Your browser doesn't support javascript.
loading
Mostrar: 20 | 50 | 100
Resultados 1 - 20 de 4.063
Filtrar
1.
J Vasc Interv Radiol ; 32(2): 282-291.e1, 2021 02.
Artigo em Inglês | MEDLINE | ID: mdl-33485506

RESUMO

PURPOSE: To compare the safety and clinical outcomes of combined transjugular intrahepatic portosystemic shunt (TIPS) plus variceal obliteration to those of TIPS alone for the treatment of gastric varices (GVs). MATERIALS AND METHODS: A single-center, retrospective study of 40 patients with bleeding or high-risk GVs between 2008 and 2019 was performed. The patients were treated with combined therapy (n = 18) or TIPS alone (n = 22). There were no significant differences in age, sex, model for end-stage liver disease score, or GV type between the groups. The primary outcomes were the rates of GV eradication and rebleeding. The secondary outcomes included portal hypertensive complications and hepatic encephalopathy. RESULTS: The mean follow-up period was 15.4 months for the combined therapy group and 22.9 months for the TIPS group (P = .32). After combined therapy, there was a higher rate of GV eradication (92% vs 47%, P = .01) and a trend toward a lower rate of GV rebleeding (0% vs 23%, P = .056). The estimated rebleeding rates were 0% versus 5% at 3 months, 0% versus 11% at 6 months, 0% versus 18% at 1 year, and 0% versus 38% at 2 years after combined therapy and TIPS, respectively (P = .077). There was no difference in ascites (13% vs 11%, P = .63), hepatic encephalopathy (47% vs 55%, P = .44), or esophageal variceal bleeding (0% vs 0%, P > .999) after the procedure between the groups. CONCLUSIONS: The GV eradication rate is significantly higher after combined therapy, with no associated increase in portal hypertensive complications. This translates to a clinically meaningful trend toward a reduction in GV rebleeding. The value of a combined treatment strategy should be prospectively studied in a larger cohort to determine the optimal management of GVs.


Assuntos
Embolização Terapêutica , Varizes Esofágicas e Gástricas/terapia , Hemorragia Gastrointestinal/terapia , Derivação Portossistêmica Transjugular Intra-Hepática , Escleroterapia , Adulto , Idoso , Idoso de 80 Anos ou mais , Terapia Combinada , Embolização Terapêutica/efeitos adversos , Varizes Esofágicas e Gástricas/diagnóstico por imagem , Varizes Esofágicas e Gástricas/etiologia , Feminino , Hemorragia Gastrointestinal/diagnóstico por imagem , Hemorragia Gastrointestinal/etiologia , Humanos , Masculino , Pessoa de Meia-Idade , Derivação Portossistêmica Transjugular Intra-Hepática/efeitos adversos , Recidiva , Estudos Retrospectivos , Escleroterapia/efeitos adversos , Fatores de Tempo , Resultado do Tratamento
3.
Cochrane Database Syst Rev ; 10: CD000553, 2020 10 22.
Artigo em Inglês | MEDLINE | ID: mdl-33089892

