Increased portal pressure during variceal bleeding may have an influence on the treatment failure rate, as well as on short- and long-term survival. However, the usefulness of hepatic hemodynamic measurement during the acute episode has not been prospectively validated, and no information exists about the outcome of hemodynamically defined high-risk patients treated with early portal decompression. Hepatic venous pressure gradient (HVPG) measurement was made within the first 24 hours after admission of 116 consecutive patients with cirrhosis with acute variceal bleeding treated with a single session of sclerotherapy injection during urgent endoscopy. Sixty-four patients had an HVPG less than 20 mm Hg (low-risk [LR] group), and 52 patients had an HVPG greater than or equal to 20 mm Hg (high-risk [HR] group). HR patients were randomly allocated into those receiving transjugular intrahepatic portosystemic shunt (TIPS; HR-TIPS group, n = 26) within the first 24 hours after admission and those not receiving TIPS (HR-non-TIPS group). The HR-non-TIPS group had more treatment failures (50% vs. 12%, P =.0001), transfusional requirements (3.7 +/- 2.7 vs. 2.2 +/- 2.3, P =.002), need for intensive care (16% vs. 3%, P <.05), and worse actuarial probability of survival than the LR group. Early TIPS placement reduced treatment failure (12%, P =.003), in-hospital and 1-year mortality (11% and 31%, respectively; P <.05). In conclusion, increased portal pressure estimated by early HVPG measurement is a main determinant of treatment failure and survival in variceal bleeding, and early TIPS placement reduces treatment failure and mortality in high risk patients defined by hemodynamic criteria.

See Covering the Cover synopsis on page 379.BACKGROUND AND AIMS: Current guidelines recommend surveillance for patients with nondysplastic Barrett's esophagus (NDBE) but do not include a recommended age for discontinuing surveillance. This study aimed to determine the optimal age for last surveillance of NDBE patients stratified by sex and level of comorbidity. METHODS: We used 3 independently developed models to simulate patients diagnosed with NDBE, varying in age, sex, and comorbidity level (no, mild, moderate, and severe). All patients had received regular surveillance until their current age. We calculated incremental costs and quality-adjusted life-years (QALYs) gained from 1 additional endoscopic surveillance at the current age versus not performing surveillance at that age. We determined the optimal age to end surveillance as the age at which incremental costeffectiveness ratio of 1 more surveillance was just less than

Variceal hemorrhage continues to be a major cause of morbidity and mortality in cirrhotic patients. Transjugular intrahepatic portosystemic shunt (TIPS) is gaining wide acceptance as a treatment for several complications of portal hypertension. The aim of the current randomized study was to compare the transjugular shunt and endoscopic sclerotherapy (ES) for the prevention of variceal rebleeding (VB) in cirrhotic patients. Forty-six consecutive cirrhotic patients with variceal bleeding were randomly allocated to receive either transjugular shunt (22 patients) or ES (24 patients) 24 hours after control of bleeding. VB (50% vs. 9%) and early (first 6 weeks) VB (33% vs. 5%) were significantly more frequent in sclerotherapy patients; the actuarial probability of being free of VB was higher in the shunt group (P F .002). Eight patients (33%) of the sclerotherapy group and 3 patients (15%) of the shunt group died; the actuarial probability of survival was higher for the shunted patients (P F .05); 6 patients in the sclerotherapy group and none in the shunt group died from VB (P F .05). No difference was found in the proportion of patients with clinically evident hepatic encephalopathy (HE). These results show that the transjugular shunt is more effective than sclerotherapy in the prevention of both early and long-term VB. Moreover, a significant improvement in survival was found in the shunt group. (HEPATOLOGY 1999;29:27-32.)Variceal bleeding in cirrhotic patients is the most important complication of portal hypertension for two main reasons: the high mortality of each episode of bleeding and the high proportion of patients that rebleed with the associated additional risk of death. 1,2 This second fact makes mandatory the application of therapeutic strategies to prevent recurrent hemorrhage. 3 The best results in terms of rebleeding prevention are obtained by surgical portal systemic shunts but are associated with high procedural mortality and high incidence of encephalopathy; this has limited its wide application and has encouraged investigations on other therapeutic options like endoscopic sclerotherapy (ES) and band ligation and drugs. 4 More recently, transjugular intrahepatic portosystemic shunt (TIPS) has been introduced in clinical use for several complications of portal hypertension 5 ; it enables the decompression of the portal venous system by means of a communication between the hepatic and the portal veins through the liver parenchyma with a percutaneous approach avoiding the risks and limitations of surgery. Several initial series have suggested that it could be of great value for variceal bleeding, 6,7 but data from comparative studies with accepted therapies are scarce. [8][9][10][11][12][13][14][15] Our aim was to compare TIPS with a widely accepted therapy with low procedural mortality and morbidity and low inclusion limitations, like ES, for the prevention of variceal rebleeding (VB) in cirrhotic patients. PATIENTS AND METHODSStudy Design. All patients presenting with a variceal hemorrhage were resusc...

Variceal hemorrhage continues to be a major cause of morbidity and mortality in cirrhotic patients. Transjugular intrahepatic portosystemic shunt (TIPS) is gaining wide acceptance as a treatment for several complications of portal hypertension. The aim of the current randomized study was to compare the transjugular shunt and endoscopic sclerotherapy (ES) for the prevention of variceal rebleeding (VB) in cirrhotic patients. Forty-six consecutive cirrhotic patients with variceal bleeding were randomly allocated to receive either transjugular shunt (22 patients) or ES (24 patients) 24 hours after control of bleeding. VB (50% vs. 9%) and early (first 6 weeks) VB (33% vs. 5%) were significantly more frequent in sclerotherapy patients; the actuarial probability of being free of VB was higher in the shunt group (P F .002). Eight patients (33%) of the sclerotherapy group and 3 patients (15%) of the shunt group died; the actuarial probability of survival was higher for the shunted patients (P F .05); 6 patients in the sclerotherapy group and none in the shunt group died from VB (P F .05). No difference was found in the proportion of patients with clinically evident hepatic encephalopathy (HE). These results show that the transjugular shunt is more effective than sclerotherapy in the prevention of both early and long-term VB. Moreover, a significant improvement in survival was found in the shunt group. (HEPATOLOGY 1999;29:27-32.)Variceal bleeding in cirrhotic patients is the most important complication of portal hypertension for two main reasons: the high mortality of each episode of bleeding and the high proportion of patients that rebleed with the associated additional risk of death. 1,2 This second fact makes mandatory the application of therapeutic strategies to prevent recurrent hemorrhage. 3 The best results in terms of rebleeding prevention are obtained by surgical portal systemic shunts but are associated with high procedural mortality and high incidence of encephalopathy; this has limited its wide application and has encouraged investigations on other therapeutic options like endoscopic sclerotherapy (ES) and band ligation and drugs. 4 More recently, transjugular intrahepatic portosystemic shunt (TIPS) has been introduced in clinical use for several complications of portal hypertension 5 ; it enables the decompression of the portal venous system by means of a communication between the hepatic and the portal veins through the liver parenchyma with a percutaneous approach avoiding the risks and limitations of surgery. Several initial series have suggested that it could be of great value for variceal bleeding, 6,7 but data from comparative studies with accepted therapies are scarce. [8][9][10][11][12][13][14][15] Our aim was to compare TIPS with a widely accepted therapy with low procedural mortality and morbidity and low inclusion limitations, like ES, for the prevention of variceal rebleeding (VB) in cirrhotic patients. PATIENTS AND METHODSStudy Design. All patients presenting with a variceal hemorrhage were resus...