Predicting survival in patients with 'non-high-risk' acute variceal bleeding receiving ß-blockers+ligation to prevent re-bleeding.

BACKGROUND & AIMS: Pre-emptive transjugular intrahepatic portosystemic shunt (TIPS) is the treatment of choice for high-risk acute variceal bleeding (AVB; i.e., Child-Turcotte-Pugh [CTP] B8-9+active bleeding/C10-13). Nevertheless, some 'non-high-risk' patients have poor outcomes despite the combination of non-selective beta-blockers and endoscopic variceal ligation for secondary prophylaxis. We investigated prognostic factors for re-bleeding and mortality in 'non-high-risk' AVB to identify subgroups who may benefit from more potent treatments (i.e., TIPS) to prevent further decompensation and mortality. METHODS: A total of 2,225 adults with cirrhosis and variceal bleeding were prospectively recruited at 34 centres between 2011-2015; for the purpose of this study, case definitions and information on prognostic indicators at index AVB and on day 5 were further refined in low-risk patients, of whom 581 (without failure to control bleeding or contraindications to TIPS) who were managed by non-selective beta-blockers/endoscopic variceal ligation, were finally included. Patients were followed for 1 year. RESULTS: Overall, 90 patients (15%) re-bled and 70 (12%) patients died during follow-up. Using clinical routine data, no meaningful predictors of re-bleeding were identified. However, re-bleeding (included as a time-dependent co-variable) increased mortality, even after accounting for differences in patient characteristics (adjusted cause-specific hazard ratio: 2.57; 95% CI 1.43-4.62; p = 0.002). A nomogram including CTP, creatinine, and sodium measured at baseline accurately (concordance: 0.752) stratified the risk of death. CONCLUSION: The majority of 'non-high-risk' patients with AVB have an excellent prognosis, if treated according to current recommendations. However, about one-fifth of patients, i.e. those with CTP ≥8 and/or high creatinine levels or hyponatremia, have a considerable risk of death within 1 year of the index bleed. Future clinical trials should investigate whether elective TIPS placement reduces mortality in these patients. IMPACT AND IMPLICATIONS: Pre-emptive transjugular intrahepatic portosystemic shunt placement improves outcomes in high-risk acute variceal bleeding; nevertheless, some 'non-high-risk' patients have poor outcomes despite the combination of non-selective beta-blockers and endoscopic variceal ligation. This is the first large-scale study investigating prognostic factors for re-bleeding and mortality in 'non-high-risk' acute variceal bleeding. While no clinically meaningful predictors were identified for re-bleeding, we developed a nomogram integrating baseline Child-Turcotte-Pugh score, creatinine, and sodium to stratify mortality risk. Our study paves the way for future clinical trials evaluating whether elective transjugular intrahepatic portosystemic shunt placement improves outcomes in presumably 'non-high-risk' patients who are identified as being at increased risk of death.

Situación actual del manejo de la hemorragia digestiva alta no varicosa en España / Current management of nonvariceal upper gastrointestinal bleeding in Spain

Introducción La mortalidad en la hemorragia digestiva alta no varicosa (HDA-NV) no ha variado. Se necesita conocer más información para mejorar las estrategias de tratamiento. Los objetivos de este estudio fueron: a) describir el perfil de presentación de los episodios de HDA-NV; b) el manejo clínico según práctica clínica habitual, y c) establecer cuáles son los resultados clínicos asociados a los tratamientos endoscópicos y médicos en España. Métodos ENERGIB fue un estudio retrospectivo de cohortes que recogió información del manejo y forma de presentación de HDA-NV en Europa. Presentamos los datos relativos a España. Los pacientes se trataron según la práctica clínica habitual. Para las variables cuantitativas se calculó la media y la desviación estándar y para las categóricas se calcularon frecuencias absolutas y relativas. Resultados Los pacientes (n = 403) fueron hombres (71%), con edad media 65 años, asociaron comorbilidad (62,5%). Los equipos encargados de su manejo fueron gastroenterólogos (57,1%) o médicos internistas (25,1%). Los inhibidores de la bomba de protones se usaron de forma empírica preendoscopia en un 80% de los casos. El 6,4% presentó persistencia y el 6,7% resangrado después de la endoscopia. La tasa de mortalidad en los 30 días posteriores fue del 3,5%.ConclusionesEste estudio permite conocer el perfil de presentación de los episodios de HDA-NV en España y el manejo en práctica clínica habitual. Este se ajusta a los estándares propuestos por las recientes guías de práctica clínica. Entre otros datos destaca que los pacientes con hemorragia son cada vez de edad más avanzada y presentan un mayor número de enfermedades asociadas, lo que podría explicar que la mortalidad se haya mantenido estable a pesar de los evidentes avances en el manejo de esta entidad (AU)

