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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 -
World Journal of Gastroenterology Oct 2020More than five decades after it was originally conceptualized as rescue therapy for patients with intractable variceal bleeding, the transjugular intrahepatic... (Review)
Review
More than five decades after it was originally conceptualized as rescue therapy for patients with intractable variceal bleeding, the transjugular intrahepatic portosystemic shunt (TIPS) procedure continues to remain a focus of intense clinical and biomedical research. By the impressive reduction in portal pressure achieved by this intervention, coupled with its minimally invasive nature, TIPS has gained increasing acceptance in the treatment of complications of portal hypertension. The early years of TIPS were plagued by poor long-term patency of the stents and increased incidence of hepatic encephalopathy. Moreover, the diversion of portal flow after placement of TIPS often resulted in derangement of hepatic functions, which was occasionally severe. While the incidence of shunt dysfunction has markedly reduced with the advent of covered stents, hepatic encephalopathy and instances of early liver failure continue to remain a significant issue after TIPS. It has emerged over the years that careful selection of patients and diligent post-procedural care is of paramount importance to optimize the outcome after TIPS. The past twenty years have seen multiple studies redefining the role of TIPS in the management of variceal bleeding and refractory ascites while exploring its application in other complications of cirrhosis like hepatic hydrothorax, portal hypertensive gastropathy, ectopic varices, hepatorenal and hepatopulmonary syndromes, non-tumoral portal vein thrombosis and chylous ascites. It has also been utilized to good effect before extrahepatic abdominal surgery to reduce perioperative morbidity and mortality. The current article aims to review the updated literature on the status of TIPS in the management of patients with liver cirrhosis.
Topics: Ascites; Esophageal and Gastric Varices; Gastrointestinal Hemorrhage; Humans; Liver Cirrhosis; Portasystemic Shunt, Transjugular Intrahepatic; Treatment Outcome
PubMed: 33088154
DOI: 10.3748/wjg.v26.i37.5561 -
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 -
Clinical Gastroenterology and... Jan 2019Gastro-esophageal varices (GEV) and variceal hemorrhage (VH) are clinical milestones in the natural history of cirrhosis, as they are closely related to the severity of... (Review)
Review
Gastro-esophageal varices (GEV) and variceal hemorrhage (VH) are clinical milestones in the natural history of cirrhosis, as they are closely related to the severity of portal hypertension and define specific stages in disease progression. Variceal hemorrhage is a life-threatening complication of cirrhosis and is one of the clinical complications that defines cirrhosis decompensation. The goal of screening and surveillance of varices is to identify patients with GEV at a high risk of bleeding, so that prevention strategies can be implemented. There have been significant updates in the management of GEV over the last years, particularly in the use of non-invasive methods to assess the degree of portal hypertension and the likelihood of having GEV. This paper is focused on esophageal varices with or without extension along the lesser curvature (type 1 or GOV1), as special considerations are required for the management of cardiofundal varices (GOV2 - esophageal varices extending into the fundus, or IGV1 - isolated gastric varices in the fundus) or isolated gastric varices type 2 (IGV2 – gastric varices elsewhere in the stomach, not in the fundus).
Topics: Epidemiological Monitoring; Esophageal and Gastric Varices; Gastrointestinal Hemorrhage; Humans; Liver Cirrhosis; Mass Screening
PubMed: 29551741
DOI: 10.1016/j.cgh.2018.03.012 -
British Medical Journal Aug 1963
Topics: Alcoholism; Esophageal and Gastric Varices; Humans
PubMed: 14042763
DOI: 10.1136/bmj.2.5356.516 -
The Israel Medical Association Journal... Feb 2013Portal hypertension is the leading cause of morbidity and mortality in liver cirrhosis. Complications of portal hypertension in cirrhotic patients include esophageal and... (Review)
Review
Portal hypertension is the leading cause of morbidity and mortality in liver cirrhosis. Complications of portal hypertension in cirrhotic patients include esophageal and gastric varices, portal hypertensive gastropathy, ascites, hepatorenal syndrome, hepatopulmonary syndrome and portopulmonary hypertension. The hepatic venous pressure gradient should be at least 10 mmHg for esophageal varices to appear, and more than 12 mmHg for acute esophageal variceal bleeding. This article reviews the pathophysiology responsible for portal hypertension and its complications, and the treatments used for esophageal varices in the setting of primary and secondary prophylaxis and during active bleeding.
Topics: Esophageal and Gastric Varices; Humans; Hypertension, Portal; Liver Cirrhosis; Primary Prevention; Secondary Prevention
PubMed: 23516775
DOI: No ID Found -
World Journal of Gastroenterology Sep 2008Capsule endoscopy is now considered as the first imaging tool for small bowel examination. Recently, new capsule endoscopy applications have been developed, such as... (Review)
Review
Capsule endoscopy is now considered as the first imaging tool for small bowel examination. Recently, new capsule endoscopy applications have been developed, such as esophageal capsule endoscopy and colon capsule endoscopy. Esophageal capsule endoscopy in patients with suspected esophageal disorders is feasible and safe, and could be also an alternative procedure in those patients refusing upper endoscopy. Although large-scale studies are needed to confirm its utility in GERD and cirrhotic patients, current results are encouraging and open a new era in esophageal examination.
