-
Endoscopy Nov 20221: ESGE recommends that patients with compensated advanced chronic liver disease (ACLD; due to viruses, alcohol, and/or nonobese [BMI < 30 kg/m] nonalcoholic...
1: ESGE recommends that patients with compensated advanced chronic liver disease (ACLD; due to viruses, alcohol, and/or nonobese [BMI < 30 kg/m] nonalcoholic steatohepatitis) and clinically significant portal hypertension (hepatic venous pressure gradient [HVPG] > 10 mmHg and/or liver stiffness by transient elastography > 25 kPa) should receive, if no contraindications, nonselective beta blocker (NSBB) therapy (preferably carvedilol) to prevent the development of variceal bleeding.Strong recommendation, moderate quality evidence. 2: ESGE recommends that in those patients unable to receive NSBB therapy with a screening upper gastrointestinal (GI) endoscopy that demonstrates high risk esophageal varices, endoscopic band ligation (EBL) is the endoscopic prophylactic treatment of choice. EBL should be repeated every 2-4 weeks until variceal eradication is achieved. Thereafter, surveillance EGD should be performed every 3-6 months in the first year following eradication.Strong recommendation, moderate quality evidence. 3: ESGE recommends, in hemodynamically stable patients with acute upper GI hemorrhage (UGIH) and no history of cardiovascular disease, a restrictive red blood cell (RBC) transfusion strategy, with a hemoglobin threshold of ≤ 70 g/L prompting RBC transfusion. A post-transfusion target hemoglobin of 70-90 g/L is desired.Strong recommendation, moderate quality evidence. 4 : ESGE recommends that patients with ACLD presenting with suspected acute variceal bleeding be risk stratified according to the Child-Pugh score and MELD score, and by documentation of active/inactive bleeding at the time of upper GI endoscopy.Strong recommendation, high quality of evidence. 5 : ESGE recommends the vasoactive agents terlipressin, octreotide, or somatostatin be initiated at the time of presentation in patients with suspected acute variceal bleeding and be continued for a duration of up to 5 days.Strong recommendation, high quality evidence. 6 : ESGE recommends antibiotic prophylaxis using ceftriaxone 1 g/day for up to 7 days for all patients with ACLD presenting with acute variceal hemorrhage, or in accordance with local antibiotic resistance and patient allergies.Strong recommendation, high quality evidence. 7 : ESGE recommends, in the absence of contraindications, intravenous erythromycin 250 mg be given 30-120 minutes prior to upper GI endoscopy in patients with suspected acute variceal hemorrhage.Strong recommendation, high quality evidence. 8 : ESGE recommends that, in patients with suspected variceal hemorrhage, endoscopic evaluation should take place within 12 hours from the time of patient presentation provided the patient has been hemodynamically resuscitated.Strong recommendation, moderate quality evidence. 9 : ESGE recommends EBL for the treatment of acute esophageal variceal hemorrhage (EVH).Strong recommendation, high quality evidence. 10 : ESGE recommends that, in patients at high risk for recurrent esophageal variceal bleeding following successful endoscopic hemostasis (Child-Pugh C ≤ 13 or Child-Pugh B > 7 with active EVH at the time of endoscopy despite vasoactive agents, or HVPG > 20 mmHg), pre-emptive transjugular intrahepatic portosystemic shunt (TIPS) within 72 hours (preferably within 24 hours) must be considered.Strong recommendation, high quality evidence. 11 : ESGE recommends that, for persistent esophageal variceal bleeding despite vasoactive pharmacological and endoscopic hemostasis therapy, urgent rescue TIPS should be considered (where available).Strong recommendation, moderate quality evidence. 12 : ESGE recommends endoscopic cyanoacrylate injection for acute gastric (cardiofundal) variceal (GOV2, IGV1) hemorrhage.Strong recommendation, high quality evidence. 13: ESGE recommends endoscopic cyanoacrylate injection or EBL in patients with GOV1-specific bleeding.Strong recommendations, moderate quality evidence. 14: ESGE suggests urgent rescue TIPS or balloon-occluded retrograde transvenous obliteration (BRTO) for gastric variceal bleeding when there is a failure of endoscopic hemostasis or early recurrent bleeding.Weak recommendation, low quality evidence. 15: ESGE recommends that patients who have undergone EBL for acute EVH should be scheduled for follow-up EBLs at 1- to 4-weekly intervals to eradicate esophageal varices (secondary prophylaxis).Strong recommendation, moderate quality evidence. 16: ESGE recommends the use of NSBBs (propranolol or carvedilol) in combination with endoscopic therapy for secondary prophylaxis in EVH in patients with ACLD.Strong recommendation, high quality evidence.
