As compared with a liberal transfusion strategy, a restrictive strategy significantly improved outcomes in patients with acute upper gastrointestinal bleeding. (Funded by Fundació Investigació Sant Pau; ClinicalTrials.gov number, NCT00414713.).

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Nonselective b-blockers are useful to prevent bleeding in patients with cirrhosis and large varices but not to prevent the development of varices in those with compensated cirrhosis and portal hypertension (PHT). This suggests that the evolutionary stage of PHT may influence the response to b-blockers. To characterize the hemodynamic profile of each stage of PHT in compensated cirrhosis and the response to b-blockers according to stage, we performed a prospective, multicenter (tertiary care setting), cross-sectional study. Hepatic venous pressure gradient (HVPG) and systemic hemodynamic were measured in 273 patients with compensated cirrhosis before and after intravenous propranolol (0.15 mg/kg): 194 patients had an HVPG !10 mm Hg (clinically significant PHT [CSPH]), with either no varices (n 5 80) or small varices (n 5 114), and 79 had an HVPG >5 and <10 mm Hg (subclinical PHT). Patients with CSPH had higher liver stiffness (P < 0.001), worse Model for End-Stage Liver Disease score (P < 0.001), more portosystemic collaterals (P 5 0.01) and splenomegaly (P 5 0.01) on ultrasound, and lower platelet count (P < 0.001) than those with subclinical PHT. Patients with CSPH had lower systemic vascular resistance (1336 6 423 versus 1469 6 335 dyne Á s Á cm -5 , P < 0.05) and higher cardiac index (3.3 6 0.9 versus 2.8 6 0.4 L/min/m 2 , P < 0.01). After propranolol, the HVPG decreased significantly in both groups, although the reduction was greater in those with CSPH (-16 6 12% versus -8 6 9%, P < 0.01). The HVPG decreased !10% from baseline in 69% of patients with CSPH versus 35% with subclinical PHT (P < 0.001) and decreased !20% in 40% versus 13%, respectively (P 5 0.001). Conclusion: Patients with subclinical PHT have less hyperdynamic circulation and significantly lower portal pressure reduction after acute b-blockade than those with CSPH, suggesting that b-blockers are more suitable to prevent decompensation of cirrhosis in patients with CSPH than in earlier stages. (HEPATOLOGY 2016;63:197-206) P ortal hypertension (PHT) is the most common complication of cirrhosis and the main determinant for developing varices or clinical decompensation (appearance of ascites, variceal bleeding, or hepatic encephalopathy). Decompensation, in turn, is the leading cause of mortality in cirrhosis. 1,2 The primary factor in the development of PHT in cirrhosis is an increased vascular resistance to portal flow through Abbreviations: CI, confidence interval; CO, cardiac output; CSPH, clinically significant portal hypertension; HR, heart rate; HVPG, hepatic venous pressure gradient; MELD, Model for End-Stage Liver Disease; PHT, portal hypertension; RCT, randomized controlled trial; SVR, systemic vascular resistance.From the

Clinical variables are insufficient to predict all cases of intracranial lesions following MHI, although they can be used to detect patients with relevant injuries. Avoiding systematic CT scan indication implies a rate of misdiagnosis that should be known and assumed when planning treatment in these patients by using guidelines based on clinical parameters.