Background Mortality related to nonvariceal upper gastrointestinal bleeding (NVUGIB) has not changed. More information is needed to improve the management of this entity. The aims of this study were: a) to determine the characteristics of bleeding episodes, b) to describe the clinical approaches routinely used in NVUGIB, and c) to identify adverse outcomes related to endoscopic or medical treatments in Spain. Methods The European survey of nonvariceal upper GI bleeding (ENERGiB) was an observational, retrospective cohort study on NVUGIB with endoscopic evaluation carried out across Europe. The present study focused on Spanish patients in the ENERGiB study. The patients were managed according to routine care. The mean and standard deviation were calculated for quantitative variables and absolute and relative frequencies were calculated for categorical variables. Results Patients (n=403) were mostly men (71%), with a mean age of 65 years, and co-morbidities (62.5%). Most of the patients were managed by gastroenterologists (57.1%) or internal medicine teams (25.1%). A proton pump inhibitor was used empirically in 80% before endoscopy. Bleeding persistence occurred in 6.4% and recurrence in 6.7%. The mortality rate at 30 days was 3.5%.ConclusionsThis study contributes to the characterization of Spanish patients and NVUGIB episodes in a real clinical setting and identifies the routine management of this entity, which is in line with the standards proposed by recent clinical practice guidelines. A notable finding was that age and the number of comorbidities in NVUGIB patients were increasing. These factors could explain the persistent mortality rate, despite the evident advances in the management of this entity (AU)

[Current management of nonvariceal upper gastrointestinal bleeding in Spain]. / Situación actual del manejo de la hemorragia digestiva alta no varicosa en España.

BACKGROUND: Mortality related to nonvariceal upper gastrointestinal bleeding (NVUGIB) has not changed. More information is needed to improve the management of this entity. The aims of this study were: a) to determine the characteristics of bleeding episodes, b) to describe the clinical approaches routinely used in NVUGIB, and c) to identify adverse outcomes related to endoscopic or medical treatments in Spain. METHODS: The European survey of nonvariceal upper GI bleeding (ENERGiB) was an observational, retrospective cohort study on NVUGIB with endoscopic evaluation carried out across Europe. The present study focused on Spanish patients in the ENERGiB study. The patients were managed according to routine care. The mean and standard deviation were calculated for quantitative variables and absolute and relative frequencies were calculated for categorical variables. RESULTS: Patients (n=403) were mostly men (71%), with a mean age of 65 years, and co-morbidities (62.5%). Most of the patients were managed by gastroenterologists (57.1%) or internal medicine teams (25.1%). A proton pump inhibitor was used empirically in 80% before endoscopy. Bleeding persistence occurred in 6.4% and recurrence in 6.7%. The mortality rate at 30 days was 3.5%. CONCLUSIONS: This study contributes to the characterization of Spanish patients and NVUGIB episodes in a real clinical setting and identifies the routine management of this entity, which is in line with the standards proposed by recent clinical practice guidelines. A notable finding was that age and the number of comorbidities in NVUGIB patients were increasing. These factors could explain the persistent mortality rate, despite the evident advances in the management of this entity.