Topics: Humans; Esophageal and Gastric Varices; Gastrointestinal Hemorrhage; Carvedilol; Endoscopy, Gastrointestinal; Cyanoacrylates; Portasystemic Shunt, Transjugular Intrahepatic
PubMed: 36174643
DOI: 10.1055/a-1939-4887 -
Gastroenterology Jan 2018Gastroesophageal reflux disease (GERD) is the most prevalent gastrointestinal disorder in the United States, and leads to substantial morbidity, though associated... (Review)
Review
Gastroesophageal reflux disease (GERD) is the most prevalent gastrointestinal disorder in the United States, and leads to substantial morbidity, though associated mortality is rare. The prevalence of GERD symptoms appeared to increase until 1999. Risk factors for complications of GERD include advanced age, male sex, white race, abdominal obesity, and tobacco use. Most patients with GERD present with heartburn and effortless regurgitation. Coexistent dysphagia is considered an alarm symptom, prompting evaluation. There is substantial overlap between symptoms of GERD and those of eosinophilic esophagitis, functional dyspepsia, and gastroparesis, posing a challenge for patient management.
Topics: Age Factors; Biopsy; Diagnosis, Differential; Dyspepsia; Eosinophilic Esophagitis; Esophageal Neoplasms; Esophagitis, Peptic; Esophagoscopy; Female; Gastroesophageal Reflux; Gastrointestinal Hemorrhage; Gastroparesis; Heartburn; Humans; Male; Obesity; Prevalence; Quality of Life; Risk Factors; Sex Factors; United States
PubMed: 28780072
DOI: 10.1053/j.gastro.2017.07.045 -
Clinics in Liver Disease Aug 2020Variceal bleeding is a complication of cirrhosis that defines decompensation. Important advances in the management of gastroesophageal varices have led to a significant... (Review)
Review
Variceal bleeding is a complication of cirrhosis that defines decompensation. Important advances in the management of gastroesophageal varices have led to a significant decrease in the morbidity and mortality. Achieving these results in clinical practice is contingent on clinicians applying the best practice strategies and appropriate referral to a tertiary center. Several quality metrics were developed by the American Association for the Study of Liver Diseases. This article aims to update outpatient and inpatient strategies to include the latest recommendations on variceal screening and surveillance, primary and secondary prophylaxis of variceal bleeding, and therapy for patients with acute variceal bleeding.
Topics: Adrenergic beta-Antagonists; Ambulatory Care; Endoscopy, Gastrointestinal; Esophageal and Gastric Varices; Gastric Fundus; Gastrointestinal Hemorrhage; Hospitalization; Humans; Ligation; Liver Cirrhosis; Secondary Prevention
PubMed: 32620275
DOI: 10.1016/j.cld.2020.04.011 -
Medicine Nov 2022Acute upper gastrointestinal bleeding (UGIB) is a typical medical emergency, with an incidence of 84 to 160 cases per 100,000 individuals and a mortality rate of... (Observational Study)
Observational Study
Acute upper gastrointestinal bleeding (UGIB) is a typical medical emergency, with an incidence of 84 to 160 cases per 100,000 individuals and a mortality rate of approximately 10%. This study aimed to identify all cases of UGIB hospitalized in a tertiary gastroenterology department, to identify possible predictive factors involved in rebleeding and mortality, potential associations between different elements and the severity of bleeding, and the differences between the upper digestive hemorrhage due to nonvariceal and variceal bleeding. This was an observational, retrospective study of patients with UGIB admitted to the tertiary Department of Gastroenterology between January 2013 and December 2020. A total of 1499 patients were enrolled in the study. One thousand four hundred and ninety-nine patients were hospitalized for 7 years with active upper digestive hemorrhage, 504 variceal bleeding, and 995 nonvariceal bleeding. When comparing variceal with nonvariceal bleeding, in nonvariceal bleeding, the mean age was higher, similar sex, higher mortality rate, higher rebleeding rate, and higher hemorrhagic shock rate. Endoscopy treatment was also performed more frequently in variceal bleeding than in nonvariceal bleeding. Severe anemia was found more frequently in patients with variceal bleeding. The mortality rate was 10% in the entire study group, which was not significantly different between the 2 batches. However, the rebleeding rate is higher in patients with variceal gastrointestinal bleeding.
