complications were compared between the two groups(PTVE and EVO).All results were expressed as mean±SD,or as a percentage.Quantitative variables were compared by two sample Student t tests, and qualitative variables were compared by the Fisher exact test or theχ 2 test(with Yates correction)where appropriate.A P value less than 0.05 was considered significant.Statistical computation was performed using SPSS 13.0 software. RESULTS:A total of 77 patients were included;45 patients who underwent EVO and 32 patients who received PTVE.During the follow-up(19.78±7.70 mo in the EVO group,vs 21.53±8.56 mo in the PTVE group) rebleeding occurred in 17 patients in the EVO group and in 4 patients in the PTVE group(37.78%vs 12.5%, P=0.028).The cumulative rebleeding-free rate was 75%,59%,and 49%in 1,2,and 3 years respectively for EVO,and 93%,84%,and 84%for PTVE(P=0.011). Cox analysis was used to identify independent factors that predicted rebleeding after treatment.Variables including age,gender,cause,Child-Pugh classification, size of gastric varices(GV),location of GV,and treatment methods were analyzed.It was revealed that Child-Pugh classification[risk ratio(RR)2.10,95%CI:1.03-4.28,P=0.040],choice of treatment(RR 0.25, 95%CI:0.08-0.80,P=0.019),and size of GV(RR 2.14, 95%CI:1.07-4.28,P=0.032)were the independent factors for predicting rebleeding.Follow-up computed tomography revealed that cyanoacrylate was retained in the varices and in the feeding veins of PTVE patients. During the follow-up,eight patients in the EVO group and four patients in the PTVE group died.The cumulative survival rates at 1,2,and 3 years were 93%,84%, and 67%respectively in the EVO group,and 97%, 88%,and 74%respectively in the PTVE group.The survival rates were not significantly different between the two groups(P=0.432).Cox analysis showed that the Child-Pugh classification was the most significant prognostic factor of survival(RR 2.77,95%CI:1.12-6.80,P=0.027).The incidence of complications was similar in both groups. CONCLUSION:With extensive and permanent obliteration of gastric varices and its feeding veins,PTVE with 2-OCA is superior to endoscopic 2-OCA injection for preventing gastric variceal rebleeding.
基金Supported partially by a Grant from Ministerio de Ciencia e Innovación SAF2009-08354Salvador Augustin is a recipient of a Río Hortega’ Fellowship Grant from the Instituto de Salud Carlos Ⅲ and is enrolled in the postgraduate programme of the Universitat Autònoma de Barcelona
文摘Management of acute variceal bleeding has greatly improved over recent years. Available data indicates that general management of the bleeding cirrhotic patient by an experienced multidisciplinary team plays a major role in the f inal outcome of this complication. It is currently recommended to combine pharmacological and endoscopic therapies for the initial treatment of the acute bleeding. Vasoactive drugs (preferable somatostatin or terlipressin) should be started as soon as a variceal bleeding is suspected (ideally during transfer to hospital) and maintained afterwards for 2-5 d. After stabilizing the patient with cautious fluid and blood support, an emergency diagnostic endoscopy should be done and, as soon as a skilled endoscopist is available, an endoscopic variceal treatment (ligation as f irst choice, sclerotherapy if endoscopic variceal ligation not feasible) should be performed. Antibiotic prophylaxis must be regarded as an integral part of the treatment of acute variceal bleeding and should be started at admission and maintained for at least 7 d. In case of failure to control the acute bleeding, rescue therapies should be immediately started. Shunt therapies (especially tran sjugular intrahepatic portosystemic shunt) are very effective at controlling treatment failures after an acute variceal bleeding. Therapeutic developments and increasing knowledge in the prognosis of this complication may allow optimization of the management strategy by adapting the different treatments to the expected risk of complications for each patient in the near future. Theoretically, this approach would allow the initiation of early aggressive treatments in high-risk patients and spare low-risk individuals unnecessary proce dures. Current research efforts will hopefully clarify this hypothesis and help to further improve the outcomes of the severe complication of cirrhosis.
