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1.
Zhonghua Gan Zang Bing Za Zhi ; 32(6): 481-483, 2024 Jun 20.
Article de Chinois | MEDLINE | ID: mdl-38964887

RÉSUMÉ

Managing cirrhosis complications is an important measure for improving patients' clinical outcomes. Therefore, in order to provide a complete disease assessment and comprehensive treatment, improve quality of life, and improve the prognosis for patients with cirrhosis, it is necessary to pay attention to complications such as thrombocytopenia and portal vein thrombosis in addition to common or severe complications such as ascites, esophagogastric variceal bleeding, hepatic encephalopathy, and hepatorenal syndrome. The relevant concept that an effective albumin concentration is more helpful in predicting the cirrhosis outcome is gradually being accepted; however, the detection method still needs further standardization and commercialization.


Sujet(s)
Encéphalopathie hépatique , Cirrhose du foie , Humains , Cirrhose du foie/complications , Cirrhose du foie/diagnostic , Encéphalopathie hépatique/étiologie , Encéphalopathie hépatique/diagnostic , Encéphalopathie hépatique/thérapie , Syndrome hépatorénal/étiologie , Syndrome hépatorénal/diagnostic , Syndrome hépatorénal/thérapie , Ascites/étiologie , Ascites/thérapie , Ascites/diagnostic , Thrombopénie/étiologie , Thrombopénie/diagnostic , Thrombopénie/thérapie , Varices oesophagiennes et gastriques/diagnostic , Varices oesophagiennes et gastriques/étiologie , Varices oesophagiennes et gastriques/thérapie , Hémorragie gastro-intestinale/étiologie , Hémorragie gastro-intestinale/diagnostic , Hémorragie gastro-intestinale/thérapie
2.
Clin Liver Dis ; 28(3): 437-453, 2024 Aug.
Article de Anglais | MEDLINE | ID: mdl-38945636

RÉSUMÉ

Interventions for portal hypertension are continuously evolving and expanding beyond the realm of medical management. When complications such as varices and ascites persist despite conservative interventions, procedures including transjugular intrahepatic portosystemic shunt creation, transvenous obliteration, portal vein recanalization, splenic artery embolization, surgical shunt creation, and devascularization are all potential interventions detailed in this article. Selection of the optimal procedure to address the underlying cause, treat symptoms, and, in some cases, bridge to liver transplantation depends on the specific etiology of portal hypertension and the patient's comorbidities.


Sujet(s)
Embolisation thérapeutique , Hypertension portale , Anastomose portosystémique intrahépatique par voie transjugulaire , Humains , Hypertension portale/chirurgie , Hypertension portale/thérapie , Hypertension portale/étiologie , Anastomose portosystémique intrahépatique par voie transjugulaire/méthodes , Embolisation thérapeutique/méthodes , Veine porte/chirurgie , Varices oesophagiennes et gastriques/chirurgie , Varices oesophagiennes et gastriques/étiologie , Varices oesophagiennes et gastriques/thérapie , Artère splénique/chirurgie , Artère splénique/imagerie diagnostique , Anastomose chirurgicale portosystémique/méthodes , Transplantation hépatique
3.
Clin Liver Dis ; 28(3): 483-501, 2024 Aug.
Article de Anglais | MEDLINE | ID: mdl-38945639

RÉSUMÉ

In portal hypertension, acute variceal bleed is the cause of 2/3rd of all upper gastrointestinal bleeding episodes. It is a life-threatening emergency in patients with cirrhosis. Nonselective beta-blockers by decreasing the hepatic venous pressure gradient are the mainstay of medical therapy for the prevention of variceal bleeding and rebleeding. Evaluation of the severity of bleed, hemodynamic resuscitation, prophylactic antibiotic, and intravenous splanchnic vasoconstrictors should precede the endoscopy procedure. Endoscopic band ligation is the recommended endotherapy. Rescue transjugular intrahepatic port-systemic shunt (TIPS) is recommended for variceal bleed refractory to endotherapy. In patients with a high risk of failure of combined pharmacologic and endoscopic therapy, pre-emptive TIPS may improve the outcome. For gastric varices, "Sarin classification" is universally applied as it is simple and has therapeutic implication. For IGV1 and GOV2, injection cyanoacrylate glue is considered the endotherapy of choice. Endoscopic ultrasound is a useful modality in the management of gastric varices.