Topics: Capsule Endoscopes; Capsule Endoscopy; Esophageal Diseases; Esophageal and Gastric Varices; Gastroesophageal Reflux; Humans; Hypertension, Portal
PubMed: 18785275
DOI: 10.3748/wjg.14.5254 -
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 Jul 2023Acute bleeding due to esophageal varices (EVs) is a life-threatening complication in patients with cirrhosis. The diagnosis of EVs is mainly through upper...
BACKGROUND
Acute bleeding due to esophageal varices (EVs) is a life-threatening complication in patients with cirrhosis. The diagnosis of EVs is mainly through upper gastrointestinal endoscopy, but the discomfort, contraindications and complications of gastrointestinal endoscopic screening reduce patient compliance. According to the bleeding risk of EVs, the Baveno VI consensus divides varices into high bleeding risk EVs (HEVs) and low bleeding risk EVs (LEVs). We sought to identify a non-invasive prediction model based on spleen stiffness measurement (SSM) and liver stiffness measurement (LSM) as an alternative to EVs screening.
AIM
To develop a safe, simple and non-invasive model to predict HEVs in patients with viral cirrhosis and identify patients who can be exempted from upper gastrointestinal endoscopy.
METHODS
Data from 200 patients with viral cirrhosis were included in this study, with 140 patients as the modelling group and 60 patients as the external validation group, and the EVs types of patients were determined by upper gastrointestinal endoscopy and the Baveno VI consensus. Those patients were divided into the HEVs group (66 patients) and the LEVs group (74 patients). The effect of each parameter on HEVs was analyzed by univariate and multivariate analyses, and a non-invasive prediction model was established. Finally, the discrimination ability, calibration ability and clinical efficacy of the new model were verified in the modelling group and the external validation group.
RESULTS
Univariate and multivariate analyses showed that SSM and LSM were associated with the occurrence of HEVs in patients with viral cirrhosis. On this basis, logistic regression analysis was used to construct a prediction model: Ln [P/(1-P)] = -8.184 -0.228 × SSM + 0.642 × LSM. The area under the curve of the new model was 0.965. When the cut-off value was 0.27, the sensitivity, specificity, positive predictive value and negative predictive value of the model for predicting HEVs were 100.00%, 82.43%, 83.52%, and 100%, respectively. Compared with the four prediction models of liver stiffness-spleen diameter to platelet ratio score, variceal risk index, aspartate aminotransferase to alanine aminotransferase ratio, and Baveno VI, the established model can better predict HEVs in patients with viral cirrhosis.
CONCLUSION
Based on the SSM and LSM measured by transient elastography, we established a non-invasive prediction model for HEVs. The new model is reliable in predicting HEVs and can be used as an alternative to routine upper gastrointestinal endoscopy screening, which is helpful for clinical decision making.
Topics: Humans; Esophageal and Gastric Varices; Spleen; Liver Cirrhosis; Hemorrhage; Elasticity Imaging Techniques
PubMed: 37476583
DOI: 10.3748/wjg.v29.i25.4072 -
Annals of Hepatology 2019Variceal bleeding is a dramatic complication of cirrhosis. Primary prophylaxis against variceal bleeding is indicated for patients with high-risk varices. In order for... (Review)
Review
Variceal bleeding is a dramatic complication of cirrhosis. Primary prophylaxis against variceal bleeding is indicated for patients with high-risk varices. In order for these patients to be identified, endoscopic screening for esophageal varices has been traditionally recommended at the time of the diagnosis of cirrhosis. Considering that many patients do not have esophageal varices in the early stages of cirrhosis and, therefore, are submitted to endoscopy unnecessarily, non-invasive methods for variceal screening have been studied. Among these non-invasive methods, the most extensively studied probably are platelet count/spleen diameter ratio, liver stiffness, spleen stiffness and an association between liver stiffness and platelet count, referred to as the Baveno VI criteria. The Baveno VI criteria has recently been recommended by different medical associations for variceal screening. This is a critical review on the non-invasive methods for variceal screening, in which the performances of the different methods are presented and the limitations of the existing evidence is discussed. Despite reasonable performances of some of these methods, especially platelet count/spleen diameter ratio and the association between liver stiffness and platelet count, we understand that the available evidence still has relevant limitations and that physicians should decide on screening cirrhotic patients for esophageal varices with endoscopy or non-invasive methods on a case-by-case basis.
Topics: Elasticity Imaging Techniques; Endoscopy, Gastrointestinal; Esophageal and Gastric Varices; Gastrointestinal Hemorrhage; Humans; Liver Cirrhosis; Mass Screening
PubMed: 31279653
DOI: 10.1016/j.aohep.2019.06.003