Falls are frequent among patients with debilitating disorders and can have a serious effect on health status. Mild cognitive disturbances associated with cirrhosis may increase the risk for falls. Identifying subjects at risk may allow the implementation of preventive measures. Our aim was to assess the predictive value of the Psychometric Hepatic Encephalopathy Score (PHES) in identifying patients likely to sustain falls. One hundred and twenty-two outpatients with cirrhosis were assessed using the PHES and were followed at specified intervals. One third of them exhibited cognitive dysfunction (CD) according to the PHES (<24). Seventeen of the forty-two patients (40.4%) with CD had at least one fall during follow-up. In comparison, only 5 of 80 (6.2%) without CD had falls (P < 0.001). Fractures occurred in 4 patients (9.5%) with CD, but in no patients without CD (P 5 0.01). Patients with CD needed more healthcare (23.8% versus 2.5%; P < 0.001), more emergency room care (14.2% versus 2.5%; P 5 0.02), and more hospitalization (9.5% versus 0%; P 5 0.01) as a result of falls than patients without CD. Patients taking psychoactive treatment (n 5 21) had a higher frequency of falls, and this was related to an abnormal PHES. In patients without psychoactive treatment (n 5 101), the incidence of falls was 32.4% in patients with CD versus 7.5% in those without CD (P 5 0.003). In the multivariate analysis, CD was the only independent predictive factor of falls (odds ratio, 10.2; 95% confidence interval, 3.4-30.4; P < 0.001). The 1-year probability of falling was 52.3% in patients with CD and 6.5% in those without (P < 0.001). Conclusion: An abnormal PHES identifies patients with cirrhosis who are at risk for falls. This psychometric test may be useful to promote awareness of falls and identify patients who may benefit from preventive strategies. (HEPATOLOGY 2012;55:1922-1930

In patients with compensated cirrhosis and large varices treated with β-blockers, an HVPG decrease ≥10% significantly reduces the risk of developing ascitic decompensation and other related complications such as refractory ascites or hepatorenal syndrome.

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Background & Aims: Combined therapy with endoscopic variceal ligation (EVL) and b-blockers ± isosorbide mononitrate (ISMN) is currently recommended to prevent variceal rebleeding. However, the role of this combined therapy has been challenged by some studies. We performed a systematic review to assess the value of combined therapy with EVL and b-blockers ± ISMN as compared with each treatment alone to prevent rebleeding. Methods: Databases, references and meeting abstracts were searched to retrieve randomized trials comparing combined therapy with EVL and bblockers ± ISMN vs either treatment alone, to prevent variceal rebleeding in cirrhosis. Random-effects model was used for meta-analysis. Results: We identified five studies comparing EVL alone or combined with drugs, including a total of 476 patients. Combination therapy reduced overall rebleeding [risk ratios (RR) = 0.44, 95% confidence interval (CI) = 0.28-0.69], and showed a trend towards lower mortality (RR = 0.58, 95% CI = 0.33-1.03), without increasing complications. We identified four trials comparing drugs alone or associated with EVL, including 409 patients. All used b-blockers plus ISMN. Variceal rebleeding decreased with combined therapy (P < 0.01) but rebleeding from oesophageal ulcers increased (P = 0.01). Overall, there was a trend towards lower rebleeding (RR = 0.76, 95% CI = 0.58-1.00) without effect on mortality (RR = 1.24, 95% CI = 0.90-1.70). Conclusions: The addition of drug therapy to EVL improves the efficacy of EVL alone. However, the addition of EVL to b-blockers and ISMN achieves a non-significant decrease of rebleeding with no effect on mortality. Although combination therapy with EVL plus b-blockers ± ISMN is adequate to prevent rebleeding, b-blockers + ISMN alone may be a valid alternative.Patients who have recovered from acute variceal haemorrhage have a median rebleeding rate of 63% within 1-2 years and mortality of 33% (1). For many years, nonselective b-blockers and endoscopic sclerotherapy (EST) were the first-line therapy to prevent rebleeding (1, 2). However, endoscopic variceal ligation (EVL) has been shown to improve the safety and the efficacy of EST and is the current endoscopic treatment of choice (2, 3). Adding EST to EVL to obliterate perforating veins has shown no additional beneficial effects as compared with EVL alone (4, 5). Pharmacological therapy also has been improved in recent years. The combination of b-blockers and isosorbide mononitrate (ISMN) enhances the reduction of portal pressure induced by b-blockers (6). This combined drug therapy has been shown to be superior to b-blockers alone and to EST (7,8). Meta-analyses of trials comparing b-blockers + ISMN with EVL have shown no significant differences in rebleeding or survival (9-11). A recent study suggests an improvement in survival favouring combined drug therapy over EVL in the long-term follow-up (12).Combining endoscopic and pharmacological therapies seems a rational approach because b-blockers may protect against rebleeding before variceal obl...