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Background: The prognosis comparison between endoscopic therapy + partial splenic embolization (PSE) and Hassab's operation is unclear in the treatment of esophageal variceal bleeding in patients with liver cirrhosis. This study aimed to compare the outcome of endoscopic therapy + PSE (EP) with a combination of splenectomy + pericardial devascularization procedure, known as Hassab's operation (SH) for esophageal variceal bleeding in patients with liver cirrhosis with hypersplenism. Methods: We enrolled 328 patients, including 125 and 203 patients who underwent EP and SH, respectively. Each group consisted of 110 patients after propensity score matching (PSM). Subsequently, we recorded and analyzed bleeding episodes and mortality in 6 months and 1, 2, and 5 years after therapies. Results: The median follow-up time in the EP and SH groups was 53 and 64 months, respectively. Bleeding incidence 6 months after therapies in the EP group was lower than that in the SH group (1.8% vs. 10.0%, P = 0.010). Additionally, complications in the perioperative period were not significantly different (0% vs. 3.6%, P = 0.008). However, the bleeding rate between the two groups was not significantly different at 1, 2, and 5 years after therapies (7.3% vs. 12.7%, P = 0.157; 10.9% vs. 16.4%, P = 0.205; 30.6% vs. 31.8%, P = 0.801), as well as mortality rate (4.5% vs 7.3%, P = 0.571). Conclusion: Compared with SH therapy, the bleeding rate 6 months after EP therapy was lower, but the long-term bleeding rate was similar. [ABSTRACT FROM AUTHOR]

Objectives: To estimate the safety and effectiveness of emergent transjugular intrahepatic portosystemic shunt (TIPS) creation for acute variceal bleeding (AVB) in cirrhotic patients with hepatocellular carcinoma (HCC). Materials and methods: Data of thirty-three patients with AVB and HCC undergoing emergent TIPS creation from January 2016 to January 2022 were enrolled and were retrospectively analyzed. The primary outcomes were the safety of emergent TIPS creation, the bleeding control rate, and the rebleeding rate. The secondary outcomes included overall survival (OS), liver function, overt hepatic encephalopathy (HE), and shunt dysfunction. Results: Emergent TIPS creation was technically successful in 33 patients (100%) and one (3.0%) patient suffered a major procedure-related adverse event. The control rate of bleeding (within 5 days) was 100%. During a median follow-up period of 26.3 months, rebleeding occurred in 6 (18.2%) patients. The median OS was 20.0 months. The 6-week and 1-year survival rates were 87% and 65%, respectively. Laboratory tests showed no significant impairment of liver function following TIPS creation. The incidences of overt HE and shunt dysfunction were 24.2% and 6.1%, respectively. Conclusion: Emergent TIPS creation is feasible and effective for treatment of AVB in cirrhotic patients with HCC. [ABSTRACT FROM AUTHOR]

Background: This study aimed to compare the efficacy of partial splenic embolization (PSE) combined with endoscopic therapy and endoscopic therapy alone in cirrhosis patients with acute variceal bleeding (AVB) and hypersplenism. Methods: Cirrhosis patients with AVB who visited three hospitals from June 2016 to June 2022 were prospectively enrolled and randomly allocated to either the endoscopic therapy combined with PSE group (EP group) or the endoscopic intervention group (E group) in a 1:1 ratio. The primary endpoint of the study was re-bleeding of varices during follow-up, and the secondary endpoints were the recurrence of varices, death, and adverse events. Results: One hundred and fourteen patients were prospectively included, of whom 110 completed the trial. The risk of variceal re-bleeding (19.3% vs. 40.4% (23/57), p = 0.013) and variceal recurrence (28.1% vs. 63.2%, p < 0.001) five years after treatment was significantly lower in the EP group than in the E group, and the EP treatment was the only significant independent risk factor affecting variceal re-bleeding and variceal recurrence in patients. The mortality rate was comparable between the EP and E groups. Peripheral blood counts and liver function all improved significantly in the EP group compared to the E group during the follow-up (p < 0.05). Conclusions: The rates of variceal re-bleeding and recurrence were significantly lower in cirrhosis patients with AVB and hypersplenism after combined endoscopic and PSE treatment compared to those who were provided endoscopic treatment only. The peripheral blood counts and liver function were also improved significantly in EP group (NCT02778425). [ABSTRACT FROM AUTHOR]

Background: The optimal timing of endoscopy in liver cirrhosis with acute variceal bleeding (AVB) remains controversial in current guidelines and studies. Methods: Consecutive patients with liver cirrhosis and AVB were screened. The timing of endoscopy was calculated from the last presentation of AVB or the admission to endoscopy. Early endoscopy was defined as the interval < 12 h, < 24 h, or < 48 h. A 1:1 propensity score matching (PSM) analysis was performed. Five-day failure to control bleeding and in-hospital mortality were evaluated. Results: Overall, 534 patients were included. When the timing of endoscopy was calculated from the last presentation of AVB, PSM analysis demonstrated that the rate of 5-day failure to control bleeding was significantly higher in early endoscopy group defined as < 48 h (9.7% versus 2.4%, P = 0.009), but not < 12 h (8.7% versus 6.5%, P = 1.000) or < 24 h (13.4% versus 6.2%, P = 0.091), and that the in-hospital mortality was not significantly different between early and delayed endoscopy groups (< 12 h: 6.5% versus 4.3%, P = 1.000; <24 h: 4.1% versus 3.1%, P = 1.000; <48 h: 3.0% versus 2.4%, P = 1.000). When the timing of endoscopy was calculated from the admission, PSM analyses did not demonstrate any significant difference in the rate of 5-day failure to control bleeding (< 12 h: 4.8% versus 12.7%, P = 0.205; <24 h: 5.2% versus 7.7%, P = 0.355; <48 h: 4.5% versus 6.0%, P = 0.501) or in-hospital mortality (< 12 h: 4.8% versus 4.8%, P = 1.000; <24 h: 3.9% versus 2.6%, P = 0.750; <48 h: 2.0% versus 2.5%, P = 1.000) between early and delayed endoscopy groups. Conclusion: Our study could not support any significant association of timing of endoscopy with cirrhotic patients with AVB. [ABSTRACT FROM AUTHOR]