Sujet(s)
Varices oesophagiennes et gastriques , Hémorragie gastro-intestinale , Hypertension portale , Anastomose portosystémique intrahépatique par voie transjugulaire , Humains , Hypertension portale/thérapie , Hypertension portale/complications , Hémorragie gastro-intestinale/étiologie , Hémorragie gastro-intestinale/thérapie , Varices oesophagiennes et gastriques/thérapie , Varices oesophagiennes et gastriques/étiologie , Ligature , Antagonistes bêta-adrénergiques/usage thérapeutique , Cirrhose du foie/complications
6.
Am J Emerg Med ; 81: 116-123, 2024 Jul.
Article de Anglais | MEDLINE | ID: mdl-38723362

RÉSUMÉ

INTRODUCTION: Upper gastrointestinal bleeding (UGIB) is a condition commonly seen in the emergency department (ED). Therefore, it is important for emergency clinicians to be aware of the current evidence regarding the diagnosis and management of this disease. OBJECTIVE: This paper evaluates key evidence-based updates concerning UGIB for the emergency clinician. DISCUSSION: UGIB most frequently presents with hematemesis. There are numerous causes, with the most common peptic ulcer disease, though variceal bleeding in particular can be severe. Nasogastric tube lavage for diagnosis is not recommended based on the current evidence. A hemoglobin transfusion threshold of 7 g/dL is recommended (8 g/dL in those with myocardial ischemia), but patients with severe bleeding and hemodynamic instability require emergent transfusion regardless of their level. Medications that may be used in UGIB include proton pump inhibitors, prokinetic agents, and vasoactive medications. Antibiotics are recommended for those with cirrhosis and suspected variceal bleeding. Endoscopy is the diagnostic and therapeutic modality of choice and should be performed within 24 h of presentation in non-variceal bleeding after resuscitation, though patients with variceal bleeding may require endoscopy within 12 h. Transcatheter arterial embolization or surgical intervention may be necessary. Intubation should be avoided if possible. If intubation is necessary, several considerations are required, including resuscitation prior to induction, utilizing preoxygenation and appropriate suction, and administering a prokinetic agent. There are a variety of tools available for risk stratification, including the Glasgow Blatchford Score. CONCLUSIONS: An understanding of literature updates can improve the ED care of patients with UGIB.


Sujet(s)
Hémorragie gastro-intestinale , Humains , Hémorragie gastro-intestinale/thérapie , Hémorragie gastro-intestinale/diagnostic , Hémorragie gastro-intestinale/étiologie , Service hospitalier d'urgences , Inhibiteurs de la pompe à protons/usage thérapeutique , Varices oesophagiennes et gastriques/thérapie , Varices oesophagiennes et gastriques/diagnostic , Varices oesophagiennes et gastriques/complications , Hématémèse/étiologie , Hématémèse/thérapie , Médecine d'urgence , Endoscopie gastrointestinale
7.
J Nippon Med Sch ; 91(2): 180-189, 2024.
Article de Anglais | MEDLINE | ID: mdl-38777781

RÉSUMÉ

BACKGROUND: The incidence of alcoholic liver cirrhosis (ALC) is increasing. However, few reports have focused on ALC-derived esophageal varices (EV). We retrospectively examined differences in overall survival (OS) and EV recurrence rate in patients after endoscopic injection sclerotherapy (EIS) for ALC and hepatic B/C virus liver cirrhosis (B/C-LC). METHODS: We analyzed data from 215 patients (B/C-LC, 147; ALC, 68) who underwent EIS. The primary endpoints were OS and EV recurrence in patients with unsuccessful abstinence ALC and those with uncontrolled B/C-LC, before and after propensity score matching (PSM) to unify the patients' background. The secondary endpoints were predictors associated with these factors, as determined by multivariate analysis. RESULTS: The observation period was 1,430 ± 1,363 days. In the analysis of all patients, OS was significantly higher in the ALC group than in the B/C-LC group (p = 0.039); however, there was no difference in EV recurrence rate (p = 0.502). Ascites and history of hepatocellular carcinoma (HCC) (p = 0.019 and p < 0.001, respectively) predicted OS, whereas age and EV size predicted recurrence (p = 0.011 and 0.024, respectively). In total, 96 patients without an HCC history were matched by PSM, and there was no significant difference in OS or EV recurrence rate (p = 0.508 and 0.246, respectively). CONCLUSION: When limited to patients without a history of HCC, OS and the EV recurrence rate were comparable in patients with ALC who continued to consume alcohol and those with B/C-LC without viral control.