Fiabilidad de la medición de la hemoglobina por HemoCue® en pacientes con hemorragia gastrointestinal / Reliability of hemoglobin measurement by HemoCue® in patients with gastrointestinal bleeding

La hemorragia gastrointestinal es una complicación frecuente en enfermedades del aparato digestivo, que requiere un seguimiento a cargo de una unidad de semicríticos, como la Unidad de Sangrantes Digestivos (USD). En el seguimiento de estos pacientes se determina diariamente la hemoglobina, por lo que se necesita un método rápido y fiable. Objetivo:Estudiar la fiabilidad del HemoCue® en pacientes con hemorragia gastrointestinal y determinar si hay diferencias en la medición de hemoglobina entre el HemoCue® y el laboratorio de referencia. Material y métodos:Estudio transversal observacional de muestras emparejadas de 54 pacientes tratados en la USD. La hemoglobina de los pacientes con hemorragia digestiva, tanto en la fase aguda (24h tras el sangrado) como en la fase hemodinámicamente estable, se midió con el HemoCue® (Angelholm, Suiza) y, simultáneamente, con el laboratorio. Los resultados se expresan como medias; para la comparación de medias se utilizaron el test de la t de Student para datos emparejados, el test de la r de Pearson para las correlaciones y el análisis de Bland y Altman para la cuantificación de las diferencias.Resultados: La etiología de la hemorragia en los 54 pacientes (34 varones) fue úlcera gastroduodenal en 26 casos, várices esofágicas en 8 casos, esofagitis en 6 casos, síndrome de Mallory-Weiss en 4 casos, gastropatía de la hipertensión portal en 9 casos y otras causas en un caso.En la fase aguda, la presión arterial media (PAM) fue de 83,8mmHg, la hemoglobina media medida con HemoCue® fue de 8,07g/dl en 0,81min en sangre capilar y la hemoglobina media medida con el laboratorio fue de 8,17g/dl en 44,87min en sangre venosa. El coeficiente de correlación r fue de 0,979. En la fase estable, la PAM fue de 100,7mmHg; la hemoglobina medida con HemoCue® fue de 9,32g/dl en 0,8min, y la medida con el laboratorio fue de 9,4g/dl en 47,83min. El coeficiente de correlación r en la fase estable fue de 0,966 (AU)

Gastrointestinal hemorrhage is a frequent complication in digestive diseases, requiring follow-up by specialized units such as the digestive bleeding unit. Hemoglobin is determined daily in the management of these patients, and consequently a rapid and reliable method for hemoglobin determination is required. Objective:To study the reliability of HemoCue® in patients with gastrointestinal hemorrhage and to determine whether there are any differences in hemoglobin measurement between HemoCue® and the reference laboratory.Materials and methodsWe performed a cross-sectional, observational paired sample study of 54 patients treated in the digestive bleeding unit. Hemoglobin was measured simultaneously by HemoCue® (Angelholm, Switzerland) and by laboratory determination in patients with gastrointestinal bleeding, both in the acute phase (first 24h of bleeding) and in the stable phase. The results are expressed as means. To compare means, Student's t-test was used for paired data, Pearson's r was used for correlations and Bland and Altman analysis was used to quantify differences.Results: Fifty-four patients (34 males) were included. The cause of the hemorrhage was duodenal/gastric ulcer in 26 patients, variceal bleeding in eight, esophagitis in five, Mallory Weiss syndrome in four, portal hypertensive gastropathy in nine and other causes in one. In the acute phase, mean arterial pressure (MAP) was 83.8, mean hemoglobin in capillary blood was 8.07g/dl by HemoCue® in 0.81min, and mean hemoglobin in venous blood was 8.17 by laboratory determination in 44.87min. Pearson's correlation coefficient was 0.979. In the stable phase, MAP was 100.7, and hemoglobin with HemoCue® was 9.32 in 0.8min and 9.4 by laboratory determination in 47.83min. Pearson's correlation coefficient in the stable phase was 0.966 (AU)

Enfermedades hepáticas durante el embarazo / No disponible

No disponible

¿Asociación entre colangiocarcinoma y mieloma múltiple? / Association between multiple myeloma and cholangiocarcinoma

No disponible