RESUMO

BACKGROUND: People with liver cirrhosis who have had one episode of variceal bleeding are at risk for repeated episodes of bleeding. Endoscopic intervention and portosystemic shunts are used to prevent further bleeding, but there is no consensus as to which approach is preferable. OBJECTIVES: To compare the benefits and harms of shunts (surgical shunts (total shunt (TS), distal splenorenal shunt (DSRS), or transjugular intrahepatic portosystemic shunt (TIPS)) versus endoscopic intervention (endoscopic sclerotherapy or banding, or both) with or without medical treatment (non-selective beta blockers or nitrates, or both) for prevention of variceal rebleeding in people with liver cirrhosis. SEARCH METHODS: We searched the CHBG Controlled Trials Register; CENTRAL, in the Cochrane Library; MEDLINE Ovid; Embase Ovid; LILACS (Bireme); Science Citation Index - Expanded (Web of Science); and Conference Proceedings Citation Index - Science (Web of Science); as well as conference proceedings and the references of trials identified until 22 June 2020. We contacted study investigators and industry researchers. SELECTION CRITERIA: Randomised clinical trials comparing shunts versus endoscopic interventions with or without medical treatment in people with cirrhosis who had recovered from a variceal haemorrhage. DATA COLLECTION AND ANALYSIS: We used standard methodological procedures expected by Cochrane. When possible, we collected data to allow intention-to-treat analysis. For each outcome, we estimated a meta-analysed estimate of treatment effect across trials (risk ratio for binary outcomes). We used random-effects model meta-analysis as our main analysis and as a means of presenting results. We reported differences in means for continuous outcomes without a meta-analytic estimate due to high variability in their assessment among all trials. We assessed the certainty of evidence using GRADE. MAIN RESULTS: We identified 27 randomised trials with 1828 participants. Three trials assessed TSs, five assessed DSRSs, and 19 trials assessed TIPSs. The endoscopic intervention was sclerotherapy in 16 trials, band ligation in eight trials, and a combination of band ligation and either sclerotherapy or glue injection in three trials. In eight trials, endoscopy was combined with beta blockers (in one trial plus isosorbide mononitrate). We judged all trials to be at high risk of bias. We assessed the certainty of evidence for all the outcome review results as very low (i.e. the true effects of the results are likely to be substantially different from the results of estimated effects). The very low evidence grading is due to the overall high risk of bias for all trials, and to imprecision and publication bias for some outcomes. Therefore, we are very uncertain whether portosystemic shunts versus endoscopy interventions with or without medical treatment have effects on all-cause mortality (RR 0.99, 95% CI 0.86 to 1.13; 1828 participants; 27 trials), on rebleeding (RR 0.40, 95% CI 0.33 to 0.50; 1769 participants; 26 trials), on mortality due to rebleeding (RR 0.51, 95% CI 0.34 to 0.76; 1779 participants; 26 trials), and on occurrence of hepatic encephalopathy, both acute (RR 1.60, 95% CI 1.33 to 1.92; 1649 participants; 24 trials) and chronic (RR 2.51, 95% CI 1.38 to 4.55; 956 participants; 13 trials). No data were available regarding health-related quality of life. Analysing each modality of portosystemic shunts individually (i.e. TS, DSRS, and TIPS) versus endoscopic interventions with or without medical treatment, we are very uncertain if each type of shunt has effect on all-cause mortality: TS, RR 0.46, 95% CI 0.19 to 1.13; 164 participants; 3 trials; DSRS, RR 0.93, 95% CI 0.65 to 1.33; 352 participants; 4 trials; and TIPS, RR 1.10, 95% CI 0.92 to 1.31; 1312 participants; 19 trial; on rebleeding: TS, RR 0.28, 95% CI 0.14 to 0.56; 127 participants; 2 trials; DSRS, RR 0.26, 95% CI 0.11 to 0.65; 330 participants; 5 trials; and TIPS, RR 0.44, 95% CI 0.36 to 0.55; 1312 participants; 19 trials; on mortality due to rebleeding: TS, RR 0.25, 95% CI 0.06 to 0.96; 164 participants; 3 trials; DSRS, RR 0.31, 95% CI 0.13 to 0.74; 352 participants; 5 trials; and TIPS, RR 0.65, 95% CI 0.40 to 1.04; 1263 participants; 18 trials; on acute hepatic encephalopathy: TS, RR 1.66, 95% CI 0.70 to 3.92; 115 participants; 2 trials; DSRS, RR 1.70, 95% CI 0.94 to 3.08; 287 participants; 4 trials, TIPS, RR 1.61, 95% CI 1.29 to 1.99; 1247 participants; 18 trials; and chronic hepatic encephalopathy: TS, Fisher's exact test P = 0.11; 69 participants; 1 trial; DSRS, RR 4.87, 95% CI 1.46 to 16.23; 170 participants; 2 trials; and TIPS, RR 1.88, 95% CI 0.93 to 3.80; 717 participants; 10 trials. The proportion of participants with shunt occlusion or dysfunction was overall 37% (95% CI 33% to 40%). It was 3% (95% CI 0.8% to 10%) following TS, 7% (95% CI 3% to 13%) following DSRS, and 47.1% (95% CI 43% to 51%) following TIPS. Shunt dysfunction in trials utilising polytetrafluoroethylene-covered stents was 17% (95% CI 11% to 24%). Length of inpatient hospital stay and cost were not comparable across trials. Funding was unclear in 16 trials; 11 trials were funded by government, local hospitals, or universities. AUTHORS' CONCLUSIONS: Evidence on whether portosystemic shunts versus endoscopy interventions with or without medical treatment in people with cirrhosis and previous hypertensive portal bleeding have little or no effect on all-cause mortality is very uncertain. Evidence on whether portosystemic shunts may reduce bleeding and mortality due to bleeding while increasing hepatic encephalopathy is also very uncertain. We need properly conducted trials to assess effects of these interventions not only on assessed outcomes, but also on quality of life, costs, and length of hospital stay.


Assuntos
Endoscopia/métodos , Varizes Esofágicas e Gástricas/terapia , Hemorragia Gastrointestinal/terapia , Cirrose Hepática/complicações , Derivação Portossistêmica Cirúrgica/métodos , Viés , Causas de Morte , Varizes Esofágicas e Gástricas/prevenção & controle , Hemorragia Gastrointestinal/epidemiologia , Hemorragia Gastrointestinal/prevenção & controle , Encefalopatia Hepática/epidemiologia , Encefalopatia Hepática/etiologia , Humanos , Análise de Intenção de Tratamento , Derivação Portossistêmica Cirúrgica/efeitos adversos , Derivação Portossistêmica Transjugular Intra-Hepática/efeitos adversos , Ensaios Clínicos Controlados Aleatórios como Assunto , Prevenção Secundária , Derivação Esplenorrenal Cirúrgica/efeitos adversos
4.
Khirurgiia (Mosk) ; (10): 60-67, 2020.
Artigo em Russo | MEDLINE | ID: mdl-33047587