Sujet(s)
Varices oesophagiennes et gastriques , Cirrhose alcoolique , Cirrhose du foie , Récidive , Sclérothérapie , Humains , Varices oesophagiennes et gastriques/étiologie , Varices oesophagiennes et gastriques/thérapie , Mâle , Femelle , Adulte d'âge moyen , Études rétrospectives , Sclérothérapie/méthodes , Cirrhose alcoolique/complications , Cirrhose du foie/complications , Résultat thérapeutique , Sujet âgé , Carcinome hépatocellulaire/thérapie , Tumeurs du foie/thérapie , Adulte , Score de propension
8.
World J Gastroenterol ; 30(19): 2615-2617, 2024 May 21.
Article de Anglais | MEDLINE | ID: mdl-38817659

RÉSUMÉ

Variceal bleed represents an important complication of cirrhosis, with its presence reflecting the severity of liver disease. Gastric varices, though less frequently seen than esophageal varices, present a distinct clinical challenge due to its higher intensity of bleeding and associated mortality. Based upon the Sarin classification, GOV1 is the most common subtype of gastric varices seen in clinical practice.


Sujet(s)
Varices oesophagiennes et gastriques , Hémorragie gastro-intestinale , Cirrhose du foie , Varices oesophagiennes et gastriques/étiologie , Varices oesophagiennes et gastriques/thérapie , Varices oesophagiennes et gastriques/diagnostic , Humains , Hémorragie gastro-intestinale/étiologie , Hémorragie gastro-intestinale/thérapie , Hémorragie gastro-intestinale/diagnostic , Cirrhose du foie/complications , Résultat thérapeutique , Indice de gravité de la maladie
10.
Rev Gastroenterol Peru ; 44(1): 67-70, 2024.
Article de Anglais | MEDLINE | ID: mdl-38734914

RÉSUMÉ

Acute gastric variceal bleeding is a life-threatening condition that could be effectively treated with endoscopic cyanoacrylate injection diluted with lipiodol. The mixture acts as a tissue adhesive that polymerizes when in contact with blood in a gastric varix. This work reports a patient that presented to the emergency department with upper gastrointestinal bleeding due to acute variceal bleeding, who developed systemic embolization following cyanoacrylate injection therapy. This complication culminated in cerebral, splenic and renal infarctions with a fatal outcome. Systemic embolization is a very rare, but the most severe complication associated with endoscopic cyanoacrylate injection and should be considered in patients undergoing this treatment.


Sujet(s)
Cyanoacrylates , Varices oesophagiennes et gastriques , Hémorragie gastro-intestinale , Adhésifs tissulaires , Humains , Cyanoacrylates/usage thérapeutique , Cyanoacrylates/administration et posologie , Cyanoacrylates/effets indésirables , Embolie/étiologie , Embolie/thérapie , Embolisation thérapeutique/méthodes , Varices oesophagiennes et gastriques/thérapie , Varices oesophagiennes et gastriques/étiologie , Issue fatale , Hémorragie gastro-intestinale/thérapie , Hémorragie gastro-intestinale/étiologie , Adhésifs tissulaires/usage thérapeutique , Adhésifs tissulaires/administration et posologie
11.
Narra J ; 4(1): e245, 2024 Apr.
Article de Anglais | MEDLINE | ID: mdl-38798860

