Bleeding varices: 1. Emergency management.

The aim of the emergency management of bleeding varices is to stop the hemorrhage nonoperatively if possible, avoiding emergency shunt surgery, an operation that has a higher mortality than elective shunt surgery. Patients with an upper gastrointestinal hemorrhage should undergo endoscopy immediately to verify the diagnosis of bleeding varices. They can then be categorized according to whether they stop bleeding spontaneously (group 1), continue to bleed slowly (group 2) or continue to bleed rapidly (group 3). Group 1 patients are discussed in the second part of this two-part series. Group 2 patients are initially treated with vasopressin given intravenously; those who fail to respond should undergo emergency angiography and receive vasopressin intra-arterially. If this fails, patients at low surgical risk should undergo urgent shunt surgery; those at high risk do better with endoscopic sclerotherapy. Group 3 patients are also given an intravenous infusion of vasopressin. Patients at low surgical risk who continue to bleed then receive tamponade with a Sengstaken--Blakemore tube. If this fails, they undergo emergency creation of an H-shaped mesocaval shunt. Patients at high surgical risk who fail to respond to vasopressin given intravenously are next treated intra-arterially. If this fails they are given either endoscopic or transhepatic sclerotherapy.     

Management of bleeding varices in the elderly.

In 207 consecutive patients the outcome of bleeding varices was compared in those aged under 65 (n = 146) and those aged over 65 (n = 61). All patients were seen during seven years and were treated by active initial and maintenance sclerotherapy. Alcoholic cirrhosis was commoner in younger patients (68 (47%) v 12 (20%] and cryptogenic cirrhosis commoner in older patients (21 (34%) v 19 (13%]. Mortality due to the first bleed was dependent on the severity of liver disease and was unrelated to age. Survival corrected for age (life table analysis) was 65% at one year and 60% at two years for both groups of patients. It is concluded that patients should not be denied active treatment for bleeding varices on the basis of age alone. In order to obtain optimum results early endoscopy and sclerotherapy is essential.     

内镜下硬化剂和套扎治疗食管静脉曲张术后对门脉高压性胃病和胃底静脉曲张的影响

目的:探讨食管静脉曲张(EV)采用内镜下套扎术(EVL)和硬化剂(EVS)治疗对患者近远期并发胃底静脉曲张(GV)以及门脉高压性胃病(PHG)并发症的影响。方法:抽选我院肝硬化上消化道出血后接受内镜下治疗的患者97例为研究对象,其中19例予以内镜下EVS治疗,78例行内镜下EVL治疗,随访1年,观察治疗3个月、6个月、1年后并发GV、PHG的近远期概率。结果:治疗3个月后,本组患者GV、PHG等并发症的发生率为17.5%(17/97)、39.2%(38/97),与治疗前比较差异无显著性(P0.05);治疗6个月后,本组患者GV、PHG等并发症的发生率为32%(31/97)、70.1%(68/97),与治疗前相比,并发人数显著增加(P0.05);治疗1年后,GV、PHG的发生率为42.3%(41/97)、88.7%(86/97),并发人数显著高于治疗前(P0.05)。结论:内镜下EVS、EVL治疗在消退食管曲张静脉和良好地控制出血的同时,还可增加PHG、GV的并发几率,值得临床重视预防。     

Simplified oesophageal transection for bleeding varices.

Thirty patients with bleeding oesophageal varices were treated by oesophageal transection using the SPTU gun. Any form of shunt was contraindicated in all the patients. Twelve operations were done as urgent procedures within 36 hours of haemorrhage. The overall operative mortality rate was 10%, and there were two late deaths during follow-up, which has so far extended from two months to two years. Three of the patients had recurrent bleeding, and residual varices were probably the source in two. There were no cases of portal systemic encephalopathy. Although the follow-up is too short to allow any definite conclusions, these early results suggest that oesophageal transection with the SPTU gun may be useful in the large proportion of patients in whom injection sclerotherapy, shunt surgery, or conservative treatment is inappropriate.     

Measurement of Variceal Pressure with a Computerized Endoscopic Manometry: Validation and Effect of Propranolol Therapy in Cirrhotic Patients

Background and Purpose

Recently, we invented a computerized endoscopic balloon manometry (CEBM) to measure variceal pressure (VP) in cirrhotic patient. The purpose of this study was to evaluate the reliability and feasibility of this method, and whether this technique provided further information to pharmacological therapy.

