Predicting failure to control bleeding and mortality in acute variceal bleeding

Burroughs, Andrew K.; Triantos, Christos

doi:10.1016/j.jhep.2007.11.006

Cited by 42 publications

(30 citation statements)

References 46 publications

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“…Since it first evolved as a new therapeutic option, EBL has been regarded as a more effective modality than endoscopic injection sclerotherapy in the control of acute hemorrhage with less reported adverse events [10][11][12]. On the other hand, some studies still advocate the use of sclerotherapy as a better treatment option up to regarding it as the gold-standard treatment [13,14].…”

Section: Discussionmentioning

confidence: 99%

Management of acute esophageal variceal bleeding by endoscopic sclerotherapy in technically difficult endoscopic band ligation cases—A population based cohort study

Esmat¹,

Hamza²,

Abbas³

et al. 2013

OJGas

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Endoscopic band ligation is regarded as the main therapeutic option for acute esophageal variceal bleeding, while sclerotherapy may be used in the acute setting if ligation is technically difficult. The incidence of difficult-to-perform band ligation in acute esophageal variceal bleeding, as well as the outcome of patients subjected to injection sclerotherapy as an alternative treatment, has not been clearly investigated. Our aim is to study the outcome of patients subjected to injection sclerotherapy in the acute setting of esophageal variceal bleeding when endoscopic band ligation is technically difficult to perform. We included 151 patients with acute esophageal variceal bleeding originnating from medium or large sized varices. All patients were planned for EBL as the 1st treatment option (EBL group 61.6%), meanwhile, EIS using 5% ethanolamine oleate was reserved as the 2nd treatment option when EBL was technically difficult (EIS group 38.4%). The mean time to restore hemodynamic stability was significantly prolonged in the EIS group (11.5 ± 6.5 hrs versus 9.5 ± 5.0 hrs, p 0.05). Initial control of bleeding was significantly higher in the EBL group versus the EIS group (96.7% vs 84.5%, p 0.021). Re-bleeding was more among the EIS group (42.9% vs 24.2%, p 0.04). There were no significant differences as regarding mortality and duration of hospital stay. So, a considerable proportion of cases presenting with acute variceal bleeding will have difficulty in performing EBL. In these patients, sclerotherapy is not a waning procedure with an accepted success rate, without much additional complications and without deranging mortality.

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Section: Discussionmentioning

confidence: 99%

Management of acute esophageal variceal bleeding by endoscopic sclerotherapy in technically difficult endoscopic band ligation cases—A population based cohort study

Esmat¹,

Hamza²,

Abbas³

et al. 2013

OJGas

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“…Bevacizumab is known to cause several typical side effects (25), including arterial hypertension, proteinuria, bleeding, and thrombosis; these side effects also have been reported in HCC trials (12)(13)(14)(15). Our main concern during the design of this protocol was the potentially increased variceal bleeding risk due to bevacizumab; this is a lifethreatening complication of advancedstage liver disease, with a particularly dismal outcome (26). This prompted us to ensure adequate treatment with prophylactic variceal band ligation prior to study initiation in patients with large esophageal varices.…”

Section: Vascular and Interventional Radiology: Hepatocellular Carcinmentioning

confidence: 95%

Hepatocellular Carcinoma: A Phase II Randomized Controlled Double-Blind Trial of Transarterial Chemoembolization in Combination with Biweekly Intravenous Administration of Bevacizumab or a Placebo

Pinter¹,

Ulbrich²,

Sieghart³

et al. 2015

Radiology

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).q RSNA, 2015 Purpose:To investigate the efficacy and safety of conventional transarterial chemoembolization (TACE) (cTACE) in combination with bevacizumab or a placebo in patients with hepatocellular carcinoma (HCC) in a randomized controlled double-blind phase II trial. Materials and Methods:This study was approved by the institutional review board, and written informed consent was obtained prior to inclusion. A total of 40 patients (20 patients per group, all 18 years or older) with histologically confirmed early-or intermediate-stage HCC and Child-Pugh class A or B cirrhosis were scheduled for inclusion. The primary endpoint was radiologic progression at 12 months according to European Association for the Study of the Liver criteria. Secondary endpoints were safety and overall survival (OS). Patients underwent cTACE with doxorubicin and intravenous administration of a placebo (cTACE-C) or bevacizumab (cTACE-B) (5 mg per kilogram of body weight) every 2 weeks for 52 weeks. After the first TACE procedure, TACE was repeated twice in 4-week intervals if indicated and technically feasible and on demand thereafter. Statistical analyses were performed with statistical software. P , .05 indicated a significant difference. Results:Thirty-two patients were recruited between January 2006 and December 2009 (29 male, three female; mean age, 61 years 6 8 [standard deviation]; Barcelona Clinic Liver Cancer stage A, n = 4; Barcelona Clinic Liver Cancer stage B, n = 28; predominant cause, alcohol [n = 15]; Child-Pugh class A disease, n = 22; Child-Pugh class B disease, n = 10; 16 patients received bevacizumab; 16 patients received a placebo). Patients underwent a median of three TACE cycles and received 13 infusions of bevacizumab versus 11 infusions of the placebo before the trial was stopped prematurely for safety reasons. Severe (grade 3-5) septic (n = 8 vs n = 3) and vascular (n = 9 vs n = 0) side effects were observed almost exclusively in the cTACE-B group. Median survival was worse in the cTACE-B group than in the cTACE-C group (5.3 vs 13.7 months; hazard ratio [HR], 1.7; 95% confidence interval [CI]: 0.8, 3.6; P = .195) and reached significance in patients with Child-Pugh class A cirrhosis (7.3 vs 26.5 months; HR, 2.6; 95% CI: 1.0, 6.6; P = .049). The primary endpoint was not met, since there was no difference in radiologic response between the groups at 3, 6, or 12 months. Conclusion:No improvement in radiologic tumor response or OS was observed in patients with HCC who received cTACE and bevacizumab, but severe and even lethal septic and vascular side effects occurred. Thus, bevacizumab cannot be recommended as an adjuvant treatment to cTACE.q RSNA, 2015