RÉSUMÉ

Budd-Chiari syndrome is one of the post-hepatic causes of portal hypertension and a potential obstruction causes liver fibrosis. In pregnancy, obstruction of hepatic veins could occur due to stenosis or thrombosis. Variceal bleeding is the most fatal complication in pregnancy with co-existing Budd-Chiari syndrome, with 29.4% incidence of abortion and 33.3% perinatal mortality. The aim of this case report was to present the management of non-cirrhotic variceal bleeding in pregnant women with Budd-Chiari syndrome in the early second trimester. We report a pregnant female at 13-14 weeks gestation presented to the hospital with profuse hematemesis. Doppler ultrasonography (USG) was utilized to confirm the diagnosis of Budd-Chiari syndrome-hepatic vein occlusion type in pregnancy. Abdominal USG revealed hepatomegaly with hepatic veins dilation, while endoscopy showed grade IV esophageal varices and grade IV gastric varices. Laboratory results indicated disseminated intravascular coagulation due to hemorrhage. The patient was given strict fluid resuscitation and three packed red cells transfusion to stabilize the hemodynamic. Bleeding was successfully managed by intravenous octreotide, tranexamic acid, and vitamin K. The case highlights that the management of non-cirrhotic variceal bleeding in pregnancy with Budd-Chiari syndrome requires a multidisciplinary approach and regular fetal monitoring to ensure optimal outcomes.


Sujet(s)
Syndrome de Budd-Chiari , Varices oesophagiennes et gastriques , Hémorragie gastro-intestinale , Deuxième trimestre de grossesse , Humains , Femelle , Syndrome de Budd-Chiari/thérapie , Syndrome de Budd-Chiari/complications , Syndrome de Budd-Chiari/diagnostic , Grossesse , Varices oesophagiennes et gastriques/thérapie , Varices oesophagiennes et gastriques/complications , Varices oesophagiennes et gastriques/étiologie , Hémorragie gastro-intestinale/thérapie , Hémorragie gastro-intestinale/étiologie , Adulte , Complications cardiovasculaires de la grossesse/thérapie , Complications cardiovasculaires de la grossesse/imagerie diagnostique
12.
Lancet Gastroenterol Hepatol ; 9(7): 646-663, 2024 Jul.
Article de Anglais | MEDLINE | ID: mdl-38642564

RÉSUMÉ

Portal hypertension represents the primary non-neoplastic complication of liver cirrhosis and has life-threatening consequences, such as oesophageal variceal bleeding, ascites, and hepatic encephalopathy. Portal hypertension occurs due to increased resistance of the cirrhotic liver vasculature to portal blood flow and is further aggravated by the hyperdynamic circulatory syndrome. Existing knowledge indicates that the profibrogenic phenotype acquired by sinusoidal cells is the initial factor leading to increased hepatic vascular tone and fibrosis, which cause increased vascular resistance and portal hypertension. Data also suggest that the phenotype of hepatic cells could be further impaired due to the altered mechanical properties of the cirrhotic liver itself, creating a deleterious cycle that worsens portal hypertension in the advanced stages of liver disease. In this Review, we discuss recent discoveries in the pathophysiology and treatment of cirrhotic portal hypertension, a condition with few pharmacological treatment options.


Sujet(s)
Hypertension portale , Cirrhose du foie , Hypertension portale/physiopathologie , Hypertension portale/étiologie , Humains , Cirrhose du foie/complications , Cirrhose du foie/physiopathologie , Varices oesophagiennes et gastriques/étiologie , Varices oesophagiennes et gastriques/physiopathologie , Varices oesophagiennes et gastriques/thérapie , Résistance vasculaire/physiologie , Foie/physiopathologie , Foie/vascularisation
13.
Z Evid Fortbild Qual Gesundhwes ; 186: 43-51, 2024 May.
Article de Anglais | MEDLINE | ID: mdl-38616470

