Emergency endoscopic variceal ligation in cirrhotic patients with blood clots in the stomach but no active bleeding or stigmata increases the risk of rebleeding
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Background/Aims: This study aimed to evaluate the efficacy and safety of emergency variceal ligation for the prevention of rebleeding in cirrhotic patients who are found on initial endoscopy to have blood clots in the stomach but no actively bleeding esophageal and gastric varices or stigmata. Methods: This study included 28 cirrhotic patients who underwent emergency prophylactic EVL and 41 who underwent an elective intervention between January 2009 and June 2014. Clinical outcomes were analyzed, including the rebleeding, 6-week mortality, and rebleeding-free survival rates. Results: The rebleeding rate was higher in the emergency than in the elective group (28.6% vs. 7.3%, P=0.041). Multivariate analysis showed that emergency prophylactic EVL (odds ratio [OR] = 7.4, 95% confidence interval [CI]=1.634.8, P=0.012) and Child-Pugh score C (OR=10.6, 95% CI=1.4-80.8, P=0.022) were associated with rebleeding. In the emergency group, the gastric varices were associated with rebleeding (OR=12.0, 95% CI=1.7-83.5, P=0.012). Conclusions: Emergency EVL may be associated with variceal rebleeding when blood clots are present in the stomach without active esophageal and gastric variceal bleeding or stigmata. Elective intervention should be considered as a safer strategy for preventing variceal rebleeding in this situation. (Clin Mol Hepatol 2016;22:466-476)
Abstract
Background/Aims: This study aimed to evaluate the efficacy and safety of emergency variceal ligation for the prevention of rebleeding in cirrhotic patients who are found on initial endoscopy to have blood clots in the stomach but no actively bleeding esophageal and gastric varices or stigmata. Methods: This study included 28 cirrhotic patients who underwent emergency prophylactic EVL and 41 who underwent an elective intervention between January 2009 and June 2014. Clinical outcomes were analyzed, including the rebleeding, 6-week mortality, and rebleeding-free survival rates. Results: The rebleeding rate was higher in the emergency than in the elective group (28.6% vs. 7.3%, P=0.041). Multivariate analysis showed that emergency prophylactic EVL (odds ratio [OR] = 7.4, 95% confidence interval [CI]=1.634.8, P=0.012) and Child-Pugh score C (OR=10.6, 95% CI=1.4-80.8, P=0.022) were associated with rebleeding. In the emergency group, the gastric varices were associated with rebleeding (OR=12.0, 95% CI=1.7-83.5, P=0.012). Conclusions: Emergency EVL may be associated with variceal rebleeding when blood clots are present in the stomach without active esophageal and gastric variceal bleeding or stigmata. Elective intervention should be considered as a safer strategy for preventing variceal rebleeding in this situation. (Clin Mol Hepatol 2016;22:466-476)
참고문헌 (31)
- Garcia-Tsao G, "Management of varices and variceal hemorrhage in cirrhosis", N Engl J Med, 362, pp.823~832 (2010)
- Garcia-Tsao G, "Practice Guidelines Committee of AASLD; Practice Parameters Committee of the ACG. Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis", Hepatology, 46, pp.922~938 (2007)
- D’Amico G, "Pharmacological treatment of portal hypertension: an evidence-based approach", Semin Liver Dis, 19, pp.475~505 (1999)
- Bosch J, "Prevention of variceal rebleeding", Lancet, 361, pp.952~954 (2003)
- de Franchis R, "Why do varices bleed?", Gastroenterol Clin North Am, 21, pp.85~101 (1992)
- de Franchis R, "Baveno V Faculty. Revising consensus in portal hypertension: report of the Baveno V consensus workshop on methodology of diagnosis and therapy in portal hypertension", J Hepatol, 53, pp.762~768 (2010)
- de Franchis R, "Definitions, methodology and therapeutic strategies in portal hypertension. A Consensus Development Workshop, Baveno, Lake Maggiore, Italy, April 5 and 6, 1990", J Hepatol, 15, pp.256~261 (1992)