Topics: Humans; Gastrointestinal Hemorrhage; Esophageal and Gastric Varices; Retrospective Studies; Acute Disease; Endoscopy, Gastrointestinal; Varicose Veins
PubMed: 36397398
DOI: 10.1097/MD.0000000000031543 -
Revista Espanola de Enfermedades... Nov 2023A 76-year-old man with multiple cardiovascular risk factors (hypertension, DM2, LD, smoker) and severe peripheral arterial disease (iliofemoral bypass, supracondylar...
A 76-year-old man with multiple cardiovascular risk factors (hypertension, DM2, LD, smoker) and severe peripheral arterial disease (iliofemoral bypass, supracondylar amputation) came to the emergency with coffee ground emesis and mild anemia. Urgent gastroscopy showed diffuse circumferential black mucosa covered by fibrin affecting the middle and distal esophageal third. Acute esophageal necrosis is a rare cause of gastrointestinal bleeding that should be suspected in patients with cardiovascular risk factors with an image of a black esophagus that is abruptly interrupted at the EGJ.
Topics: Male; Humans; Aged; Necrosis; Esophageal Diseases; Hematemesis; Gastrointestinal Hemorrhage; Acute Disease
PubMed: 36205331
DOI: 10.17235/reed.2022.9217/2022 -
Gut Nov 2015These updated guidelines on the management of variceal haemorrhage have been commissioned by the Clinical Services and Standards Committee (CSSC) of the British Society...
These updated guidelines on the management of variceal haemorrhage have been commissioned by the Clinical Services and Standards Committee (CSSC) of the British Society of Gastroenterology (BSG) under the auspices of the liver section of the BSG. The original guidelines which this document supersedes were written in 2000 and have undergone extensive revision by 13 members of the Guidelines Development Group (GDG). The GDG comprises elected members of the BSG liver section, representation from British Association for the Study of the Liver (BASL) and Liver QuEST, a nursing representative and a patient representative. The quality of evidence and grading of recommendations was appraised using the AGREE II tool.The nature of variceal haemorrhage in cirrhotic patients with its complex range of complications makes rigid guidelines inappropriate. These guidelines deal specifically with the management of varices in patients with cirrhosis under the following subheadings: (1) primary prophylaxis; (2) acute variceal haemorrhage; (3) secondary prophylaxis of variceal haemorrhage; and (4) gastric varices. They are not designed to deal with (1) the management of the underlying liver disease; (2) the management of variceal haemorrhage in children; or (3) variceal haemorrhage from other aetiological conditions.
Topics: Algorithms; Esophageal and Gastric Varices; Gastrointestinal Hemorrhage; Humans; Liver Cirrhosis
PubMed: 25887380
DOI: 10.1136/gutjnl-2015-309262 -
F1000Research 2019Gastrointestinal bleeding is one of the major causes of death in patients with cirrhosis, and gastroesophageal varices represent the main source of hemorrhage. Even... (Review)
Review
Gastrointestinal bleeding is one of the major causes of death in patients with cirrhosis, and gastroesophageal varices represent the main source of hemorrhage. Even though in the last decades survival has been improved because of the widespread adoption of effective treatments and optimization of general medical care, mortality is still significantly high, and decompensated patients pose a complex challenge requiring a multidisciplinary approach that is crucial to improve survival. The aims of this commentary are to review the most recent advances in the management of esophageal variceal bleeding and to highlight useful information to aid hepatologists in clinical practice.