RÉSUMÉ

Facing increasing economization in the health care sector, clinicians have to adapt not only to the ever-growing economic challenges, but also to a patient-oriented health care. Treatment costs are the most important variable for optimizing success when facing scarce human resources, increasing material- and infrastructure costs in general, as well as low revenue flexibility due to flat rates per case in Germany, the so-called Diagnosis-Related Groups (DRG). University hospitals treat many patients with particularly serious illnesses. Therefore, their share of complex and expensive treatments, such as liver cirrhosis, is significantly higher. The resulting costs are not adequately reflected in the DRG flat rate per case, which is based on an average calculation across all hospitals, which increases this economic pressure. Thus, the aim of this manuscript is to review cost and revenue structures of the management of varices in patients with cirrhosis at a university center with a focus on hepatology. For this monocentric study, the data of 851 patients, treated at the Gastroenterology Department of a University Hospital between 2016 and 2020, were evaluated retrospectively and anonymously. Medical services (e.g., endoscopy, radiology, laboratory diagnostics) were analyzed within the framework of activity-based-costing. As part of the cost unit accounting, the individual steps of the treatment pathways of the 851 patients were monetarily evaluated with corresponding applicable service catalogs and compared with the revenue shares of the cost center and cost element matrix of the German (G-) DRG system. This study examines whether university-based high-performance medicine is efficient and cost-covering within the framework of the G-DRG system. We demonstrate a dramatic underfunding of the management of varicose veins in cirrhosis in our university center. It is therefore generally questionable whether and to what extent an adequate care for this patient collective is reflected in the G-DRG system.


Sujet(s)
Varices oesophagiennes et gastriques , Hôpitaux universitaires , Cirrhose du foie , Humains , Allemagne , Cirrhose du foie/économie , Cirrhose du foie/complications , Hôpitaux universitaires/économie , Hôpitaux universitaires/organisation et administration , Varices oesophagiennes et gastriques/économie , Varices oesophagiennes et gastriques/étiologie , Varices oesophagiennes et gastriques/thérapie , Mâle , Femelle , Programmes nationaux de santé/économie , Groupes homogènes de malades/économie , Adulte d'âge moyen , Études rétrospectives , Sujet âgé , Gastroentérologie/économie , Gastroentérologie/organisation et administration , Adulte
14.
Dig Dis Sci ; 69(6): 2008-2017, 2024 Jun.
Article de Anglais | MEDLINE | ID: mdl-38616215

RÉSUMÉ

BACKGROUND: The Veterans Health Administration provides care to more than 100,000 Veterans with cirrhosis. AIMS: This implementation evaluation aimed to understand organizational resources and barriers associated with cirrhosis care. METHODS: Clinicians across 145 Department of Veterans Affairs (VA) medical centers (VAMCs) were surveyed in 2022 about implementing guideline-concordant cirrhosis care. VA Corporate Data Warehouse data were used to assess VAMC performance on two national cirrhosis quality measures: HCC surveillance and esophageal variceal surveillance or treatment (EVST). Organizational factors associated with higher performance were identified using linear regression models. RESULTS: Responding VAMCs (n = 124, 86%) ranged in resource availability, perceived barriers, and care processes. In multivariable models, factors independently associated with HCC surveillance included on-site interventional radiology and identifying patients overdue for surveillance using a national cirrhosis population management tool ("dashboard"). EVST was significantly associated with dashboard use and on-site gastroenterology services. For larger VAMCs, the average HCC surveillance rate was similar between VAMCs using vs. not using the dashboard (47% vs. 41%), while for smaller and less resourced VAMCs, dashboard use resulted in a 13% rate difference (46% vs. 33%). Likewise, higher EVST rates were more strongly associated with dashboard use in smaller (55% vs. 50%) compared to larger (57% vs. 55%) VAMCs. CONCLUSIONS: Resources, barriers, and care processes varied across diverse VAMCs. Smaller VAMCs without specialty care achieved HCC and EVST surveillance rates nearly as high as more complex and resourced VAMCs if they used a population management tool to identify the patients due for cirrhosis care.