RESUMO

OBJECTIVE: To improve prediction of recurrent bleeding after endoscopic sclerotherapy of esophageal varices. MATERIAL AND METHODS: A prospective, observational, case-control study was performed. Immediate and long-term results of endoscopic sclerotherapy of esophageal varices were studied in 91 patients for the period from 2002 to 2016. Multiple regression analysis with binary response model was applied to analyze the prediction models. RESULTS: Recurrent bleeding occurred in 80.5 (20; 182) days after sclerotherapy (range 0-2557 days). Spearman's correlation analysis revealed a significant relationship between bleeding recurrence and erythrocyte count (R= -0.32), Child-Pugh class of liver cirrhosis (R=0.49), Child-Pugh score (5-15) (R=0.54), content of amino acids, HPro/Pro ratio (R=0.71). Prognostic indicators were selected by stepwise inclusion of predictors. Thus, the final version of regression equation is as follows: Y=exp (-0.17+0.93×Child-Pugh score-106.42×HPro/Pro)/[1+exp(-0.17+0.93×Child-Pugh score-106.42×HPro/Pro)]. High risk of recurrent bleeding from esophageal varices within 1 year after endoscopic sclerotherapy is determined by Y-value >0.5. An accuracy of this model is 89.6%, Se 94.3%, Sp 79.2%, PPV 90.9%, NPV 86.4%, OR 63.3, LR + 4.53, LR - 0.07. CONCLUSION: Thus, the proposed method is highly informative, effective, available and can be widely used in clinical practice.


Assuntos
Varizes Esofágicas e Gástricas/terapia , Hemorragia Gastrointestinal/etiologia , Escleroterapia/efeitos adversos , Estudos de Casos e Controles , Criança , Varizes Esofágicas e Gástricas/complicações , Varizes Esofágicas e Gástricas/tratamento farmacológico , Varizes Esofágicas e Gástricas/cirurgia , Esofagoscopia/efeitos adversos , Esofagoscopia/métodos , Humanos , Prognóstico , Estudos Prospectivos , Recidiva , Medição de Risco , Escleroterapia/métodos
5.
Zhonghua Wai Ke Za Zhi ; 58(10): 808-812, 2020 Oct 01.
Artigo em Chinês | MEDLINE | ID: mdl-32993269

RESUMO

Esophagogastric variceal bleeding (EVB) is the most dangerous complication of cirrhotic portal hypertension.With the continuous emergence of research findings on EVB, multiple disciplinary team, including internal medicine department, surgery department, intervention therapy department, radiology department, has become a new mode for the prevention and treatment of EVB. This article first reviewed the classification of esophageal varices and gastric varices, and then reviewed the recent research findings of EVB from three aspects: primary prophylaxis, active variceal bleeding treatment, and secondary prophylaxis.The aim was to provide new ideas for the individualized prevention and treatment of EVB.


Assuntos
Varizes Esofágicas e Gástricas , Hemorragia Gastrointestinal/terapia , Hipertensão Portal , Cirrose Hepática/complicações , Varizes Esofágicas e Gástricas/classificação , Varizes Esofágicas e Gástricas/etiologia , Varizes Esofágicas e Gástricas/terapia , Hemorragia Gastrointestinal/etiologia , Hemorragia Gastrointestinal/prevenção & controle , Humanos , Hipertensão Portal/etiologia , Hipertensão Portal/terapia
6.
Vnitr Lek ; 66(4): 32-41, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32972182

RESUMO

Liver cirrhosis is the most common reason of clinically significant portal hypertension in the western countries. Portal vein or hepatic veins thrombosis is less common. Variceal bleeding is the most severe life threatening complication of portal hypertension. Appropriate treatment includes initial general management, fluid replacement and hemosubstitution, antibiotic prophylaxis, vasoactive medication and endoscopic treatment. Transjugular intrahepatic portosystemic shunt (TIPS) is standard option in case of first line treatment failure. Dedicated esophageal metal stent or balloon tamponade could be used as a bridge to the TIPS or in case of TIPS contraindication. Non selective beta-blockers and endoscopic therapy are used in primary and secondary prophylaxis.


Assuntos
Varizes Esofágicas e Gástricas , Hipertensão Portal , Derivação Portossistêmica Transjugular Intra-Hepática , Varizes Esofágicas e Gástricas/complicações , Varizes Esofágicas e Gástricas/terapia , Hemorragia Gastrointestinal/etiologia , Hemorragia Gastrointestinal/terapia , Humanos , Hipertensão Portal/complicações , Cirrose Hepática/complicações
7.
J Vasc Interv Radiol ; 31(9): 1382-1391.e2, 2020 09.
Artigo em Inglês | MEDLINE | ID: mdl-32792277