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“…Considering that raised anti Xa levels were predictive for 6-week mortality and that approximately 57% of variceal bleeders with raised anti Xa levels had HCC, this might re ect the con rmed strong association between HCC and bleeding-related mortality in portal hypertensive bleeding [30,31]. Patients with HCC have higher hepatic venous pressure gradient (HVPG) compared to patients without HCC [32] and HVPG is a known predictive factor of mortality in patients with variceal bleeding [30]. However, this does not explain the higher mortality rate following acute variceal bleeding in patients with HCC; whether endogenous heparinoids in patients with HCC are related to worse shortterm survival needs further investigation.…”

Section: Discussionmentioning

confidence: 93%

“…Experimental studies on hepatoma cells have shown that heparin inhibits cellular invasion [28], whereas clinical studies have described a positive e ect of LMWHs on cancer survival [29]. Considering that raised anti Xa levels were predictive for 6-week mortality and that approximately 57% of variceal bleeders with raised anti Xa levels had HCC, this might re ect the con rmed strong association between HCC and bleeding-related mortality in portal hypertensive bleeding [30,31]. Patients with HCC have higher hepatic venous pressure gradient (HVPG) compared to patients without HCC [32] and HVPG is a known predictive factor of mortality in patients with variceal bleeding [30].…”

Section: Discussionmentioning

confidence: 98%

Endogenous Heparinoids Detected by anti-Xa Activity are Present in Blood during Acute Variceal Bleeding in Cirrhosis. A Prospective Study

Triantos

Louvros

Kalafateli

et al. 2014

JGLD

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Background & Aims: Endogenous heparinoids have been detected by thromboelastography and quantified by clotting based anti-Xa activity assays in patients with cirrhosis, but their presence in variceal bleeding has not been established yet.Methods: Clotting based anti-Xa activity was measured in A) 30 cirrhotics with variceal bleeding, B) 15 noncirrhotics with peptic ulcer bleeding, C) 10 cirrhotics without infection or bleeding, and D) 10 cirrhotics with hepatocellular carcinoma (HCC).Results: Anti-Xa activity was not detected in ulcer bleeders or in cirrhotics without infection or bleedingbut was present in seven (23%) variceal bleeders (median levels: 0.03 u/mL (0.01-0.07)) and was quantifiable for 3 days in six of seven patients. Four of seven variceal bleeders with anti-Xa activity present had HCC (p=0.023). Age, creatinine, platelet count and total infections the second day from admission were significantly correlated with the presence of measureable anti-Xa levels (p=0.014, 0.032, 0.004 and 0.019, respectively). In the HCC group, anti-Xa activity was present in three patients (30%) [median levels: 0.05 u/mL (0.01-0.06)].Conclusions: In this study, variceal bleeders and 30% of the patients with HCC had endogenous heparinoids that were detected by a clotting based anti-Xa activity assay, whereas there was no anti Xa activity present in patients with cirrhosis without infection, or bleeding or HCC, nor in those with ulcer bleeding. Thus, the anti-Xa activity is likely to be a response to bacterial infection and/or presence of HCC in cirrhosis.List of abbreviations: AFP, alpha-fetoprotein; aPTT, activated partial thromboplastin time; CP, Child-Pugh; FXa, activated factor X; GAGS, glycosaminoglycans; Hb, hemoglobin; HCC, hepatocellular carcinoma; HVPG, hepatic venous pressure gradient; INR, International normalized ratio; LMWHs, low molecular weight heparins; MELD, Model for End-stage Liver Disease; PPP, platelet-poor plasma; PRBC, packed red blood cells; PT, prothrombin time; SBP, sponataneous bacterial peritonitis; TEG, thromboelastography; WBC, white blood cells.

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Predicting failure to control bleeding and mortality in acute variceal bleeding

Cited by 42 publications

References 46 publications

Management of acute esophageal variceal bleeding by endoscopic sclerotherapy in technically difficult endoscopic band ligation cases—A population based cohort study

Management of acute esophageal variceal bleeding by endoscopic sclerotherapy in technically difficult endoscopic band ligation cases—A population based cohort study

Hepatocellular Carcinoma: A Phase II Randomized Controlled Double-Blind Trial of Transarterial Chemoembolization in Combination with Biweekly Intravenous Administration of Bevacizumab or a Placebo

Endogenous Heparinoids Detected by anti-Xa Activity are Present in Blood during Acute Variceal Bleeding in Cirrhosis. A Prospective Study

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