Sujet(s)
Cirrhose du foie , Department of Veterans Affairs (USA) , Humains , Cirrhose du foie/thérapie , Cirrhose du foie/épidémiologie , États-Unis/épidémiologie , Department of Veterans Affairs (USA)/organisation et administration , Varices oesophagiennes et gastriques/thérapie , Varices oesophagiennes et gastriques/épidémiologie , Varices oesophagiennes et gastriques/étiologie , Varices oesophagiennes et gastriques/diagnostic , Tumeurs du foie/thérapie , Tumeurs du foie/épidémiologie , Carcinome hépatocellulaire/thérapie , Carcinome hépatocellulaire/épidémiologie , Hôpitaux des anciens combattants/organisation et administration , Mâle , Adhésion aux directives/statistiques et données numériques , Femelle
15.
Eur J Gastroenterol Hepatol ; 36(7): 941-944, 2024 Jul 01.
Article de Anglais | MEDLINE | ID: mdl-38625820

RÉSUMÉ

OBJECTIVE: A set of indicators has been reported to measure the quality of care for cirrhotic patients, and previously published studies report variable adherence rates to these indicators. This study aimed to assess the quality of care provided to cirrhotic outpatients before and after an educational intervention by determining its impact on adherence to quality indicators. METHODS: We conducted a quasi-experimental, cross-sectional study including 324 cirrhotic patients seen in 2017 and 2019 at a tertiary teaching hospital in Spain. Quality indicators were assessed in five domains: documentation of cirrhosis etiology, disease severity assessment, hepatocellular carcinoma (HCC) screening, variceal bleeding prophylaxis, and vaccination. After identifying areas for improvement, an educational intervention was implemented. A second evaluation was performed after the intervention to assess changes in adherence rates. RESULTS: Before the intervention, adherence rates were excellent (>90%) for indicators related to variceal bleeding prophylaxis and documentation of cirrhosis etiology, acceptable (60-80%) for HCC screening and disease severity assessment, and poor (<50%) for vaccinations. After the educational intervention, there was a statistically significant improvement in adherence rates for eight indicators related to HCC screening (70-90%), disease severity assessment (90%), variceal bleeding prophylaxis (>90%), and vaccinations (60-90%). CONCLUSION: Our study demonstrates a significant improvement in the quality of care provided to cirrhotic outpatients after an educational intervention. The findings highlight the importance of targeted educational interventions to enhance adherence to quality indicators in the management of cirrhosis.


Sujet(s)
Cirrhose du foie , Amélioration de la qualité , Indicateurs qualité santé , Humains , Cirrhose du foie/complications , Cirrhose du foie/thérapie , Femelle , Mâle , Études transversales , Adulte d'âge moyen , Sujet âgé , Tumeurs du foie/thérapie , Varices oesophagiennes et gastriques/étiologie , Varices oesophagiennes et gastriques/thérapie , Varices oesophagiennes et gastriques/prévention et contrôle , Carcinome hépatocellulaire/thérapie , Hémorragie gastro-intestinale/étiologie , Hémorragie gastro-intestinale/prévention et contrôle , Espagne , Vaccination , Indice de gravité de la maladie , Soins ambulatoires/normes , Adhésion aux directives , Éducation du patient comme sujet/normes
16.
Clin Res Hepatol Gastroenterol ; 48(5): 102339, 2024 May.
Article de Anglais | MEDLINE | ID: mdl-38583800

RÉSUMÉ

Esophageal cancer ranked ten of the most common cancers in China. With the advancement of high-quality endoscopy and chromoendoscopic technique, early esophageal cancer can be diagnosed more easily, even combined with esophageal-gastric fundal varices. Endoscopic resection of early esophageal cancer is a minimally invasive treatment method for early esophageal cancer, and endoscopic submucosal dissection (ESD) is one of the standard treatments for early esophageal cancer in view of the risk of bleeding, the patient in this study successfully received ESD treatment after using endoscopic variceal ligation and endoscopic injection of tissue glue and sclerosing agent before ESD surgery. ESD treatment is safe and feasible for early esophageal cancer patients with cirrhosis of esophageal-gastric fundal varices.