RESUMO

PURPOSE: To investigate from a population health perspective the effects of transjugular intrahepatic portosystemic shunt (TIPS) creation on recurrent variceal bleeding and survival in patients with cirrhosis. MATERIALS AND METHODS: Patients with cirrhosis who presented to outpatient and acute-care hospitals in California (2005-2011) and Florida (2005-2014) with variceal bleeding comprised the study cohort. Patients entered the study cohort at their first presentation for variceal bleeding; all subsequent hospital encounters were then evaluated to determine subsequent interventions, complications, and mortality data. RESULTS: A total of 655,577 patients with cirrhosis were identified, of whom 42,708 (6.5%) had at least 1 episode of variceal bleeding and comprised the study cohort. The median follow-up time was 2.61 years. A TIPS was created in 4,201 (9.8%) of these patients. There were significantly greater incidences of coagulopathy (83.9% vs 72.8%; P < .001), diabetes (45.5% vs 38.8%; P < .001), and hepatorenal syndrome (15.3% vs 12.5%; P < .001) in TIPS recipients vs those without a TIPS. Following propensity-score matching, TIPS recipients were found to have improved overall survival (82% vs 77% at 12 mo; P < .001) and a lower rate of recurrent variceal bleeding (88% vs 83% recurrent bleeding-free survival at 12 months,; P < .001) than patients without a TIPS. Patients with a TIPS had a significant increase in encounters for hepatic encephalopathy vs those without (1.01 vs 0.49 per year; P < .001). CONCLUSIONS: TIPS improves recurrent variceal bleeding rates and survival in patients with cirrhosis complicated by variceal bleeding. However, TIPS creation is also associated with a significant increase in hepatic encephalopathy.


Assuntos
Varizes Esofágicas e Gástricas/terapia , Hemorragia Gastrointestinal/prevenção & controle , Cirrose Hepática/terapia , Derivação Portossistêmica Transjugular Intra-Hepática , California/epidemiologia , Comorbidade , Bases de Dados Factuais , Varizes Esofágicas e Gástricas/diagnóstico por imagem , Varizes Esofágicas e Gástricas/mortalidade , Feminino , Florida/epidemiologia , Hemorragia Gastrointestinal/diagnóstico por imagem , Hemorragia Gastrointestinal/mortalidade , Encefalopatia Hepática/epidemiologia , Humanos , Cirrose Hepática/diagnóstico , Cirrose Hepática/mortalidade , Masculino , Derivação Portossistêmica Transjugular Intra-Hepática/efeitos adversos , Derivação Portossistêmica Transjugular Intra-Hepática/mortalidade , Recidiva , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento
8.
Clin Imaging ; 68: 143-147, 2020 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-32615516

RESUMO

Coagulopathy coupled with severe portal hypertension in the setting of cirrhosis increases the risk of mortality from variceal bleeding in pregnant women. Studies suggest transjugular intrahepatic portosystemic shunt (TIPS) creation to be a safe procedure during pregnancy in preventing variceal bleeding complications; however, it is not typically employed in severely decompensated cirrhosis. This case report of a pregnant woman presenting at 34.7 weeks' gestation demonstrates successful variceal mapping, emergent TIPS creation and variceal embolization to allow safe cesarean delivery despite severe hypofibrinogenemia and decompensated alcoholic cirrhosis. With careful medical optimization, angiographic imaging and vascular interventional radiology may be employed outside of usual indications to achieve safe pregnancy delivery and postpartum recovery.


Assuntos
Varizes Esofágicas e Gástricas , Derivação Portossistêmica Transjugular Intra-Hepática , Varizes Esofágicas e Gástricas/complicações , Varizes Esofágicas e Gástricas/diagnóstico por imagem , Varizes Esofágicas e Gástricas/terapia , Feminino , Hemorragia Gastrointestinal/diagnóstico por imagem , Hemorragia Gastrointestinal/terapia , Humanos , Cirrose Hepática/complicações , Cirrose Hepática/diagnóstico por imagem , Gravidez , Terceiro Trimestre da Gravidez , Radiologia Intervencionista , Resultado do Tratamento
9.
Medicine (Baltimore) ; 99(24): e20721, 2020 Jun 12.
Artigo em Inglês | MEDLINE | ID: mdl-32541523

RESUMO

The aim of this study was to compare the efficacy and safety of cap-assisted endoscopic injection sclerotherapy (EIS) versus direct EIS in the management of esophageal variceal bleeding in patients with cirrhosis.This retrospective study included patients with cirrhosis and esophageal variceal bleeding who underwent EIS with or without the use of a transparent cap at Shandong Provincial Hospital between December 2014 and April 2017. Patients were divided into two groups: Group A (EIS with transparent cap, n = 50) and Group B (direct EIS, n = 45). Data collected included patients' demographics, procedure details, and rates of variceal eradication, variceal rebleeding, variceal recurrence, and survival during the follow-up period. All data were expressed as mean ±â€ŠSD. Quantitative variables were compared with Student t test; qualitative variables were compared with the Fisher exact test or chi-square test. P values less than .05 were considered significant.The mean follow-up duration was similar in both groups (16.3 ±â€Š10.2 mo in Group A and 15.5 ±â€Š9.5 mo in Group B). The volume of sclerosant (64.86 ±â€Š10.62 vs 104.73 ±â€Š21.25 ml, P = .044), mean number of sessions (2.37 ±â€Š1.15 vs 5.70 ±â€Š1.57, P = .042), time required to perform endoscopic treatment (6.57 ±â€Š1.50 vs 11.22 ±â€Š2.29 minutes, P = .049), and time to initial esophageal varices eradication (5.43 ±â€Š1.38 vs 8.93 ±â€Š1.5 wk, P = .041) were significantly smaller in the cap-assisted EIS group than in the direct EIS group. The probability of variceal recurrence and rebleeding was significantly higher in the direct EIS group than in the cap-assisted EIS group (14% versus 35.6% and 20% versus 40%). Only 22 patients (44%) developed complications in the cap-assisted group versus 30 patients (66.7%) in the EIS group (P = .039). The probability of survival was similar in both groups (86% versus 75.6%, P = .133).Modified EIS with the use of a transparent cap resulted in lower rates of esophageal variceal recurrence, rebleeding, and complications, compared with direct EIS.