Background: Upper gastrointestinal (GI) hemorrhage, caused by acute esophageal variceal bleeding, is a common complication and a leading cause of death in patients with cirrhosis. Therefore, predicting the risk in order to employ an active management to prevent rebleeding and death is crucial. Currently, there are many prognostic scoring systems that have been proposed, but research is needed to find a valid score which can be applied in clinical practice in each country and population. Aims: To compare the value of ALBI (Albumin-Bilirubin), PALBI (Platelet Albumin-Bilirubin), AIMS65, model for end-stage liver disease (MELD), and Child-Pugh scores (CPS) approaches in predicting early rebleeding and in-hospital mortality of acute variceal bleeding in patients with cirrhosis. Subjects and methods: We performed a cross-sectional descriptive study on cirrhotic patients with acute variceal bleeding who were being treated at the Department of Gastroenterology, Intensive care unit--Military Hospital 103 and the Institute for Treatment of Digestive Diseases--108 Military Central Hospital from September 2020 to May 2022. We calculated ALBI, PALBI, AIMS65, MELD, Child-Pugh values and compared them with the rates of early rebleeding and in-hospital mortality. Then, determined and compared the prognostic value through an analysis of the area under the curve (AUC). Results: 222 patients with acute esophageal variceal bleeding were eligible for inclusion in the study. The rates of rebleeding and in-hospital mortality were 9.0% and 6.8%, respectively. Regarding the prognosis of early rebleeding, the ALBI and PALBI scores have good prognostic value (AUROC 0.74; 95% CI: 0.63-0.85 and AUROC 0.7; 95% CI: 0.59-0.81; p = 0.004, respectively), while the Child-Pugh, MELD, AIMS65 scores have little prognostic value, with AUROC < 0.70. Regarding prognosis of in-hospital mortality: the ALBI, PALBI, MELD and AIMS65 all have good value in predicting in-hospital mortality, with AUROC of 0.81 (95% CI: 0.68-0.93, respectively; p < 0.001); 0.8 (95% CI: 0.69-0.91; p < 0.001); 0.83 (95% CI: 0.72-0.93; p < 0.001); and 0.82 (95% CI: 0.76-0.87, p < 0.001), respectively. While Child-Pugh score only has medium prognostic value, with AUROC 0.79 (95% CI: 0.66-0.92; p < 0.05). However, there was no significant difference between these prognostic scoring systems. Conclusion: the ALBI, PALBI, MELD and AIMS65 scores all had similar good value in predicting in-hospital mortality, but with early rebleeding prognosis, only ALBI and PALBI had good value. CPS does not show prognostic value like other scores, both in predicting early rebleeding and in-hospital mortality. [ABSTRACT FROM AUTHOR]

Background and aims: Acute variceal bleeding (AVB) is a life-threatening complication of cirrhosis. Acute-on-chronic liver failure (ACLF) is a syndrome characterized by acute decompensation of cirrhosis, multiple organ failures and high short-term mortality. This study aimed to evaluate the role of ACLF in the risk stratification of cirrhotic patients with AVB. Methods: Prospective data of 335 cirrhotic patients hospitalized for AVB were retrospectively extracted from Medical Information Mart for Intensive Care (MIMIC)-IV database. ACLF was defined by European Association for the Study of Liver-Chronic Liver Failure Consortium and diagnosed/graded with chronic liver failure-organ failure (CLIF-OF) score. Cox-proportional hazards regression analysis was performed to identify the risk factors for 6-week morality in AVB patients. Discrimination and calibration of prognostic scores were evaluated by plotting the receiver operating characteristics (ROC) curve and calibration curve, respectively. Overall performance was assessed by calculating the Brier score and R2 value. Results: A total of 181 (54.0%) patients were diagnosed with ACLF (grade 1: 18.2%, grade 2: 33.7%, grade 3: 48.1%) at admission. The 6-week mortality in patients with ACLF was significantly higher than that in patients without ACLF (43.6% vs. 8.4%, P < 0.001) and increased in line with the severity of ACLF (22.5%, 34.2% and 63.8% for ACLF grade 1, 2 and 3, P < 0.001). In multivariate analysis, presence of ACLF remained as an independent risk factor for 6-week mortality after adjusting for confounding factors (HR = 2.12, P = 0.03). The discrimination, calibration and overall performance of CLIF-C ACLF and CLIF-C AD were superior to the traditional prognostic scores (CTP, MELD and MELD-Na) in the prediction of 6-week mortality of patients with and without ACLF, respectively. Conclusion: The prognosis of cirrhotic patients with AVB is poor when accompanied by ACLF. ACLF at admission is an independent predictor for the 6-week mortality in cirrhotic patients with AVB. CLIF-C ACLF and CLIF-C AD are the best prognostic scores in AVB patients with and without ACLF, respectively, and can be used for the risk stratification of these two distinct entities. [ABSTRACT FROM AUTHOR]

Background: There is strong evidence demonstrating the incidence of Acute Coronary Syndrome (ACS) among patients with cirrhosis, with the initiation of antiplatelet therapy being subject to debate due to an increased risk of bleeding. This study aimed to determine mortality among patients presenting with concomitant Acute Variceal Bleeding (AVB) and ACS at Index admission. Furthermore, the recurrence of AVB and ACS among patients discharged with or without antiplatelet therapy was determined. Methods: This retrospective study was conducted at the Aga Khan University Hospital, Karachi, Pakistan on patients ≥ 18 years of age admitted to our ER with concomitant ACS and AVB between January 2002 to December 2017. Follow-up for 6 months or till death (if < 6 months), was observed, to help determine the incidence of recurrent AVB and ACS. The incidence of AVB and ACS was then compared amongst patient groups based on the usage of anti-platelet drugs on discharge. Results: A total of 29 patients were included, with a mean age of 58.7 ± 11.0 years. Seven patients died on admission, having worse underlying liver disease. No mortality was reported among the remaining 22 patients. All 22 patients underwent surveillance endoscopy with variceal band ligation until obliteration, as needed. Only 7 patients from the surviving cohort received antiplatelet therapy. After 6.05 ± 1.1 months of follow-up, 1/22 (4.5%) developed recurrent AVB and 2/22 (9.1%) developed cardiovascular events. Importantly, there was no significant difference in the incidence of recurrent AVB (P = 1.000) and ACS (P = 0.091), depending on the use of antiplatelet therapy. Conclusion: Concomitant AVB and ACS is a severe disorder with increased mortality among cirrhotic patients at presentation. The incidence of AVB does not seem to exacerbate with the use of antiplatelet agents, provided successful obliteration of varices is achieved using elective band ligation. [ABSTRACT FROM AUTHOR]