Topics: Acute Disease; Esophageal and Gastric Varices; Gastrointestinal Hemorrhage; Humans; Hypertension, Portal; Liver Cirrhosis
PubMed: 31281637
DOI: 10.12688/f1000research.18807.1 -
Clinics in Liver Disease Nov 2014Transjugular intrahepatic portosystemic shunt (TIPS) is an established procedure for the complications of portal hypertension. The largest body of evidence for its use... (Review)
Review
Transjugular intrahepatic portosystemic shunt (TIPS) is an established procedure for the complications of portal hypertension. The largest body of evidence for its use has been supported for recurrent or refractory variceal bleeding and refractory ascites. Its use has also been advocated for acute variceal bleed, hepatic hydrothorax, and hepatorenal syndrome. With the replacement of bare metal stents with polytetrafluoroethylene-covered stents, shunt patency has improved dramatically, thus, improving outcomes. Therefore, reassessment of its utility, management of its complications, and understanding of various TIPS techniques is important.
Topics: Esophageal and Gastric Varices; Gastrointestinal Hemorrhage; Humans; Polytetrafluoroethylene; Portasystemic Shunt, Transjugular Intrahepatic; Stents
PubMed: 25438287
DOI: 10.1016/j.cld.2014.07.006 -
World Journal of Gastroenterology Aug 2013Bleeding from esophageal varices is a life threatening complication of portal hypertension. Primary prevention of bleeding in patients at risk for a first bleeding... (Review)
Review
Bleeding from esophageal varices is a life threatening complication of portal hypertension. Primary prevention of bleeding in patients at risk for a first bleeding episode is therefore a major goal. Medical prophylaxis consists of non-selective beta-blockers like propranolol or carvedilol. Variceal endoscopic band ligation is equally effective but procedure related morbidity is a drawback of the method. Therapy of acute bleeding is based on three strategies: vasopressor drugs like terlipressin, antibiotics and endoscopic therapy. In refractory bleeding, self-expandable stents offer an option for bridging to definite treatments like transjugular intrahepatic portosystemic shunt (TIPS). Treatment of bleeding from gastric varices depends on vasopressor drugs and on injection of varices with cyanoacrylate. Strategies for primary or secondary prevention are based on non-selective beta-blockers but data from large clinical trials is lacking. Therapy of refractory bleeding relies on shunt-procedures like TIPS. Bleeding from ectopic varices, portal hypertensive gastropathy and gastric antral vascular ectasia-syndrome is less common. Possible medical and endoscopic treatment options are discussed.
Topics: Adrenergic beta-Antagonists; Anti-Bacterial Agents; Endoscopy; Esophageal and Gastric Varices; Gastrointestinal Hemorrhage; Hemostasis, Endoscopic; Humans; Hypertension, Portal; Ligation; Portasystemic Shunt, Transjugular Intrahepatic; Stents; Treatment Outcome; Vasoconstrictor Agents
PubMed: 23964137
DOI: 10.3748/wjg.v19.i31.5035 -
Clinical Medicine (London, England) Oct 2015Acute oesophageal symptoms include acute dysphagia or food bolus impaction (most commonly due to strictures, Schatzki ring and eosinophilic oesophagitis), acute chest... (Review)
Review
Acute oesophageal symptoms include acute dysphagia or food bolus impaction (most commonly due to strictures, Schatzki ring and eosinophilic oesophagitis), acute chest pain with odynophagia due to oesophageal infections, motility disorders and acute oesophageal rupture (of which oesophageal intramural haematoma is a subtype). Acute full thickness oesophageal rupture carries a high mortality if not recognised early; the clinical features and conditions with which this may be confused are presented and discussed.
Topics: Acute Disease; Esophageal Achalasia; Esophageal Diseases; Esophageal Motility Disorders; Esophageal Spasm, Diffuse; Hematoma; Humans; Infections; Rupture, Spontaneous
PubMed: 26430190
DOI: 10.7861/clinmedicine.15-5-477