Assuntos
Endoscopia , Varizes Esofágicas e Gástricas/terapia , Escleroterapia/métodos , Adulto , Desenho de Equipamento , Varizes Esofágicas e Gástricas/complicações , Feminino , Humanos , Injeções/instrumentação , Cirrose Hepática/complicações , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Escleroterapia/instrumentação , Resultado do Tratamento
10.
Am J Gastroenterol ; 115(10): 1650-1656, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-32516202

RESUMO

INTRODUCTION: Both transient elastography (TE)-based and non-TE-based criteria exist for detection of varices needing treatment (VNT) in patients with asymptomatic advanced chronic liver disease (CLD). However, their performance in clinical settings at different risk thresholds of detection of VNT and in regions where elastography is not widely available is unknown. We aimed to validate existing noninvasive criteria in our patients with CLD and identify best TE- and non-TE-based criteria for VNT screening at usual risk thresholds. METHODS: Patients with compensated advanced CLD (cACLD) who underwent esophagogastroduodenoscopy and TE within 3 months were included. Diagnostic performance of Baveno VI, expanded Baveno VI, platelet-model for end-stage liver disease, and platelet-albumin (Rete Sicilia Selezione Terapia-hepatitis C virus) criteria were estimated. Decision curve analysis was conducted for different predictors across range of threshold probabilities. A repeat analysis including all patients with compensated CLD (cACLD and non-cACLD) was performed to simulate absence of TE. RESULTS: A total of 1,657 patients (cACLD, 895; non-cACLD, 762) related to hepatitis B virus (38.2%), hepatitis C virus (33.4%), nonalcoholic steatohepatitis (14.7%), and alcohol (11.8%) were included. Baveno VI identified maximum VNT (97.3%) and had best negative predictive value (96.9%), followed by platelet-albumin criteria. Expanded Baveno VI and platelet-model for end-stage liver disease had intermediate performance. At threshold probability of 5%, Baveno VI criteria showed maximum net benefit, and platelet-albumin criteria was next best, with need for 95 additional elastographies to detect 1 additional VNT. Similar results were obtained on including all patients with compensated CLD irrespective of TE. DISCUSSION: Baveno VI criteria maximizes VNT yield at 5% threshold probability. An acceptable alternative is the platelet-albumin criteria in resource-limited settings.


Assuntos
Técnicas de Imagem por Elasticidade , Varizes Esofágicas e Gástricas/diagnóstico , Cirrose Hepática/diagnóstico por imagem , Adulto , Grupo com Ancestrais do Continente Asiático , Técnicas de Apoio para a Decisão , Doença Hepática Terminal , Endoscopia do Sistema Digestório , Varizes Esofágicas e Gástricas/etiologia , Varizes Esofágicas e Gástricas/terapia , Feminino , Hepatite B Crônica/complicações , Hepatite C Crônica/complicações , Humanos , Índia , Fígado/diagnóstico por imagem , Cirrose Hepática/sangue , Cirrose Hepática/complicações , Cirrose Hepática/metabolismo , Cirrose Hepática Alcoólica/sangue , Cirrose Hepática Alcoólica/complicações , Cirrose Hepática Alcoólica/diagnóstico por imagem , Cirrose Hepática Alcoólica/metabolismo , Masculino , Pessoa de Meia-Idade , Hepatopatia Gordurosa não Alcoólica/complicações , Contagem de Plaquetas , Valor Preditivo dos Testes , Estudos Retrospectivos , Medição de Risco , Albumina Sérica/metabolismo , Índice de Gravidade de Doença , Adulto Jovem
11.
Endoscopy ; 52(11): 1036-1038, 2020 11.
Artigo em Inglês | MEDLINE | ID: mdl-32408356

RESUMO

BACKGROUND: COVID-19 has spread rapidly around the world. The Austrian government implemented a lockdown on 16 March to contain further spread of the disease. We investigated the effects of lockdown on acute upper gastrointestinal (GI) bleeding in Austria. METHODS: We contacted 98 Austrian hospitals performing emergency endoscopies. The hospitals were asked to report upper GI endoscopies performed for recent hematemesis, melena, or both, and exhibiting endoscopically visible signs of bleeding. The study period was from 3 weeks before (calendar Week 9) to 3 weeks after (Week 14) initiation of the lockdown. RESULTS: 61 % of Austrian hospitals, and importantly all major state hospitals, responded. A total of 575 upper GI bleedings occurred during the 3 weeks before and 341 during the 3 weeks after initiation of lockdown (40.7 % reduction). There was a 54.6 % decline in nonvariceal bleeding events at Week 14 compared with Week 9 (89 vs. 196), whereas rates of variceal hemorrhage did not change (15 vs. 17). CONCLUSIONS: National lockdown resulted in a dramatic decrease in upper GI bleeding events in Austrian hospitals.