Background: There has always been a debate on the optimal timing of endoscopy in patients with acute variceal bleeding (AVB). Objective: This study aimed to examine the relation between the timing of endoscopy and the short-term outcomes of patients with AVB. Methods: Patients with AVB who underwent endoscopy within 24 h after admission at our tertiary care center from 2014 to 2022 were evaluated retrospectively. The primary outcomes were the 6-week mortality and re-bleeding. The secondary outcomes included the total number of blood units transfused, the length of hospital stay, and the need for salvage therapy. We used Cox proportional hazards model to analyze the predictors of 6-week mortality in all patients as well as in those who were at high risk of further bleeding or death. Results: A total of 312 patients were enrolled. Among them, 170 patients (54.49%) underwent urgent endoscopy (< 6 h), and 142 patients (45.51%) underwent early endoscopy (6–24 h). There were no significant differences between the urgent-endoscopy group and the early-endoscopy group, regarding the 6-week mortality (16.47% vs. 10.56%; P value = 0.132) and 6-week re-bleeding rate (11.2% vs. 16.2%; P value = 0.196). In multivariate analysis, time to endoscopy was independent of 6-week mortality (P value = 0.170), but the time between the beginning of bleeding and endoscopy (within 12 h) was significantly associated with low 6-week mortality (OR: 0.16; 95% CI: 0.06–0.46; P value = 0.001). Time to endoscopy was still not associated with 6-week mortality in patients at high risk for further bleeding or death (Glasgow-Blatchford score ≥ 12, n = 138, P value = 0.902). Conclusions: Endoscopy performed within 6 h of admission, rather than within 6 to 24 h, did not improve six-week clinical outcomes in patients in stable condition with AVB and even those who were at high risk of further bleeding and death. [ABSTRACT FROM AUTHOR]

To determine the risk factors for emergency endoscopic variceal ligation (EVL) failure in acute variceal bleeding (AVB). Data from 161 cirrhosis patients with oesophageal variceal bleeding who underwent emergency EVL treatment at the Second Hospital of Hebei Medical University from January 2018 to May 2021 were retrospectively analysed. Enrolled patients were divided into a successful treatment group and a failed treatment group. The variables studied were demographic, clinical, imaging, laboratory, and endoscopic data from the enrolled patients. Of the enrolled patients, 19 patients experienced emergency EVL failure. Of these patients, nine underwent emergency endoscopic treatment again, six patients were treated with a Sengstaken–Blakemore tube for haemostasis and endoscopic treatment, four patients received drug therapy. The presence of portal vein thrombosis (PVT) in the failure group was higher than that in the success group (p <.05). Active bleeding on endoscopy was associated with emergency EVL failure for patients with Child–Pugh class C (p <.05). Child–Pugh class C with active bleeding on endoscopy or the presence of PVT could increase the risk of emergency EVL failure. The patient's condition should be fully evaluated before emergency endoscopic treatment to reduce the risk of failure. [ABSTRACT FROM AUTHOR]

Background: Atezolizumab–bevacizumab is the new standard for advanced hepatocellular carcinoma (HCC) but its impact on portal hypertension (PHT) is unknown. We aimed to identify predictive factors of acute variceal bleeding (AVB) and to monitor PHT parameters under treatment. Methods: We conducted a prospective study including all cirrhotic patients treated with atezolizumab–bevacizumab since 2020. We performed monitoring of PHT using upper endoscopy at inclusion and at 6 months and hepatic venous pressure gradient (HVPG) at inclusion, 3 and 6 months after the beginning of treatment. We also included a retrospective series of patients treated with sorafenib. Time‐to‐events data were estimated by Kaplan–Meier with the log‐rank test, along with Cox models. Results: Forty‐three patients treated with atezolizumab–bevacizumab were included (male 79.1%, Child‐Pugh A 86%). At baseline, 48.8% were treated with curative anticoagulation, 16.3% already experienced AVB and 25.6% had large oesophageal varices (EV). Sorafenib group characteristics were similar. Vascular invasion was present in 60.5% and median was HVPG 8.5 mm Hg. No significant modification in HVPG and EV size was observed at 6 months in the whole cohort but also when considering vascular invasion and radiological response. 14% presented AVB within a median time of occurrence of 3 months, without bleeding‐related death. In multivariate analysis, history of AVB (HR = 10.58, p =.03) was associated with AVB. AVB incidence was higher in atezolizumab–bevacizumab compared to sorafenib group (21% vs. 5% at 1 year, p =.02). Conclusions: Atezolizumab–bevacizumab treatment was associated with a higher risk of AVB compared to sorafenib. A history of AVB was associated with AVB during follow‐up, which questions the use of bevacizumab in this setting. [ABSTRACT FROM AUTHOR]