文摘AIM:To investigate the effect of antiviral therapy with nucleoside analogs in hepatitis B virus(HBV)-related cirrhosis and esophageal varices.METHODS:Eligible patients with HBV-related cirrhosis and esophageal varices who consulted two tertiary hospitals in Beijing,China,the Chinese Second Artillery General Hospital and Chinese PLA General Hospital,were enrolled in the study from January 2005 to December 2009. Of 117 patients,79 received treatment with different nucleoside analogs and 38 served as controls. Bleeding rate,change in variceal grade and non-bleeding duration were analyzed. Multivariate Cox proportional hazard regression was used to identify factors related to esophageal variceal bleeding.antiviral group compared to the control group(29.1%vs 65.8%,P < 0.001). Antiviral therapy was an independent factor related to esophageal bleeding in multivariate analysis(HR = 11.3,P < 0.001). The mean increase in variceal grade per year was lower in the antiviral group(1.0 ± 1.3 vs 1.7 ± 1.2,P = 0.003). Nonbleeding duration in the antiviral group was prolonged in the Kaplan-Meier model. Viral load rebound was observed in 3 cases in the lamivudine group and in 1 case in the adefovir group,all of whom experienced bleeding. Entecavir and adefovir resulted in lower bleeding rates(17.2% and 28.6%,respectively) than the control(P < 0.001 and P = 0.006,respectively),whereas lamivudine(53.3%) did not(P = 0.531).CONCLUSION:Antiviral therapy delays the progression of esophageal varices and reduces bleeding risk in HBV-related cirrhosis,however,high-resistance agents tend to be ineffective for long-term treatment.
文摘BACKGROUND Acute variceal bleeding is one of the deadliest complications of cirrhosis,with a high risk of in-hospital rebleeding and mortality.Some risk scoring systems to predict clinical outcomes in patients with upper gastrointestinal bleeding have been developed.However,for cirrhotic patients with variceal bleeding,data regarding the predictive value of these prognostic scores in predicting in-hospital outcomes are limited and controversial.AIM To validate and compare the overall performance of selected prognostic scoring systems for predicting in-hospital outcomes in cirrhotic patients with variceal bleeding.METHODS From March 2017 to June 2019,cirrhotic patients with acute variceal bleeding were retrospectively enrolled at the Second Affiliated Hospital of Xi’an Jiaotong University.The clinical Rockall score(CRS),AIMS65 score(AIMS65),Glasgow-Blatchford score(GBS),modified GBS(mGBS),Canada-United Kingdom-Australia score(CANUKA),Child-Turcotte-Pugh score(CTP),model for endstage liver disease(MELD)and MELD-Na were calculated.The overall performance of these prognostic scoring systems was evaluated.RESULTS A total of 330 cirrhotic patients with variceal bleeding were enrolled;the rates of in-hospital rebleeding and mortality were 20.3%and 10.6%,respectively.For inhospital rebleeding,the discriminative ability of the CTP and CRS were clinically acceptable,with area under the receiver operating characteristic curves(AUROCs)of 0.717(0.648-0.787)and 0.716(0.638-0.793),respectively.The other tested scoring systems had poor discriminative ability(AUROCs<0.7).For inhospital mortality,the CRS,CTP,AIMS65,MELD-Na and MELD showed excellent discriminative ability(AUROCs>0.8).The AUROCs of the mGBS,CANUKA and GBS were relatively small,but clinically acceptable(AUROCs>0.7).Furthermore,the calibration of all scoring systems was good for either inhospital rebleeding or death.CONCLUSION For cirrhotic patients with variceal bleeding,in-hospital rebleeding and mortality rates remain high.The CTP and CRS can be used clinically to predict in-hospital rebleeding.The performances of the CRS,CTP,AIMS65,MELD-Na and MELD are excellent at predicting in-hospital mortality.
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.