Patients and Methods

VP measurements were performed in 83 cirrhotic patients and compared with HVPG as well as endoscopic bleeding risk parameters. Furthermore, VP was assessed before and during propranolol therapy in 30 patients without previous bleeding.

Results

VP measurements were successful in 96% (83/86) of all patients. Of the 83 patients, the VP correlated closely with the HVPG (P<0.001). The presence of red colour signs and the size of varices were strongly associated with VP. Patients with previous bleeding had higher VP than those who had not yet experienced bleeding. In univariate analysis, the level of VP, the size of varices, and red color signs predicted a higher risk of bleeding. The multiple logistic regression model revealed that VP was the major risk factor for bleeding. In 30 patients receiving propranolol, VP significantly decreased from 21.1±3.5 mmHg before therapy to 18.1±3.3 mmHg after 3 months and to 16.3±4.0 mmHg after 6 months. Comparing the mean decrease in VP with that in hepatic venous pressure gradient (HVPG), the decrease in VP was more obvious than HVPG response to propranolol.

Conclusions

This study showed that CEBM is safe and practical to assess VP in cirrhotic patient. It has the potential to be used as a clinical method to assess the risk of variceal bleeding and the effects of pharmacological therapy.

Trial registration

Effect of vasoactive drugs on esophageal variceal hemodynamics in patients with portal hypertension. Chinese Clinical Trial Registry –TRC-08000252.     

Surgical management of portal hypertension.

Portal hypertension is frequently complicated by upper gastrointestinal tract bleeding and ascites. Hemorrhage from esophageal varices is the most common cause of death from portal hypertension. Medical treatment, including resuscitation, vasoactive drugs, and endoscopic sclerosis, is the preferred initial therapy. Patients with refractory hemorrhage frequently are referred for immediate surgical intervention (usually emergency portacaval shunt). An additional cohort of patients with a history of at least 1 episode of variceal hemorrhage is likely to benefit from elective shunt operations. Shunt operations are classified as total, partial, or selective shunts based on their hemodynamic characteristics. Angiographically created shunts have been introduced recently as an alternative to operative shunts in certain circumstances. Devascularization of the esophagus or splenectomy is done for specific indications. Medically intractable ascites is a separate indication for surgical intervention. Liver transplantation has been advocated for patients whose portal hypertension is a consequence of end-stage liver disease. In the context of an increasingly complex set of treatment options, we present an overview of surgical therapy for complications of portal hypertension.     

Assessing the implications of publication bias for two popular estimates of between-study variance in meta-analysis

Perhaps the greatest threat to the validity of a meta-analysis is the possibility of publication bias, where studies with interesting or statistically significant results are more likely to be published. This obviously impacts on inference concerning the treatment effect but also has implications for estimates of between-study variance. Two popular and established estimation methods are considered and formulae for assessing the implications of the bias are provided in terms of a general process for selecting studies. Meta-analysts, concerned that publication bias may be present, can use these as part of a sensitivity analysis to assess the robustness of their estimates of between-study variance using any selection process that is likely to be used in practice. The procedure is illustrated using a meta-analysis of clinical trials concerning the effectiveness of endoscopic sclerotherapy for preventing death in patients with cirrhosis and oesophagogastric varices.     

Operations for portal hypertension due to extrahepatic obstruction: results and 10 year follow up.

Between 1976 and 1984, 136 patients with portal hypertension due to extrahepatic obstruction were operated on. Twenty two patients had emergency and 114 elective operations. The operative mortality was 9% and 1%, respectively. Altogether 117 patients (86%) were followed up for from two to 10 years: 17 rebled, none developed encephalopathy or sepsis after splenectomy, and 90% and 75% were alive at five and 10 years respectively. Unlike endoscopic sclerotherapy and treatment with propranolol, operative treatment of variceal bleeding can usually be completed during one admission and carries a low mortality and a fairly low morbidity. Operation seems to be the best form of treatment for poor patients living far from medical facilities in developing countries and may be the treatment of choice in developed countries as well.     

Randomised trial of octreotide for long term management of cirrhosis after variceal haemorrhage.