Background and aims: Limited data exist regarding outcomes of acute variceal bleeding (AVB) in patients with acute-on-chronic liver failure (ACLF), especially in those with hepatic failure. We evaluated the outcomes of AVB in patients with ACLF in a multinational cohort of APASL ACLF Research Consortium (AARC). Methods: Prospectively maintained data from AARC database on patients with ACLF who developed AVB (ACLF-AVB) was analysed. This data included demographic profile, severity of liver disease, and rebleeding and mortality in 6 weeks. These outcomes were compared with a propensity score matched (PSM) cohort of ACLF matched for severity of liver disease (MELD, AARC score) without AVB (ACLF without AVB). Results: Of the 4434 ACLF patients, the outcomes in ACLF-AVB (n = 72) [mean age—46 ± 10.4 years, 93% males, 66% with alcoholic liver disease, 65% with alcoholic hepatitis, AARC score: 10.1 ± 2.2, MELD score: 34 (IQR: 27–40)] were compared with a PSM cohort selected in a ratio of 1:2 (n = 143) [mean age—44.9 ± 12.5 years, 82.5% males, 48% alcoholic liver disease, 55.7% alcoholic hepatitis, AARC score: 9.4 ± 1.5, MELD score: 32 (IQR: 24–40)] of ACLF-without AVB. Despite PSM, ACLF patients with AVB had a higher baseline HVPG than without AVB (25.00 [IQR: 23.00–28.00] vs. 17.00 [15.00–21.75] mmHg; p = 0.045). The 6-week mortality in ACLF patients with or without AVB was 70.8% and 53.8%, respectively (p = 0.025). The 6-week rebleeding rate was 23% in ACLF-AVB. Presence of ascites [hazard ratio (HR) 2.2 (95% CI 1.03–9.8), p = 0.026], AVB [HR 1.9 (95% CI 1.2–2.5, p = 0.03)], and MELD score [HR 1.7 (95% CI 1.1–2.1), p = 0.001] independently predicted mortality in the overall ACLF cohort. Conclusion: Development of AVB confers poor outcomes in patients with ACLF with a high 6-week mortality. Elevated HVPG at baseline represents a potential risk factor for future AVB in ACLF. [ABSTRACT FROM AUTHOR]

Background and Aim: A preemptive transjugular intrahepatic portosystemic shunt (p‐TIPSS) after acute variceal bleeding (AVB) is advocated. However, when compared with the current standard of care, the survival benefit of p‐TIPSS is questionable. We performed a systematic review, meta‐analysis, and trial sequential analysis of randomized control trials (RCTs) to assess the survival benefit of p‐TIPSS in patients with cirrhosis and AVB. Methods: Comprehensive literature search of three bibliographic databases (MEDLINE, Embase, and Cochrane) was conducted from inception till May 2021. All study types evaluating the survival benefit of p‐TIPSS in AVB were considered for inclusion. The relative risk (RR) of mortality and rebleeding at 6 weeks and mortality at 1 year with a random‐effects model was computed. Trial sequential analysis was performed for the primary outcome of 6‐week mortality. Results: A total of nine studies (four RCTs and five cohort studies) comprising 2861 patients with AVB were included. The overall pooled risks of mortality at 6 weeks and 1 year were 17.9% (95% confidence interval [CI]: 16.5–19.3%) and 26.7% (95% CI: 25.0–28.3%), respectively. Although p‐TIPSS was associated with lower 6‐week rebleeding risk (RR = 0.20; 95% CI = 0.13–0.29, I2 = 0%), data from pooled RCTs showed no significant difference in mortality at 6 weeks (RR = 0.33; 95% CI = 0.08–1.36, I2 = 63%) or at 1 year (RR = 0.76; 95% CI = 0.51–1.14, I2 = 30%). Using trial sequential analysis, required sample size to detect a 20% relative risk reduction in mortality at 6 weeks with p‐TIPSS was estimated to be 6317, which is beyond the total number of patients available for analysis. Conclusions: This meta‐analysis found that the available data from RCTs are insufficient to confer 6‐week mortality benefit with p‐TIPSS compared with standard of care; thus, adequately powered RCTs are required. [ABSTRACT FROM AUTHOR]

Acute variceal bleeding (AVB) is a life-threatening condition that needs risk stratification to guide clinical treatment. Which risk system could reflect the prognosis more accurately remains controversial. We aimed to conduct a meta-analysis of the predictive value of GBS, AIMS65, Rockall (clinical Rockall score and full Rockall score), CTP and MELD. PubMed, Web of Science, Embase, Cochrane library, WANGFANG and CNKI were searched. Twenty-eight articles were included in the study. The Meta-DiSc software and MedCalc software were used to pool the predictive accuracy. Concerning in-hospital mortality, CTP, AIMS65, MELD, Full-Rockall and GBS had a pooled AUC of 0.824, 0.793, 0.788, 0.75 and 0.683, respectively. CTP had the highest sensitivity of 0.910 (95% CI: 0.864–0.944) with a specificity of 0.666 (95% CI: 0.635–0.696). AIMS65 had the highest specificity of 0.774 (95% CI: 0.749–0.798) with a sensitivity of 0.679 (95% CI: 0.617–0.736). For follow-up mortality, MELD, AIMS65, CTP, Clinical Rockall, Full-Rockall and GBS showed a pooled AUC of 0.798, 0.77, 0.746, 0.704, 0.678 and 0.618, respectively. CTP had the highest specificity (0.806, 95% CI: 0.763–0.843) with a sensitivity of 0.722 (95% CI: 0.628–0.804). GBS had the highest sensitivity 0.800 (95% CI: 0.696–0.881) with a specificity of 0.412 (95% CI: 0.368–0.457). As for rebleeding, no score performed particularly well. No risk scores were ideally identified by our systematic review. CTP was superior to other risk scores in identifying AVB patients at high risk of death in hospital and patients at low risk within follow-up. Guidelines have recommended the use of GBS to risk stratification of patients with upper gastrointestinal bleeding. However, if the cause of upper gastrointestinal bleeding is suspected oesophageal and gastric varices, extra care should be taken. Because in this meta-analysis, the ability of GBS was limited. CTP was superior in identifying AVB patients at high risk of death in hospital and low risk within follow-up. GBS, though recommended by the Guidelines, should be cautiously used when assessing AVB patients. [ABSTRACT FROM AUTHOR]