- Triantos C, "Endoscopic treatment of esophageal varices in patients with liver cirrhosis", World J Gastroenterol, 20, pp.13015~13026 (2014)
- Kahloon A, "Endoscopic therapy with 2-octyl-cyanoacrylate for the treatment of gastric varices", Dig Dis Sci, 59, pp.2178~2183 (2014)
- Beppu K, "Prediction of variceal hemorrhage by esophageal endoscopy", Gastrointest Endosc, 27, pp.213~218 (1981)
- Altamirano J, "Predicting 6-week mortality after acute variceal bleeding: role of Classification and Regression Tree analysis", Ann Hepatol, 8, pp.308~315 (2009)
- 이자영, "정맥류 출혈에 의한 사망 및 재출혈 예측 인자의 유용성 비교: Child-Pugh 점수, MELD 점수, Rockall 점수", Clinical and Molecular Hepatology, 8(2002), pp.458~464 (2002), 대한간학회
- D’Amico G, "The treatment of portal hypertension: a meta-analytic review", Hepatology, 22, pp.332~354 (1995)
- Goulis J, "Bacterial infection is independently associated with failure to control bleeding in cirrhotic patients with gastrointestinal hemorrhage", Hepatology, 27, pp.1207~1212 (1998)
- D’Amico G, "Natural history. Clinical-haemodynamic correlations. Prediction of the risk of bleeding", Baillieres Clin Gastroenterol, 11, pp.243~256 (1997)
- Wang MT, "Prognostic factors associated with rebleeding in cirrhotic inpatients complicated with esophageal variceal bleeding", Chin Med J (Engl), 124, pp.1493~1497 (2011)
- Zhao JR, "Risk factors for early rebleeding and mortality in acute variceal hemorrhage", World J Gastroenterol, 20, pp.17941~17948 (2014)
- Lee SW, "Independent factors associated with recurrent bleeding in cirrhotic patients with esophageal variceal hemorrhage", Dig Dis Sci, 54, pp.1128~1134 (2009)
- Sempere L, "Assessing the short- and long-term prognosis of patients with cirrhosis and acute variceal bleeding", Rev Esp Enferm Dig, 101, pp.236~248 (2009)
- de Franchis R, "Baveno VI Faculty. Expanding consensus in portal hypertension: Report of the Baveno VI Consensus Workshop: Stratifying risk and individualizing care for portal hypertension", J Hepatol, 63, pp.743~752 (2015)
- Abraldes JG, "Hepatic venous pressure gradient and prognosis in patients with acute variceal bleeding treated with pharmacologic and endoscopic therapy", J Hepatol, 48, pp.229~236 (2008)
- Augustin S, "Effectiveness of combined pharmacologic and ligation therapy in high-risk patients with acute esophageal variceal bleeding", Am J Gastroenterol, 106, pp.1787~1795 (2011)
- Augustin S, "Predicting early mortality after acute variceal hemorrhage based on classification and regression tree analysis", Clin Gastroenterol Hepatol, 7, pp.1347~1354 (2009)
- D’Amico G, "Cooperative Study Group. Upper digestive bleeding in cirrhosis. Post-therapeutic outcome and prognostic indicators", Hepatology, 38, pp.599~612 (2003)
- Moitinho E, "Prognostic value of early measurements of portal pressure in acute variceal bleeding", Gastroenterology, 117, pp.626~631 (1999)
- Moitinho E, "Multicenter randomized controlled trial comparing different schedules of somatostatin in the treatment of acute variceal bleeding", J Hepatol, 35, pp.712~718 (2001)
- Moreau R, "Acute renal failure in patients with cirrhosis: perspectives in the age of MELD", Hepatology, 37, pp.233~243 (2003)
- Schepke M, "Prognostic factors for patients with cirrhosis and kidney dysfunction in the era of MELD: results of a prospective study", Liver Int, 26, pp.834~839 (2006)
- Sarin SK, "Prevalence, classification and natural history of gastric varices: a long-term follow-up study in 568 portal hypertension patients", Hepatology, 16, pp.1343~1349 (1992)
- Saad WE, "Transjugular Intrahepatic Portosystemic Shunt (TIPS) versus Balloon-occluded Retrograde Transvenous Obliteration (BRTO) for the Management of Gastric Varices", Semin Intervent Radiol, 28, pp.339~349 (2011)
- Hong CH, "Treatment of patients with gastric variceal hemorrhage: endoscopic Nbutyl- 2-cyanoacrylate injection versus balloon-occluded retrograde transvenous obliteration", J Gastroenterol Hepatol, 24, pp.372~378 (2009)
