Vipul Jairath1, Sunita Rehal2, Richard Logan3, Brennan Kahan2, Sarah Hearnshaw4, Simon Stanworth5, Simon Travis6, Michael Murphy5, Kelvin Palmer7, Andrew Burroughs8. 1. NHS Blood & Transplant, John Radcliffe Hospital, Oxford, UK; Translational Gastroenterology Unit, John Radcliffe Hospital, Oxford, UK. Electronic address: vipul.jairath@nhsbt.nhs.uk. 2. MRC Clinical Trials Unit, London, UK. 3. Division of Epidemiology and Public Health & Nottingham Digestive Disease Centre, University of Nottingham, UK. 4. Royal Victoria Infirmary, Newcastle, UK. 5. NHS Blood & Transplant, John Radcliffe Hospital, Oxford, UK. 6. Translational Gastroenterology Unit, John Radcliffe Hospital, Oxford, UK. 7. Western General Hospital, Edinburgh, UK. 8. The Royal Free Hospital, London, UK.
Abstract
BACKGROUND: Despite advances in treatment, acute variceal haemorrhage remains life-threatening. AIM: To describe contemporary characteristics, management and outcomes of patients with cirrhosis and acute variceal haemorrhage and risk factors for rebleeding and mortality. METHODS: Multi-centre clinical audit conducted in 212 UK hospitals. RESULTS: In 526 cases of acute variceal haemorrhage, 66% underwent endoscopy within 24h with 64% (n=339) receiving endoscopic therapy. Prior to endoscopy, 57% (n=299) received proton pump inhibitors, 44% (n=232) vasopressors and 27% (n=144) antibiotics. 73% (n=386) received red cell transfusion, 35% (n=184) fresh frozen plasma and 14% (n=76) platelets, with widely varying transfusion thresholds. 26% (n=135) experienced further bleeding and 15% (n=80) died by day 30. The Model for End Stage Liver Disease score was the best predictor of mortality (area under the receiver operating curve=0.74, P<0.001). Neither the clinical nor full Rockall scores were useful predictors of outcome. Coagulopathy was strongly associated with rebleeding (odds ratio 2.23, 95% CI 1.22-4.07, P=0.01, up to day 30) and mortality (odds ratio 3.06, 95% CI 1.29-7.26, P=0.01). CONCLUSIONS: Although mortality has improved following acute variceal haemorrhage, rebleeding rates remain appreciably high. There are notable deficiencies in the use of vasopressors and endoscopic therapy. More work is needed to understand the optimum transfusion strategies. Better risk stratification tools are required to identify patients needing more intensive support.
BACKGROUND: Despite advances in treatment, acute variceal haemorrhage remains life-threatening. AIM: To describe contemporary characteristics, management and outcomes of patients with cirrhosis and acute variceal haemorrhage and risk factors for rebleeding and mortality. METHODS: Multi-centre clinical audit conducted in 212 UK hospitals. RESULTS: In 526 cases of acute variceal haemorrhage, 66% underwent endoscopy within 24h with 64% (n=339) receiving endoscopic therapy. Prior to endoscopy, 57% (n=299) received proton pump inhibitors, 44% (n=232) vasopressors and 27% (n=144) antibiotics. 73% (n=386) received red cell transfusion, 35% (n=184) fresh frozen plasma and 14% (n=76) platelets, with widely varying transfusion thresholds. 26% (n=135) experienced further bleeding and 15% (n=80) died by day 30. The Model for End Stage Liver Disease score was the best predictor of mortality (area under the receiver operating curve=0.74, P<0.001). Neither the clinical nor full Rockall scores were useful predictors of outcome. Coagulopathy was strongly associated with rebleeding (odds ratio 2.23, 95% CI 1.22-4.07, P=0.01, up to day 30) and mortality (odds ratio 3.06, 95% CI 1.29-7.26, P=0.01). CONCLUSIONS: Although mortality has improved following acute variceal haemorrhage, rebleeding rates remain appreciably high. There are notable deficiencies in the use of vasopressors and endoscopic therapy. More work is needed to understand the optimum transfusion strategies. Better risk stratification tools are required to identify patients needing more intensive support.
Authors: Nikolaus Pfisterer; Caroline Schmidbauer; Florian Riedl; Andreas Maieron; Vanessa Stadlbauer; Barbara Hennlich; Remy Schwarzer; Andreas Puespoek; Theresa Bucsics; Maria Effenberger; Simona Bota; Michael Gschwantler; Markus Peck-Radosavljevic; Mattias Mandorfer; Christian Madl; Michael Trauner; Thomas Reiberger Journal: Wien Klin Wochenschr Date: 2020-12-03 Impact factor: 1.704
Authors: Juan Cristóbal Gana; Lorena I Cifuentes; Daniela Gattini; Luis A Villarroel Del Pino; Alfredo Peña; Romina Torres-Robles Journal: Cochrane Database Syst Rev Date: 2019-09-24