Résumé: L'hémorragie digestive haute sur hypertension portale est une complication majeure et grave de la cirrhose, grevée d'un taux de mortalité de 10 % à 20 %. Sa prise en charge est codifiée par les recommandations de Baveno VI. Après une prise en charge médicale adéquate, une endoscopie initiale permet une hémostase dans 80 % des cas. Pour les 20 % d'échecs au traitement endoscopique, la pose d'un TIPS doit être discutée. Malheureusement, tous les centres ne disposent pas d'un accès au TIPS 24 heures/24 et 7 jours/7, raison pour laquelle des traitements endoscopiques de seconde ligne peuvent être proposés. La sonde de tamponnement est la technique la plus ancienne avec une « facilité » de pose et une bonne efficacité sur l'arrêt du saignement des varices œsophagiennes lors de la phase aiguë. Toutefois, avec un taux élevé de récidive au moment de son retrait et de nombreux effets secondaires, celle-ci est de moins en moins utilisée, d'autant plus qu'une prothèse œsophagienne couverte dédiée à la prise en charge des ruptures de varices œsophagiennes en échec de ligature élastique a été récemment développée. Celle-ci présente de meilleurs résultats en termes d'efficacité et d'effets secondaires mais son prix est un frein à son utilisation. La poudre hémostatique a également une place dans le traitement de seconde ligne car elle est simple d'application, elle conduit à un taux élevé d'hémostase endoscopique, la récidive hémorragique est faible et il existe très peu d'effets secondaires. La sclérothérapie peut être utilisée du fait d'un taux d'arrêt du saignement correct mais les récidives hémorragiques sont nombreuses, elle n'améliore ni la survie ni l'éradication des varices et son utilisation n'est pas dénuée de risques. Cet article a pour but de présenter les différentes techniques disponibles pour la prise en charge d'une hémorragie sur hypertension portale après échec d'un premier traitement endoscopique et/ou en attente de la pose d'un TIPS. Upper GI bleeding due to portal hypertension is a major and serious complication of cirrhosis, with a mortality rate of 10% to 20%. Its management is codified by the Baveno VI criteria. After adequate medical management, initial endoscopy can treat the bleeding in 80 % of cases. For the 20% of cases where endoscopic treatment fails, the placement of a TIPS should be discussed. Unfortunately, not all centers have 24/7 access to TIPS, which is why second-line endoscopic treatments can be offered and will be discussed in this article. The tamponade balloon catheter is the oldest technique with good efficacy in stopping bleeding from oesophageal varices in the acute phase. However, with a high rate of recurrence at the time of its removal and numerous side effects, it is less and less used, especially since a covered oesophageal prosthesis dedicated to the management of oesophageal varicose vein ruptures in failure of elastic ligation has been recently developed. It has better results in terms of efficacy and side effects, but its price is a barrier to its use. Haemostatic powder also has a place in second line treatment as it is simple to apply, has a high rate of endoscopic haemostasis, recurrence of bleeding is low and there are very few side effects. Finally, sclerotherapy can be used because of a good rate of bleeding arrest, but there are many recurrences of bleeding, it does not improve survival or eradication of varicose veins and its use is not without risk. The aim of this article is to present the different methods available for the management of haemorrhage due to portal hypertension after failure of a first endoscopic treatment and/or while waiting for the installation of a TIPS. [ABSTRACT FROM AUTHOR]

Background: The effect of acute kidney injury (AKI) on patients with acute variceal bleeding (AVB) using the recently proposed International Club of Ascites (ICA) criteria is unclear. This study aimed to evaluate the incidence of AKI using the ICA criteria and factors associated with the outcomes in cirrhotic patients with AVB.Methods: This retrospective cohort study included data of cirrhotic patients with AVB from two centers in Korea. The association of the ICA criteria for AKI with 6-week mortality was analyzed through univariate and multivariate analyses using the Cox proportional hazard model.Results: In total, there were 546 episodes of AVB in 390 patients, of which 425 and 121 episodes were due to esophageal and gastric variceal bleeding, respectively. Moreover, 153 patients fulfilled the ICA criteria for AKI, and 64, 30, 39, and 20 patients were diagnosed with stages 1a, 1b, 2, and 3, respectively. Conversely, 97 patients developed AKI within 42 days as per the conventional criteria. The 6-week mortality rate was significantly higher in patients with ICA-AKI than in patients without ICA-AKI; the occurrence of ICA-AKI was an independent factor for predicting the 6-week mortality.Conclusion: The ICA criteria could help diagnose renal dysfunction earlier, and presence of AKI is a predictor of mortality in patients with cirrhosis and AVB. [ABSTRACT FROM AUTHOR]

Background: Acute variceal bleeding (AVB) is a life-threatening condition that needs risk stratification to guide clinical treatment. Which risk system could reflect the prognosis more accurately remains controversial. We aimed to conduct a meta-analysis of the predictive value of GBS, AIMS65, Rockall (clinical Rockall score and full Rockall score), CTP and MELD. Method: PubMed, Web of Science, Embase, Cochrane library, WANGFANG and CNKI were searched. Twenty-eight articles were included in the study. The Meta-DiSc software and MedCalc software were used to pool the predictive accuracy. Results: Concerning in-hospital mortality, CTP, AIMS65, MELD, Full-Rockall and GBS had a pooled AUC of 0.824, 0.793, 0.788, 0.75 and 0.683, respectively. CTP had the highest sensitivity of 0.910 (95% CI: 0.864-0.944) with a specificity of 0.666 (95% CI: 0.635-0.696). AIMS65 had the highest specificity of 0.774 (95% CI: 0.749-0.798) with a sensitivity of 0.679 (95% CI: 0.617-0.736). For follow-up mortality, MELD, AIMS65, CTP, Clinical Rockall, Full-Rockall and GBS showed a pooled AUC of 0.798, 0.77, 0.746, 0.704, 0.678 and 0.618, respectively. CTP had the highest specificity (0.806, 95% CI: 0.763-0.843) with a sensitivity of 0.722 (95% CI: 0.628-0.804). GBS had the highest sensitivity 0.800 (95% CI: 0.696-0.881) with a specificity of 0.412 (95% CI: 0.368-0.457). As for rebleeding, no score performed particularly well. Conclusions: No risk scores were ideally identified by our systematic review. CTP was superior to other risk scores in identifying AVB patients at high risk of death in hospital and patients at low risk within follow-up. Guidelines have recommended the use of GBS to risk stratification of patients with upper gastrointestinal bleeding. However, if the cause of upper gastrointestinal bleeding is suspected oesophageal and gastric varices, extra care should be taken. Because in this meta-analysis, the ability of GBS was limited. [ABSTRACT FROM AUTHOR]