OBJECTIVE: To assess the efficacy of long term octreotide as adjuvant treatment to programmed endoscopic sclerotherapy after acute variceal haemorrhage in cirrhotic portal hypertension. DESIGN: Randomised clinical trial. SETTING: University hospital. SUBJECTS: 32 patients with cirrhotic portal hypertension. INTERVENTIONS: Programmed injection sclerotherapy with subcutaneous octreotide 50 micrograms twice daily for 6 months, or programmed injection sclerotherapy alone. MAIN OUTCOME MEASURES: Episodes of recurrent variceal bleeding and survival. RESULTS: Significantly fewer patients receiving combined octreotide and sclerotherapy had episodes of recurrent variceal bleeding compared with patients given sclerotherapy alone (1/16 v 7/16; P = 0.037, Fisher''s exact test), and their survival was significantly improved (P < 0.02, log rank test); this improvement was maintained for 12 months after the end of the study. Combined treatment also resulted in a sustained decrease in portal pressure (median decrease -6.0 mm Hg, interquartile range -10 to -4.75 mm Hg, P = 0.0002) compared with sclerotherapy alone (median increase 1.5 mm Hg, interquartile range 0.25 to 3.25 mm Hg), as well as a significant improvement in liver function as assessed by plasma concentrations of bilirubin, albumin, and alanine aminotransferase and by hepatocyte metabolism of aminopyrine labelled with carbon-14. CONCLUSION: Long term octreotide may be a valuable adjuvant to endoscopic sclerotherapy for acute variceal haemorrhage in cirrhotic portal hypertension.     

Comparison of the results of sclerotherapy of esophageal varices using a rigid esophagoscope and fiber-optics esophagoscope

The authors compared the results of 20 emergency and 100 elective varicosclerotisations with rigid esophagoscope and the same number of obliterations with the use of esophagofiberoscope. Haemorrhage was stopped in 90% of patients injected through the rigid esophagoscope and in 80% of patients in whom esophagofiberoscope was used. Hospital mortality rate in patients with bleeding esophageal warices was 25% in both groups. Complications were seen in 4.2% of procedures carried out with the rigid esophagoscope, and 5.8% of obliterations with esophagofiberoscope. The authors recommend rigid esophagoscope for emergency sclerotherapy and for the initial 2-3 series of injections in patients with large varices. Esophagofiberoscope is prefered in case of repeated, elective varicosclerotisations, first injections and recurrence of esophageal varices following obliterative therapy.     

Selection of operation in patients with bleeding esophageal varices.

The results of surgical treatment of bleeding esophageal varices over an 8-year period in 155 patients are reviewed. Primary treatment of bleeding was conservative, with intravenous administration of vasopressin and balloon tamponade. Emergency operations were carried out after 48 hours in persons with persistent bleeding who were surgical candidates. Operative mortality was higher in this group (40%) than in those undergoing elective or urgent operations (each 10%). Postoperative encephalopathy occurred in 35% of patients and was correlated closely to late death after establishment of a shunt. The mesocaval shunt is no better than the portacaval but appears to be a good alternative in an emergency. In a controlled trial the distal splenorenal shunt was found to be associated with a lower rate of postoperative encephalopathy than the portacaval shunt, but thus far the long-term survival rates have not differed.     

Radiology and endoscopy in acute upper gastrointestinal bleeding.

Of 112 patients admitted with acute upper gastrointestinal bleeding, the presumed bleeding site was detected in 61-5% of cases by radiology and in 57% of cases on endoscopy. Thirty-one patients who had barium-meal examination were operated on and the surgical and radiological findings agreed in 26 (84%). Twenty-three patients who had endoscopy were operated on and the surgical and endoscopic findings agreed in 15 (65%). In 10 cases radiology detected a lesion not identified on endoscopy and in nine endoscopy detected a lesion not seen at radiology. We suggest that when there are two potential sources of bleeding radiology as well as endoscopy can detect the actively bleeding lesion. The supplementary nature of radiology and endoscopy is emphasised and we conclude that both methods should be used if there is any doubt at the initial radiological or endoscopic examination about the source of the bleeding.     

Role of esophageal brushing cytology in monitoring patients treated with sclerotherapy for esophageal varices.