Assuntos
Betacoronavirus , Controle de Doenças Transmissíveis , Infecções por Coronavirus/prevenção & controle , Varizes Esofágicas e Gástricas/epidemiologia , Hemorragia Gastrointestinal/epidemiologia , Pandemias/prevenção & controle , Pneumonia Viral/prevenção & controle , Isolamento Social , Áustria , Infecções por Coronavirus/epidemiologia , Infecções por Coronavirus/transmissão , Endoscopia , Varizes Esofágicas e Gástricas/diagnóstico , Varizes Esofágicas e Gástricas/terapia , Hemorragia Gastrointestinal/diagnóstico , Hemorragia Gastrointestinal/terapia , Humanos , Pneumonia Viral/epidemiologia , Pneumonia Viral/transmissão
12.
Aliment Pharmacol Ther ; 52(1): 98-106, 2020 07.
Artigo em Inglês | MEDLINE | ID: mdl-32452561

RESUMO

BACKGROUND: Early-transjugular intrahepatic porto-systemic shunt (TIPSS) has been recommended in international guidelines for high-risk patients with oesophageal variceal bleeding. AIM: To validate the results of a previous randomised control trial which supports use of early-TIPSS. METHODS: In a two-centre open-label parallel-group randomised control trial, patients with cirrhosis and acute variceal bleeding were recruited following haemostasis with vaso-active drugs and endoscopic band ligation. Participants were randomised to standard of care or early-TIPSS. The primary outcome was 1-year survival, secondary outcomes included early and late rebleeding, and complications of portal hypertension. RESULTS: Fifty-eight patients (58 ± 11.12 years; 32.7% female) were randomised. After one year, seven patients died in the standard of care group and six in the early-TIPSS group, a 1-year survival of 75.9% vs 79.3% respectively (P = 0.79). Variceal rebleeding occurred in eight patients in the standard of care group compared with three patients in the early-TIPSS group (P = 0.09). Not all participants randomised to early-TIPSS received the intervention in time. For those receiving TIPSS per-protocol, variceal rebleeding rates were reduced (0% vs 27.6%, P = 0.04) but this had no effect on survival (76.9% vs 75.9%, P = 0.91). Serious adverse events were similar in both treatment groups, except that rates of hepatic encephalopathy were higher in patients receiving TIPSS (46.1% vs 20.7%, P < 0.05). CONCLUSIONS: Early-TIPSS reduced variceal rebleeding, increased encephalopathy but had no effect on survival in high-risk patients with oesophageal variceal bleeding. Early-TIPSS may not be feasible in many centres however, larger studies are needed. ClinicalTrials.gov reference: NCT02377141.


Assuntos
Varizes Esofágicas e Gástricas/terapia , Derivação Portossistêmica Transjugular Intra-Hepática , Idoso , Varizes Esofágicas e Gástricas/mortalidade , Feminino , Encefalopatia Hepática/etiologia , Humanos , Masculino , Pessoa de Meia-Idade , Derivação Portossistêmica Transjugular Intra-Hepática/efeitos adversos , Recidiva , Padrão de Cuidado
13.
N Engl J Med ; 382(14): 1299-1308, 2020 04 02.
Artigo em Inglês | MEDLINE | ID: mdl-32242355

RESUMO

BACKGROUND: It is recommended that patients with acute upper gastrointestinal bleeding undergo endoscopy within 24 hours after gastroenterologic consultation. The role of endoscopy performed within time frames shorter than 24 hours has not been adequately defined. METHODS: To evaluate whether urgent endoscopy improves outcomes in patients predicted to be at high risk for further bleeding or death, we randomly assigned patients with overt signs of acute upper gastrointestinal bleeding and a Glasgow-Blatchford score of 12 or higher (scores range from 0 to 23, with higher scores indicating a higher risk of further bleeding or death) to undergo endoscopy within 6 hours (urgent-endoscopy group) or between 6 and 24 hours (early-endoscopy group) after gastroenterologic consultation. The primary end point was death from any cause within 30 days after randomization. RESULTS: A total of 516 patients were enrolled. The 30-day mortality was 8.9% (23 of 258 patients) in the urgent-endoscopy group and 6.6% (17 of 258) in the early-endoscopy group (difference, 2.3 percentage points; 95% confidence interval [CI], -2.3 to 6.9). Further bleeding within 30 days occurred in 28 patients (10.9%) in the urgent-endoscopy group and in 20 (7.8%) in the early-endoscopy group (difference, 3.1 percentage points; 95% CI, -1.9 to 8.1). Ulcers with active bleeding or visible vessels were found on initial endoscopy in 105 of the 158 patients (66.4%) with peptic ulcers in the urgent-endoscopy group and in 76 of 159 (47.8%) in the early-endoscopy group. Endoscopic hemostatic treatment was administered at initial endoscopy for 155 patients (60.1%) in the urgent-endoscopy group and for 125 (48.4%) in the early-endoscopy group. CONCLUSIONS: In patients with acute upper gastrointestinal bleeding who were at high risk for further bleeding or death, endoscopy performed within 6 hours after gastroenterologic consultation was not associated with lower 30-day mortality than endoscopy performed between 6 and 24 hours after consultation. (Funded by the Health and Medical Fund of the Food and Health Bureau, Government of Hong Kong Special Administrative Region; ClinicalTrials.gov number, NCT01675856.).