Background: The survival of early placement (within 72h after admission) of transjugular intrahepatic portosystemic shunts (early-TIPS) in patients with cirrhosis and acute variceal bleeding (AVB) is controversial. Objectives: We performed a systemic review and meta-analysis to assess whether early-TIPS could improve survival in patients with cirrhosis and acute variceal bleeding. Methods: A systematic search of the literature was conducted in PubMed, EMBASE, and Cochrane Library published before 25 June 2019 for eligible studies that compared early-TIPS with a combination of endoscopic variceal ligation (EVL) and pharmacotherapy in the therapeutic effect in AVB patients. Results: A total of five studies with 1,754 participants were enrolled. The early-TIPS demonstrated a significant improvement in prevention of treatment failure (OR=0.11,95%CI=0.05-0.23), 6-weeks mortality (OR=0.24,95%CI=0.13-0.46), rebleeding within 6 weeks (OR=0.21,95%CI=0.12-0.36), rebleeding within 1 year (OR=0.16,95%CI=0.07-0.36), new or worsening ascites (OR=0.33,95%CI=0.21-0.53), except in encephalopathy (OR=1.29,95%CI=0.996-1.67). For 1-year mortality, a significant prior effect was also observed in early-TIPS (OR=0.64,95%CI=0.46-0.90), and the beneficial effect in Child-Pugh C patients (OR=0.35,95%CI=0.18-0.68) was equal to Child-Pugh B patients (OR=0.34,95%CI=0.25-0.58). No difference in liver transplantation and mortality caused by liver failure was observed. Conclusions: Early covered-TIPS could be recommended for the management of AVB patients in cirrhosis demonstrating a significant improvement in treatment failure, both short- and long-term mortality, rebleeding risk, and new or worsening ascites compared to standard therapy, especially for high-risk AVB patients. It will also apply to patients with Child-Pugh A until solutions to prevent hepatic encephalopathy in future research are found. [ABSTRACT FROM AUTHOR]

Cirrhosis is a serious and life-threatening condition which imposes a significant socioeconomic burden on affected individuals and healthcare systems. Cirrhosis can result in portal hypertension, which may lead to major complications, including acute variceal bleeding and hepatorenal syndrome. Without prompt treatment, these complications may be life-threatening. Over the past 2 decades, new treatment modalities and treatment strategies have been introduced, which have improved patients' prognosis, but the initial management of these severe complications continues to present a challenge. The present recommendations aim to increase clinicians' knowledge on the importance of early diagnosis and treatment, and to provide evidence-based management strategies to potentially, further improve patient outcomes. Special attention was given to the role of terlipressin. A comprehensive non-systematic literature search was undertaken to evaluate the evidence for the diagnosis and initial management of acute variceal bleeding and hepatorenal syndrome in patients with cirrhosis. Recommendations on the diagnosis and initial management of acute variceal bleeding and hepatorenal syndrome in patients with cirrhosis have been developed based on the best available evidence and the expert opinion of the consensus panel following a comprehensive review of the available clinical data. Prompt identification and timely treatment of acute variceal bleeding and hepatorenal syndrome are essential to reduce the burden. [ABSTRACT FROM AUTHOR]

Vasoconstrictors are often used as the first line therapy for acute esophageal variceal hemorrhage. They might also be used for a few days after endoscopic therapy to prevent early rebleeding. International guidelines recommend the use of vasoconstrictor therapy when acute esophageal variceal hemorrhage is suspected and continuation of the therapy until 3 to 5 days after endoscopic treatment. However, the duration of use of vasoconstrictors after endoscopic therapy is not clear. This review shows that if variceal bleeding is successfully controlled by endoscopic variceal ligation, the combination of vasoconstrictors can be reduced to less than 1 day. [ABSTRACT FROM AUTHOR]

Background: Continuous infusion of terlipressin causes more stable reduction in portal venous pressure than intermittent infusion. The aim of the study was to compare the efficacy of continuous infusion vs. intermittent boluses of terlipressin to control acute variceal bleeding (AVB) in patients with portal hypertension.Methods: Eighty-six consecutive patients with portal hypertension and AVB were randomized to receive either continuous intravenous infusion (Group A, n = 43) or intravenous boluses of terlipressin (Group B, n = 43). Group A received 1 mg intravenous bolus of terlipressin followed by a continuous infusion of 4 mg in 24 h. Group B received 2 mg intravenous bolus of terlipressin followed by 1 mg intravenous injection every 6 h. Upper gastrointestinal (UGI) endoscopy was done within 12 h of admission. Endoscopic variceal ligation (EVL) was done using a multi-band ligator. In both groups, treatment was continued up to 5 days. The primary endpoint was rebleeding or death within 5 days of admission.Results: Patients in group A had lower rate of treatment failure (4.7%) as compared to patients in group B (20.7%) (p = 0.02). Within 6 weeks, four and eight patients died in group A and B, respectively (p = 0.21). Model for end-stage liver disease sodium (MELD-Na) score and continuous infusion of terlipressin showed significant relationship with treatment failure on multivariate analysis.Conclusions: Continuous infusion of terlipressin may be more effective than intermittent infusion to prevent treatment failure in patients with variceal bleeding. There is significant relationship between MELD-Na score [Odd ratio = 1.37 (95% CI-1.16 - 1.62), p-value < 0.001] and continuous infusion of terlipressin [Odd ratio = 0.18 (95% CI-0.037 - 0.91), p-value - 0.04] with treatment failure. [ABSTRACT FROM AUTHOR]