Recent reports claim that there might be a relationship between sclerotherapy for esophageal varices and cancer of the esophagus. The discovery of a squamous cell cancer of the lower esophagus in a patient treated three years previously with sclerotherapy led us to set up a follow-up protocol. In order to assess this relationship and to monitor the evolution of such lesions, 68 patients treated with sclerotherapy with polidocanol because of esophageal varices were examined endoscopically at six-month intervals, and brushing samples were taken. The ages of the patients ranged between 35 and 81 years, and all had portal hypertension due to cirrhosis; 10 patients with the same disease but without bleeding varices were also examined. The interval between sclerotherapy and the first cytologic follow-up examination averaged 34 months, while the interval to the last follow-up examination averaged 40 months. One patient was examined four times (1.4%), 10 three times (14.7%), 39 twice (57.4%) and 18 only once (26.5%). Two cases were interpreted as nuclear hyperplasia associated with inflammation and were found to have regressed at a subsequent examination; all the other cases were reported as negative although sometimes associated with inflammation. None of the controls showed any abnormalities. While the occurrence of esophageal cancer after sclerotherapy might be associated with other risk factors, such as alcohol intake and smoking, esophageal brushing cytology can successfully monitor these patients and detect early stages of neoplasia.     

Dyspepsia: is a trial of therapy appropriate?

Dyspepsia is a common, benign condition that may be distinguished from gastroesophageal reflux, irritable bowel syndrome and pancreatobiliary, coronary or musculoskeletal disease by a careful history and physical examination. However, the presence or absence of a peptic ulcer in dyspepsia can be determined only by an endoscopic examination or a barium-contrast radiograph. Although the American College of Physicians has recommended trying drug therapy for patients with dyspepsia before diagnostic tests are done, new data support early diagnosis. Although therapy is initially cheaper than endoscopic examination, over a year the costs even out because most patients with dyspepsia eventually need an endoscopic examination, and many patients with nonulcer dyspepsia are given medication unnecessarily. Endoscopic examination, if available to general practitioners, is the most cost-effective approach to dyspepsia. An approach that does not include endoscopy lacks the opportunity to offer patients convincing reassurance that their illness is not serious, which is arguably the most important treatment in cases of nonulcer dyspepsia. Studies supporting the use of endoscopic examination predate the treatment of peptic ulcers with antibiotics, which makes an initial endoscopic examination to determine whether the patient has an ulcer even more important.     

食管胃底静脉曲张患者行内镜下静脉曲张套扎术及内镜下组织胶注射术后早期再出血的危险因素研究

目的：研究行内镜下静脉曲张套扎术及内镜下组织胶注射术治疗的食管胃底静脉曲张患者的术后早期出血的危险因素。方法：回顾性分析在我院治疗的103例食管胃底静脉曲张患者的临床资料,对患者的性别、年龄、发病原因、有无脾切除史、是否有肝脏病史、有无分流及断流等临床情况进行统计分析,同时结合治疗前后患者的临床表现、相关实验室检查指标、影像学指标及胃镜指标等对患者早期再出血发生的原因进行分析,寻找独立的危险因素。结果：103例患者在术后早期再出血发生率10．7％;对其危险因素进行分析可知,肝功能分级、凝血酶原时间、门静脉血栓、血红蛋白含量为术后早期再出血的独立危险因素。结论：在进行手术前,应充分的最好术前准备,尽最大能力使患者的各项危险因素（肝功能分级、凝血酶原时间、门静脉血栓、血红蛋白含量）维持在正常水平,以减少术后出血的发生。     

Self-Expandable Metal Stents for Persisting Esophageal Variceal Bleeding after Band Ligation or Injection-Therapy: A Retrospective Study

Background and Study Aims

Despite a pronounced reduction of lethality rates due to upper gastrointestinal bleeding, esophageal variceal bleeding remains a challenge for the endoscopist and still accounts for a mortality rate of up to 40% within the first 6 weeks. A relevant proportion of patients with esophageal variceal bleeding remains refractory to standard therapy, thus making a call for additional tools to achieve hemostasis. Self-expandable metal stents (SEMS) incorporate such a tool.

Methods

We evaluated a total number of 582 patients admitted to our endoscopy unit with the diagnosis “gastrointestinal bleeding” according to our documentation software between 2011 and 2014. 82 patients suffered from esophageal variceal bleeding, out of which 11 cases were refractory to standard therapy leading to SEMS application. Patients with esophageal malignancy, fistula, or stricture and a non-esophageal variceal bleeding source were excluded from the analysis. A retrospective analysis reporting a series of clinically relevant parameters in combination with bleeding control rates and adverse events was performed.