Assuntos
Endoscopia Gastrointestinal , Varizes Esofágicas e Gástricas/diagnóstico , Hemorragia Gastrointestinal/diagnóstico , Úlcera Péptica Hemorrágica/diagnóstico , Doença Aguda , Idoso , Varizes Esofágicas e Gástricas/terapia , Feminino , Hemorragia Gastrointestinal/mortalidade , Hemorragia Gastrointestinal/terapia , Hospitalização , Humanos , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Úlcera Péptica Hemorrágica/mortalidade , Úlcera Péptica Hemorrágica/terapia , Medição de Risco , Fatores de Tempo , Tempo para o Tratamento
14.
Medicine (Baltimore) ; 99(17): e19727, 2020 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-32332612

RESUMO

Successful treatment of esophagogastric varices (EGV) with giant portal-systemic shunt is challenging. To explore the feasibility and safety of a novel hybrid procedure involving interventional radiology and endoscopy in the same sitting.Three cases clinically diagnosed to have decompensated cirrhosis and EGV with giant gastrorenal shunt (GRS) on contrast-enhanced computed tomography (CT) were included. The hybrid procedures included: indirect portography, hepatic vein pressure gradient (HVPG) measurement, HVPG-based partial splenic embolization (PSE), retrospective GRS balloon occlusion, endoscopic histoacryl injection (EHI), balloon catheter radiography and withdrawal. All the procedures were done in the same operation room. Main outcomes measurements included operation time, complications, and re-bleeding events.Hybrid interventions were performed successfully in 3 cases with a mean operation time of 63.3 minutes without any major intra- and post-operation complications. No rebleeding occurred at 6-month follow-up.Synchronous hybrid intervention combining radiology and endoscopy is feasible and safe for patients with EGV and giant GRS, preliminary study with limited cases deserves further exploration.


Assuntos
Endoscopia Gastrointestinal/métodos , Varizes Esofágicas e Gástricas/diagnóstico por imagem , Varizes Esofágicas e Gástricas/terapia , Derivação Portossistêmica Cirúrgica/métodos , Radiologia Intervencionista/métodos , Oclusão com Balão/efeitos adversos , Oclusão com Balão/métodos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Derivação Portossistêmica Cirúrgica/normas , Estudos Retrospectivos
15.
Orv Hetil ; 161(15): 583-587, 2020 04 01.
Artigo em Húngaro | MEDLINE | ID: mdl-32323522

RESUMO

Introduction: Variceal bleeding is a life-threatening complication of portal hypertension with a six-week mortality rate of approximately 20%. Aim: To analyse whether the changes introduced in the treatment of variceal gastrointestinal haemorrhage in our department affected the mortality rate of these patients. Method: A retrospective method was used to compare the data of patients treated with variceal bleeding in 2014 and 2015. In 2015, two changes were made in the treatment of patients with variceal bleeding: all patients were treated in the subintensive care unit and terlipressin was administered to all patients susceptible to variceal haemorrhage. Bleeding was mitigated by means of sclerotherapy and/or ligation. Significance was calculated using Student's t-test, then we performed logistic regression to find out what treatment factors affect mortality rate. Patients: 2014 vs. 2015 figures ­ number of patients: 24 vs. 30, average age: 59.8 vs. 57.6 years, male (%): 70.8 vs. 66.7. There were no significant differences between the Child­Pugh stages of the two years, p = 0.53. For the analysis we also grouped patients based on whether irrespective of the year of treatment they were administered terlipressin or not. Number of patients: 22 vs. 32, average age: 60.4 vs. 57.4, male (%): 63.6 vs. 70.6. Results: Mortality in 2015 and 2014: 23% and 33%, respectively. Mortality of patients treated with terlipressin: 18.2 vs. 34.4, p = 0.09. Child­Pugh stages had the strongest influence on mortality (stage A vs. B p = 0.05, stage A vs. C p = 0.02). Terlipressin administered in Child­Pugh stage C reduced mortality at a rate bordering on significance (p = 0.055). Conclusion: Despite the comparatively small number of cases, the changes introduced in our department in 2015 in the treatment of variceal gastrointestinal haemorrhages resulted in a significant reduction of hospital mortality rates. Orv Hetil. 2020; 161(15): 583­587.