Acute variceal bleeding should be suspected in all patients with cirrhosis presenting with upper gastrointestinal bleeding. Vasoactive drugs and prophylactic antibiotics must be started as soon as possible, even before performing the diagnostic endoscopy. Once the patient is hemodynamically stable, upper gastrointestinal endoscopy should be performed in order to confirm the diagnosis and provide endoscopic therapy (preferably banding ligation). After this initial approach, the most appropriate therapy to prevent both early and late rebleeding must be instituted following a risk stratification strategy. The present chapter will focus on the initial management of patients with acute variceal bleeding, including general management and hemostatic therapies, as well as the available treatments in case of failure to control bleeding or development of rebleeding. [ABSTRACT FROM AUTHOR]

Background and aims American College of Gastroenterology and American Association for the Study of Liver Disease guidelines recommend endoscopic and pharmacologic treatment for esophageal variceal bleed. Transjugular intrahepatic portosystemic shunt (TIPS) placement is reserved for cases of therapeutic failure. Several studies have suggested improved prevention of rebleeding and improved survival without excess hepatic encephalopathy in patients who receive TIPS within the first 5 days after bleeding (early TIPS). In this meta-analysis, we evaluated the safety and efficacy of early TIPS versus endoscopic therapy for secondary prophylaxis after acute esophageal variceal bleeding in cirrhotic patients. Methods Pubmed, Medline, Embase, ClinicalTrials.gov, and ISI Web of Science were searched for randomized controlled trials that compared early TIPS to endoscopic therapy. The primary outcome was mortality at 1 year; secondary outcomes were rebleeding and hepatic encephalopathy at 1 year. Results Nine randomized controlled trials involving 608 cirrhotic patients were identified. Early TIPS was associated with a significant risk reduction in 1-year mortality (RR, 0.68; 95% CI, 0.49-0.96; P = 0.03) and 1-year incidence of variceal rebleeding (RR, 0.28; 95% CI, 0.20-0.40; P < 0.001) without significant heterogeneity among studies (I2 = 30% and 47%, respectively). No significant difference in the incidence of hepatic encephalopathy at 1 year was observed (RR, 1.36; 95% CI, 0.72-2.56; P = 0.34); however, there was significant heterogeneity among studies (I2 = 68%). Conclusion TIPS placed within 5 days after a major esophageal variceal hemorrhage is superior to endoscopic treatment in reducing subsequent bleeding. Early TIPS placement is also associated with superior 1-year survival without significantly increasing the incidence of hepatic encephalopathy. [ABSTRACT FROM AUTHOR]

As soon as acute gastrointestinal bleeding is confirmed in patients with portal hypertension, treatment with vasoactive drugs and prophylactic antibiotics should be instituted. Once hemodynamic stability has been achieved, emergency endoscopy should be performed and endoscopic therapy (preferably with legation) should be carrier out when variceal bleeding is disclosed. It is advisable to maintain drug therapy for 5 days to prevent early rebleeding. When this treatment fails, TIPS should be considered. Balloon tamponade is indicated in patients with massive bleeding, as a bridge until definitive treatment could be instituted. Self-expanding metal stents are an alternative to tamponade which may even improve the outcomes. Recent data suggest that patients at high-risk of failure may benefit from invasive treatments such as early TIPS, while those with low-risk may do well with less intensive therapy including shorter administration of vasoactive drugs. However, these possibilities should be further investigated in future studies providing therapy according to stratification of risk. [ABSTRACT FROM AUTHOR]

Background and Aim: Risk factors for acute variceal bleeding in patients with hepatocellular carcinoma (HCC) and concurrent main portal vein thrombosis (PVT) remain unclear. We aimed to determine risk factors of in-hospital mortality after acute variceal bleeding for HCC patients with concurrent main PVT. Methods: We conducted a retrospective analysis of 102 HCC patients (83% men and 17% women) with concurrent main PVT and acute variceal bleeding. All patients received emergent endoscopy to define the bleeding source. Multivariable Cox proportional hazard regression analysis consisting of clinical, laboratory, and endoscopic parameters was performed to identify predictive factors for intrahospital mortality. Results: Twenty-eight (27.5%) patients died within admission. The median survival of all patients was 56 days. Multivariable Cox proportional hazard regression analyses revealed Child-Pugh score (adjusted hazard ratio [aHR]: 1.29 for each point; 95% confidence interval [CI]: 1.11-1.50), active bleeding on index endoscopy (aHR: 7.50; 95% CI: 3.05- 18.4), esophageal varices as the bleeder (compared with gastric varices, aHR: 14.3; 95% CI: 3.12-66.1), failure to control bleeding (aHR: 38.0; 95% CI: 7.44-194), and serum creatinine (aHR: 1.28 for each increase of 1 mg/dL; 95% CI: 1.09-1.50) independently predicted in-hospital mortality. Conclusions: Hepatic reserve, active bleeding on index endoscopy, failure to control bleeding, esophageal varices as the bleeder when compared with gastric varices, and renal function were independent predictive factors for in-hospital mortality in HCC patients with acute variceal bleeding and concurrent main PVT. [ABSTRACT FROM AUTHOR]

Background/Aim: Balloon tamponade has been widely available in emergency situations of acute variceal bleeding. To lessen the complications of Balloon tamponade, a new special type of stent for exclusive use in acute variceal bleeding has been developed. This study aims to investigate the effectiveness and safety of the new self?expandable metal stents (SEMS) in the initial control of acute variceal bleeding. We also hypothesized that using SEMS can bridge the acute bleeding episode converting endoscopic management by sclerotherapy or band ligation to an elective procedure. Patients and Methods: Twenty patients with acute variceal bleeding were included in the study and 16 of them were allocated to receive stent treatment. Results: Stent deployment was successful in 15 of 16 patients (93.75%). Technical errors were reported in 3 (18.75%) patients. Initial control of variceal bleeding was reported in 14 (out of 16) (87.5%) patients. The mean duration of the procedure was 10 (±6) min. Mortality was reported in 4 (25.0%) patients. Conclusion: SEMS is a safe and effective mean to control acute variceal bleeding. [ABSTRACT FROM AUTHOR]