Results

The initial bleeding control rate after SEMS application was 100%. Despite this success, we observed a 27% mortality rate within the first 42 days. All of these patients died due to non-directly hemorrhage-associated reasons. The majority of patients exhibited an extensive demand of medical care with prolonged hospital stay. Common complications were hepatic decompensation, pulmonary infection and decline of renal function. Interestingly, we found in 7 out of 11 patients (63.6%) stent dislocation at time of control endoscopy 24 h after hemostasis or at time of stent removal. The presence of hiatal hernia did not affect obviously stent dislocation rates. Refractory patients had significantly longer hospitalization times compared to non-refractory patients.

Conclusions

Self-expandable metal stents for esophageal variceal bleeding seem to be safe and efficient after failed standard therapy. Stent migration appeared to be a common incident that did not lead to reactivation of bleeding in any of our patients. SEMS should be considered a reasonable treatment option for refractory esophageal variceal bleeding after treatment failure of ligature and sclerotherapy and non-availability of or contraindication for other measures (e.g. TIPS).     

内镜下3种方法治疗食管静脉曲张破裂出血临床效果比较

目的:探讨治疗肝硬化导致的食管静脉曲张破裂出血的有效方法。方法:回顾性分析40例因肝硬化致食管静脉曲张破裂出血患者的临床资料,比较采用内镜下套扎、硬化及套扎序贯硬化3种治疗方法的止血率、静脉曲张消失率和再出血率。结果:EVL组、EVS组和EVL+EVS组治疗1个周期后止血率分别为86.67%、92.31%和91.67%,差异无统计学意义(X2=0.299,P=0.861);治疗3周期后静脉曲张消失率分别为80.00%、84.61%和91.67%,差异无统计学意义(X2=0.714,P=0.700)。治疗后3个月、6个月、12个月、24个月再出血率EVL+EVS组EVS组EVL组,差异有统计学意义(X2=13.198,P=0.040)。结论:3种方法治疗食管静脉曲张破裂出血均有很好的效果,可根据患者实际情况选择。无特殊适应症的情况下,优先选择EVS或EVL和EVS相配合的序贯疗法可取得较好的效果。     

Recurrent Haemorrhage after Acute Gastrointestinal Bleeding

A retrospective survey of 472 consecutive hospital admissions for acute upper gastrointestinal bleeding showed that patients with a large initial bleed are more likely to bleed again than those with a small initial bleed. The incidence of recurrent haemorrhage is also related to the interval since the last bleeding episode, so that patients showing no clinical evidence of haemorrhage for 48 hours are unlikely to bleed again in the near future. Patients admitted after a haematemesis have a higher incidence of recurrent haemorrhage than those admitted after melaena only. Aetiology has been confirmed as an additional important factor, the incidence being highest in those with oesophageal varices or a chronic gastric ulcer. Contrary to widespread belief, age does not appear to affect the incidence of recurrent haemorrhage, nor do other constitutional factors such as sex or the ABO blood group.     

Clinical findings,early endoscopy,and multivariate analysis in patients bleeding from the upper gastrointestinal tract.

A simple system has been developed to identify patients with upper gastrointestinal tract haemorrhage who run a high risk of continued bleeding or rebleeding. The system is based on six items of patient data available at or soon after arrival in hospital. It was evaluated in a prospective study of 66 patients with upper gastrointestinal tract haemorrhage. Over half of the patients classified by the system into a high-risk category either continued bleeding or rebled after apparent cessation (as against one out of 33 patients in the low-risk category). The high-rish group also had a higher mortality (21%) than those in the low-risk group (nil). The addition or subtraction of early endoscopic findings made little difference to the accuracy of prognosis.     

Anorexia nervosa and bulimia nervosa.

No definitive therapy exists for anorexia nervosa (AN) or bulimia nervosa (BN). Nevertheless, biologic and psychologic research into these disorders has increased over the last decade. We examine the various drugs available for treatment. Advances in pharmacotherapy for AN have been modest and have reflected efforts either to stimulate hunger and weight gain or to control complications of the starvation process. Food remains the "drug" of choice. Antidepressants have been found to be beneficial in the treatment of BN. The meaning of this in the context of a relation between BN and mood disorders remains unclear, since coexistent depression does not predict a positive response to these drugs. Pharmacotherapy represents a single but important dimension of the management of patients with eating disorders. The optimal integration of drug therapy and psychotherapy and the identification of predictors of a positive response to drugs have yet to be addressed by clinical research.