Circadian occurrence of variceal bleeding in patients with liver cirrhosis

Abstract

Several clinical events have a rhythmicity over the 24 h period. We assessed the presence of periodic rhythm in the occurrence of haematemesis in patients with liver cirrhosis under different daylight regimens, namely during standard time and during daylight savings. Over a 48 month period there were 2 12 consecutive admissions of 1 18 cirrhotics with variceal bleeding. Complete data were available for 181 episodes of bleeding: 121 (66.9%) started with haematemesis and 60 (33.1%) started with melaena. One hundred and two (56%) episodes occurred during daylight savings and 79 (44%) occurred during standard time. The cosinor test showed a 24 h biphasic peak for the occurrence of haematemesis (09.45 and 21.45 h). Moreover, a biphasic diurnal asymmetric frequency was also found by multiple component rhythmometry. The time peaks of onset of variceal haemorrhage did not change significantly during standard time and daylight savings. Patients with more than one haematemesis episode significantly bled over the same time interval. The present study confirms that over the 24 h period variceal bleeding in cirrhotic patients occurs with a predictable rhythmicity that does not seem to be under the control of the lightdark cycle. The finding of a chronorisk for variceal haemorrhage addresses specific questions for pathophysiological studies as well as for new treatment strategies.

Circadian pattern of acute variceal bleeding among cirrhotic Egyptian patients

“…Interestingly, the period of highest fi brinolytic capacity reported in the present study overlapped with the reported peak time of hematemesis [8][9][10][11][12]. This temporal observation alone dose not establish a cause-effect relation with variceal hemorrhage and experimental observations are warranted.…”

“…In the 1990s, a biphasic circadian rhythm of variceal hemorrhage was identifi ed, with two distinct peaks in the early morning and in the evening [8][9][10][11], reproducible with the evening peak greater than the other [8,11]. Our study shows the existence of a statistically significant circadian rhythm of acute hematemesis with two time peaks at hour 04:00 and hour 17:00.…”

“…The pathophysiology of the acute event is still unclear. In 1990's, several authors have shown a similar rhythmic circadian distribution of variceal hemorrhage in cirrhotic patients [8][9][10][11][12]. All of them found variceal hemorrhages occurring more frequently in the evening and in the early morning.…”

“…Another work group suggested that the upright posture may decrease the variceal fl ow velocity mainly because of the reduction in splanchnic blood fl ow [14]. The possible involvement of the clotting system in the bleeding events of cirrhosis has been invoked by several authors [8,10,11,13], but there is still a poor evidence about its participation in variceal hemorrhage. A cross-sectional study showed an increased bleeding risk in patients with cirrhosis with hyperfi brinolysis [15], but no study has yet evaluated such a condition in a diurnal setting.…”

Chronobiological analysis of seasonal variations of variceal hemorrhage

“…Similarly, several studies have shown that there is circadian rhythm in portal blood flow and portal pressure and that the onset of variceal hemorrhage is influenced by these factors. 1,2 However, there is still a paucity of definitive information on circannual rhythm in the hemodynamics of splanchnic circulation and seasonal variation of variceal hemorrhage. To investigate the risk of variceal hemorrhage in patients with portal hypertension from a viewpoint of chronobiology, we analyzed the seasonal variations of the incidence of variceal hemorrhage by chronobiological statistical methods.…”