Sujet(s)
Mucosectomie endoscopique , Tumeurs de l'oesophage , Varices oesophagiennes et gastriques , Sclérothérapie , Humains , Mâle , Carcinome épidermoïde/chirurgie , Carcinome épidermoïde/thérapie , Mucosectomie endoscopique/effets indésirables , Varices oesophagiennes et gastriques/thérapie , Varices oesophagiennes et gastriques/étiologie , Tumeurs de l'oesophage/chirurgie , Tumeurs de l'oesophage/thérapie , Tumeurs de l'oesophage/complications , Carcinome épidermoïde de l'oesophage/chirurgie , Carcinome épidermoïde de l'oesophage/thérapie , Oesophagoscopie/méthodes , Ligature/méthodes , Sclérothérapie/méthodes , Sujet âgé
17.
Sci Rep ; 14(1): 9467, 2024 04 24.
Article de Anglais | MEDLINE | ID: mdl-38658605

RÉSUMÉ

Data on emergency endoscopic treatment following endotracheal intubation in patients with esophagogastric variceal bleeding (EGVB) remain limited. This retrospective study aimed to explore the efficacy and risk factors of bedside emergency endoscopic treatment following endotracheal intubation in severe EGVB patients admitted in Intensive Care Unit. A total of 165 EGVB patients were enrolled and allocated to training and validation sets in a randomly stratified manner. Univariate and multivariate logistic regression analyses were used to identify independent risk factors to construct nomograms for predicting the prognosis related to endoscopic hemostasis failure rate and 6-week mortality. In result, white blood cell counts (p = 0.03), Child-Turcotte-Pugh (CTP) score (p = 0.001) and comorbid shock (p = 0.005) were selected as independent clinical predictors of endoscopic hemostasis failure. High CTP score (p = 0.003) and the presence of gastric varices (p = 0.009) were related to early rebleeding after emergency endoscopic treatment. Furthermore, the 6-week mortality was significantly associated with MELD scores (p = 0.002), the presence of hepatic encephalopathy (p = 0.045) and postoperative rebleeding (p < 0.001). Finally, we developed practical nomograms to discern the risk of the emergency endoscopic hemostasis failure and 6-week mortality for EGVB patients. In conclusion, our study may help identify severe EGVB patients with higher hemostasis failure rate or 6-week mortality for earlier implementation of salvage treatments.


Sujet(s)
Varices oesophagiennes et gastriques , Hémorragie gastro-intestinale , Intubation trachéale , Cirrhose du foie , Nomogrammes , Humains , Varices oesophagiennes et gastriques/chirurgie , Varices oesophagiennes et gastriques/étiologie , Varices oesophagiennes et gastriques/complications , Varices oesophagiennes et gastriques/thérapie , Mâle , Femelle , Adulte d'âge moyen , Hémorragie gastro-intestinale/étiologie , Hémorragie gastro-intestinale/thérapie , Hémorragie gastro-intestinale/mortalité , Hémorragie gastro-intestinale/chirurgie , Facteurs de risque , Cirrhose du foie/complications , Intubation trachéale/effets indésirables , Études rétrospectives , Sujet âgé , Hémostase endoscopique/méthodes , Pronostic , Adulte
18.
Langenbecks Arch Surg ; 409(1): 116, 2024 Apr 09.
Article de Anglais | MEDLINE | ID: mdl-38592545