Assuntos
Varizes Esofágicas e Gástricas/terapia , Hemorragia Gastrointestinal/terapia , Cirrose Hepática/complicações , Terlipressina/uso terapêutico , Vasoconstritores/uso terapêutico , Idoso , Varizes Esofágicas e Gástricas/etiologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Terlipressina/efeitos adversos , Resultado do Tratamento , Varizes/fisiopatologia , Vasoconstritores/efeitos adversos
17.
Medicine (Baltimore) ; 99(11): e19485, 2020 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-32176084

RESUMO

Urgent endoscopy (UE) is important to the diagnosis and treatment of liver cirrhosis patients with esophageal variceal bleeding (EVB). It was reported that a second-look endoscopy may benefit acute upper gastrointestinal bleeding (UGIB) caused by peptic ulcer, while whether it could improve UGIB caused by liver cirrhosis associated EVB remains unclear. This study aimed to investigate the characteristics of second UE for liver cirrhosis with EVB and further examined the potential prognostic factors.Patients aged ≥18 years who underwent UE for EVB within 2 hours after the admission were included and divided into scheduled second-look group (n = 245) and uncontrolled bleeding group (n = 352) based on the indications for second UE within 48 hours after initial endoscopy. Demographic and clinical data were collected and analyzed. Univariate and multivariate analysis were used to identify the risk factors for prognosis. The value of different scoring system was compared.Statistical differences were found on history of bleeding and hepatocellular carcinoma, ascites, endoscopic type of bleeding, between scheduled second-look group and uncontrolled bleeding group. Univariate and multivariate logistic regression analysis confirmed that ascites, hemoglobin <60 g/L, AIMS65 score and failure to identify in initial UE were independent risk factors for bleeding uncontrolled after initial UE, and age, bilirubin level, initial unsatisfactory UE hemostasis, failure to identify bleeding on initial UE and tube/urgent TIPS suggested in initial UE were independent risk factors for 42-day mortality.A second-look UE could bring benefit for liver cirrhosis patients with EVB without increasing the complication rate.


Assuntos
Varizes Esofágicas e Gástricas/terapia , Hemorragia Gastrointestinal/terapia , Hemostase Endoscópica/estatística & dados numéricos , Cirrose Hepática/complicações , Cirurgia de Second-Look/estatística & dados numéricos , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , China , Árvores de Decisões , Varizes Esofágicas e Gástricas/complicações , Varizes Esofágicas e Gástricas/mortalidade , Feminino , Hemorragia Gastrointestinal/complicações , Hemorragia Gastrointestinal/mortalidade , Humanos , Modelos Logísticos , Masculino , Registros Médicos , Pessoa de Meia-Idade , Prognóstico , Estudos Retrospectivos , Fatores de Risco , Índice de Gravidade de Doença , Adulto Jovem
19.
Br J Radiol ; 93(1108): 20190751, 2020 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-32017608

RESUMO

OBJECTIVE: To determine the utility of low-dose gelatin sponge particles and 5% ethanolamine oleate iopamidol (EOI) mixture in retrograde transvenous obliteration (GERTO) for gastric varices (GV). METHODS: 57 consecutive patients who underwent balloon-occluded retrograde transvenous obliteration (B-RTO) for GV were divided into three groups with Hirota's grade by balloon-occluded retrograde transvenous venography. Hirota's Grade 1 patients were assigned to G1 group and underwent treatment with 5% EOI. Grade ≥ 2 patients prior to August 2015 were G ≥ 2 group treated with 5% EOI, and those treated thereafter were GERTO group. The amount of EOI used per unit GV volume (EOI/GV ratio), the times to embolization and recurrence rate of GV were evaluated. RESULTS: The EOI/GV ratio was 0.66 ± 0.19 in G1, 1.5 ± 0.8 in G ≥ 2, and 0.58 ± 0.23 in GERTO (G ≥ 2 vs GERTO, p < 0.0001). The times to embolization were 26.5 ± 10.5 min for G1, 39.2 ± 26.8 for G ≥ 2, and 21.4 ± 9.4 for GERTO (G ≥ 2 vs GERTO, p = 0.005). The recurrence rate was not significantly different in any of the groups. CONCLUSION: GERTO was performed in lower amount of sclerosants and in less time compared to conventional B-RTO in Hirota's grade ≥2. ADVANCES IN KNOWLEDGE: Feasibility of low-dose gelatin sponge particles and 5% EOI mixture as sclerosants for GV.


Assuntos
Oclusão com Balão/métodos , Varizes Esofágicas e Gástricas/terapia , Gelatina/administração & dosagem , Iopamidol/administração & dosagem , Ácidos Oleicos/administração & dosagem , Soluções Esclerosantes/administração & dosagem , Idoso , Oclusão com Balão/efeitos adversos , Combinação de Medicamentos , Varizes Esofágicas e Gástricas/diagnóstico por imagem , Estudos de Viabilidade , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Tomografia Computadorizada Multidetectores , Flebografia/métodos
SELEÇÃO DE REFERÊNCIAS
DETALHE DA PESQUISA
...