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Background. Acute variceal bleeding is the major cause of death in patients with chronic liver disease. This justifies the search for a more effective therapy to achieve rapid and definitive hemostasis in every patient. At present, the recommended standard treatment for acute variceal bleeding consists of immediate drug treatment with terlipressin or octreotide together with early endoscopic band ligation or sclerotherapy. In the case of ectopic varices terlipressin and cyanoacrylate embolization (if varices can be reached by endoscope) are in use. Focus. The treatment is considered to have failed when bleeding continues or significant bleeding recurs within 48 h. This indicates the need for emergency transjugular intrahepatic portosystemic shunting (TIPS) which has been regarded as rescue treatment of choice when standard treatment fails. Although randomized studies against supportive treatment are lacking, the high efficacy and relatively low mortality after TIPS implantation are convincing. It is reasonable that smaller shunts should be preferred (probably 8 mm in diameter) since most patients have an increased risk of liver failure. To increase the effect of the shunt with respect to acute hemostasis it should be combined with transjugular embolization of the varices. Conclusion. Only strict adherence to the definition of failure of standard treatment and a generous indication to the TIPS implantation before multiorgan failure occurs may decrease the high mortality of acute variceal bleeding. [ABSTRACT FROM AUTHOR]

This paper reports the clinical results of a retrospective study comparing endoscopic injection sclerotherapy (EIS) and back-up surgical treatment after EIS in the management of acute variceal bleeding. The 74 patients included in the study were divided into 2 groups. Group I consisted of 41 patients who received EIS over a mean period of 2.2 sessions and Group II consisted of 33 patients who underwent EIS and subsequent surgical intervention, in the form of 19 distal splenorenal shunts and 14 nonshunting procedures. The overall percentage of patients in whom initial control of variceal bleeding was achieved was 91.8 per cent. Four of the Group II patients were saved by emergency nonshunting operations. Rebleeding was experienced by 4 (28.6 per cent) of the 14 patients who underwent nonshunting surgery but by only 1 (5.3 per cent) of the 19 patients who underwent selective shunt surgery. The cumulative survival in Group II was significantly superior to that in Group I with 2 year survival being achieved in 66.7 per cent of the Group II patients but in only 23 per cent of Group I patients. Thus, the combination of initial EIS and back-up surgical intervention may be more benefical than sclerotherapy alone for patients with acute variceal bleeding, while, the distal splenorenal shunt may be a more suitable surgical technique for patients having previously EIS. [ABSTRACT FROM AUTHOR]

Hemorrhage from esophageal and/or gastral varices is a major and often fatal complication of portal hypertension caused by liver cirrhosis [1]. Each bleeding episode is associated with a mortality rate in the range of 30–50%, which is much higher than after acute myocardial infarction. Thus, cirrhotics with acute variceal bleeding are high-risk patients and should be treated in experienced intensive care units to provide immediate hemostasis and adequate prevention of early rebleeding and multiorgan complications. [ABSTRACT FROM AUTHOR]

The purpose of the present study was to compare the efficacy of emergency endoscopic variceal sclerotherapy (EVS) using 3% aqueous phenol as an initial procedure to control acute oesophageal variceal bleed. One hundred and ninety-five consecutive patients presenting with acute variceal bleed were included in the study. Protocol based endoscopic sclerotherapy and management of bleeding oesophageal varices was done. Immediate cessation of bleeding, re-bleeding within the first 72 h, success of first injection, final success of EVS, short-term mortality, influence of aetiology of portal hypertension and severity of liver disease on these results were studied. Immediate cessation of bleeding was obtained in 191 out of 195 patients (97.9%). Twenty-seven (13.8%) patients re-bled within 72 h. On re-injection final success of EVS was 87.2% (170/195 patients). There was no significant difference between final success rate in cirrhotic versus non-cirrhotic patients (103/118 (87.3%) vs. 67/77 (87%)). Success of first sclerotherapy session was significantly higher than that of second sclerotherapy session. Surgical rescue was required in 25 (12.8%) patients. Mortality was 3.6%. Failure of EVS and mortality was significantly higher in Child's C group ( P = 0.04, Relative risk = 0.5, confidence interval 0.22−1.16). EVS remains an effective and cost effective modality of treatment to control acute variceal bleeding irrespective of aetiology of portal hypertension provided strict protocol based management is followed. With timely surgical rescue for the failures, the overall mortality can be reduced to less than 5%. [ABSTRACT FROM AUTHOR]

Background/Aims Although current guidelines recommend performing endoscopy within 12 hours for acute variceal bleeding (AVB), the optimal timing of endoscopy for AVB remains controversial. To perform a systematic review and meta-analysis of all eligible studies to assess the effect of endoscopy timing on mortality and rebleeding in AVB. Methods PubMed, Cochran Library, and EMBASE through January 2019 were searched for relevant publications. Overall mortality rate, rebleeding rate, and other clinical outcomes (successful hemostasis, need for salvage therapy, length of hospital stay, and number of blood transfusions) were determined. For Non-randomized studies, the risk of bias assessment tool was used to assess methodological quality of included publications. Mantel- Haenszel random effect model of RevMan software (Cochrane) was used to analyze binary endpoints and inverse variance method was used to analyze continuous outcomes. Results This meta-analysis included five studies with 854 and 453 participants undergoing urgent endoscopy (≤12 hours) and nonurgent endoscopy (>12 hours), respectively. There was no significant difference in overall mortality rate between urgent and nonurgent groups (odds ratio [OR], 0.72; 95% CI, 0.36 to 1.45; p=0.36). Rebleeding rate was similar between urgent and nonurgent groups (OR, 1.21; 95% CI, 0.76 to 1.93; p=0.41). Other outcomes were also similar between the two groups. Conclusions This study demonstrated that endoscopy timing did not affect mortality or rebleeding rate of patients with AVB. Therefore, an appropriate timing of endoscopy would be more important than an urgent endoscopy depending on each patient's condition. [ABSTRACT FROM AUTHOR]