RÉSUMÉ

INTRODUCTION: Isolated splenic vein thrombosis (iSVT) is a common complication of pancreatic disease. Whilst patients remain asymptomatic, there is a risk of sinistral portal hypertension and subsequent bleeding from gastric varices if recanalisation does not occur. There is wide variation of iSVT treatment, even within single centres. We report outcomes of iSVT from tertiary referral hepatobiliary and pancreatic (HPB) units including the impact of anticoagulation on recanalisation rates and subsequent variceal bleeding risk. METHODS: A retrospective cohort study including all patients diagnosed with iSVT on contrast-enhanced CT scan abdomen and pelvis between 2011 and 2019 from two institutions. Patients with both SVT and portal vein thrombosis at diagnosis and isolated splenic vein thrombosis secondary to malignancy were excluded. The outcomes of anticoagulation, recanalisation rates, risk of bleeding and progression to portal vein thrombosis were examined using CT scan abdomen and pelvis with contrast. RESULTS: Ninety-eight patients with iSVT were included, of which 39 patients received anticoagulation (40%). The most common cause of iSVT was acute pancreatitis n = 88 (90%). The recanalisation rate in the anticoagulation group was 46% vs 15% in patients receiving no anticoagulation (p = 0.0008, OR = 4.7, 95% CI 1.775 to 11.72). Upper abdominal vascular collaterals (demonstrated on CT scan angiography) were significantly less amongst patients who received anticoagulation treatment (p = 0.03, OR = 0.4, 95% CI 0.1736 to 0.9288). The overall rate of upper GI variceal-related bleeding was 3% (n = 3/98) and it was independent of anticoagulation treatment. Two of the patients received therapeutic anticoagulation. CONCLUSION: The current data supports that therapeutic anticoagulation is associated with a statistically significant increase in recanalisation rates of the splenic vein, with a subsequent reduction in radiological left-sided portal hypertension. However, all patients had a very low risk of variceal bleeding regardless of anticoagulation. The findings from this retrospective study should merit further investigation in large-scale randomised clinical trials.


Sujet(s)
Varices oesophagiennes et gastriques , Pancréatite , Thrombose , Humains , Maladie aigüe , Anticoagulants/effets indésirables , Varices oesophagiennes et gastriques/thérapie , Hémorragie gastro-intestinale , Études rétrospectives , Appréciation des risques , Veine liénale/imagerie diagnostique
19.
Emerg Radiol ; 31(3): 359-365, 2024 Jun.
Article de Anglais | MEDLINE | ID: mdl-38664278

RÉSUMÉ

BACKGROUND: Vascular plug-assisted retrograde transvenous obliteration (PARTO) obliterates the gastric varices and portosystemic shunt, thus resulting in a lower rebleeding rate than endoscopic glue/sclerotherapy. AIMS: To evaluate the safety and efficacy of PARTO as salvage therapy in liver cirrhosis with gastric variceal bleed (GVB) after failed endotherapy. We assessed the clinical success rate and changes in liver function at 6- months. MATERIALS AND METHODS: Patients who underwent salvage PARTO after failed endotherapy for GVB (between December 2021 and November 2022) were searched and analyzed from the hospital database. Clinical success rate and rebleed rate were obtained at six months. Child-Pugh score (CTP) and Model for end-stage liver disease (MELD) score were calculated and compared between baseline and 6-month follow-up. RESULTS: Fourteen patients (n = 14, Child-Pugh class A/B) underwent salvage PARTO. Nine had GOV-2, and five had IGV-1 varices. The mean shunt diameter was 11.6 ± 1.6 mm. The clinical success rate of PARTO was 100% (no recurrent gastric variceal hemorrhage within six months). No significant deterioration in CTP (6.79 ± 0.98 vs. 6.21 ± 1.52; p = 0.12) and MELD scores (11.5 ± 4.05 vs. 10.21 ± 3.19; p = 0.36) was noted at 6 months. All patients were alive at 6 months. One patient (n = 1, 7.1%) bled from esophageal varices after three days of PARTO and was managed with variceal banding. 21.4% (3/14) patients had progression of esophageal varices at 6 months requiring prophylactic band ligation. Three patients (21.4%) had new onset or worsening ascites and responded to low-dose diuretics therapy. CONCLUSIONS: PARTO is a safe and effective procedure for bleeding gastric varices without any deterioration in liver function even after six months. Patient selection is critical to prevent complications. Further prospective studies with larger sample size are required to validate our findings.


Sujet(s)
Varices oesophagiennes et gastriques , Hémorragie gastro-intestinale , Thérapie de rattrapage , Humains , Varices oesophagiennes et gastriques/thérapie , Mâle , Femelle , Thérapie de rattrapage/méthodes , Hémorragie gastro-intestinale/thérapie , Hémorragie gastro-intestinale/étiologie , Hémorragie gastro-intestinale/imagerie diagnostique , Adulte d'âge moyen , Sujet âgé , Études rétrospectives , Cirrhose du foie/complications , Adulte , Embolisation thérapeutique/méthodes , Résultat thérapeutique
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