Background and aims Risk stratification to identify patients with high risk of variceal rebleeding is particularly important in patients with decompensated cirrhosis. In clinical practice, eliminating gastroesphageal varices thoroughly after sequential endoscopic treatment reduces the rebleeding rate, however, no simple method has been build to predict high risk of variceal rebleeding. We conducted this study to explore the value of the number of endoscopic sessions required to eradicate gastroesphageal varices in identifying high risk of rebleeding. Patients and methods Consecutive cirrhotic patients received sequential endoscopic therapy between January 2015 and March 2020 were enrolled. Endoscopic treatment was performed every 1–4 weeks until the eradication of varices. The primary endpoint was variceal rebleeding. Results A total of 146 patients were included of which 60 patients received standard therapy and 86 patients underwent sequential endoscopic treatment alone. The cut-off value of the number of sequential endoscopic sessions is 3.5 times. Variceal rebleeding was significant higher in patients with endoscopic sessions > 3 times versus ≤ 3 times (61.5% vs. 17.5%, p < 0.001). Variceal rebleeding of patients with endoscopic sessions ≤ 3 times was significant lower than patients with > 3 times in group of standard therapy (19.6% vs. 88.9%, p < 0.001) and endoscopic therapy (15.9% vs. 47.1%, p = 0.028) respectively. Conclusion The number of sequential endoscopic sessions required to eradicate the varices is related to the risk of variceal rebleeding in patients with cirrhosis. If three times of endoscopic treatment can not eradicate the varices, a more aggressive treatment such as TIPS should be seriously considered.
The purpose of this study was to investigate the effect of body mass index (BMI) on the prevalence of overt hepatic encephalopathy (OHE) after the transjugular intrahepatic portosystemic shunt (TIPS) procedure in decompensated cirrhotic patients. A retrospective observational cohort study of 145 cirrhotic patients receiving TIPS was carried out in our department from 2017 to 2020. The relationships between BMI and clinical outcomes including OHE, as well as risk factors of developing post-TIPS OHE, were analyzed. BMI was categorized as normal weight (18.5 ≤ BMI < 23.0 kg/m2), underweight (BMI < 18.5 kg/m2), and overweight/obese (BMI ≥ 23.0 kg/m2). Among the 145 patients, 52 (35.9%) were overweight/obese and 50 (34%) had post-TIPS OHE. Overweight/obese patients more frequently had OHE compared with normal weight patients (OR: 2.754, 95% CI: 1.236–6.140; p = 0.013). Overweight/obesity (p = 0.013) and older age (p = 0.030) were independent risk factors for post-TIPS OHE according to the logistic regression analysis. Kaplan–Meier curve analysis suggested that overweight/obese patients had the highest cumulative incidence of OHE (log-rank p = 0.0118). In conclusion, overweight/obesity and older age may raise the risk of post-TIPS OHE in cirrhotic patients.
Purpose The liver stiffness-spleen diameter to platelet ratio score (LSPS model) can identify a high risk of decompensated events in cirrhotic patients. We aimed to evaluate the value of the LSPS model as a risk stratification strategy in the secondary prevention for cirrhotic patients with esophageal and gastric variceal bleeding (EGVB). Methods Consecutive EGVB patients who underwent liver stiffness measurement by acoustic radiation force impulse, platelet count and ultrasonography were enrolled between January 2013 and December 2019. We calculated the LSPS of all patients and followed up for over 2 years. The primary outcome was rebleeding. Transplant-free survival and overt hepatic encephalopathy (OHE) were the secondary outcomes. Results A total of 131 patients were analyzed. The median value of the LSPS model is 0.1879. We developed risk stratification based on the LSPS model and divided the patients into two groups: the high-LSPS (LSPS > 0.1879) group and the low-LSPS (LSPS ≤ 0.1879) group. Sixty-two (47.33%) patients suffered rebleeding, in which there were 21 (31.92%) patients with low LSPS and 41 (63.08%) patients with high LSPS (hazard ratio 2.883; 95% confidence interval, 1.723-4.822, P < 0.001). For the whole cohort, the rates of transplant-free survival and OHE were consistently similar between the two groups at 2 years. Conclusion The LSPS is a reliable, noninvasive method for the detection of a high risk of rebleeding for the secondary prevention of EGVB.
Background: Wedge hepatic vein pressure (WHVP) accurately estimates the portal pressure (PP) in chronic sinusoidal portal hypertension patients. Whether this applies to patients with acute portal hypertension due to hepatic sinusoidal obstruction syndrome (HSOS) is unclear. Our aim was to assess the agreement between WHVP and PP in patients with HSOS by comparing them to decompensated cirrhosis patients. Methods: From December 2013 to December 2021, patients with pyrrolidine alkaloid-induced HSOS (PA-HSOS) receiving hepatic venous pressure gradient (HVPG) measurement and transjugular intrahepatic portosystem shunt (TIPS) were retrospectively collected and matched with those of patients with virus- or alcohol-related cirrhosis as a cirrhosis group. Pearson’s correlation (R), intraclass correlation coefficient (ICC), scatter plots, and the Bland–Altman method were performed for agreement evaluation. Results: A total of 64 patients were analyzed (30 PA-HSOS and 34 cirrhosis groups). The correlation between WHVP and PP was moderate in the PA-HSOS group (R: 0.58, p = 0.001; ICC: 0.68, p = 0.002) but good in the cirrhosis group (R: 0.81, p < 0.001; ICC: 0.90, p < 0.001). The percentage of patients with inconsistent WHVP and PP in the two groups was 13 (43.3%) and 15 (26.5%) (p = 0.156), respectively, and an overestimation of PP was more common in the PA-HSOS group (33.3% vs. 2.9%, p = 0.004). HVPG and portal pressure gradient (PPG) consistency was poor in both groups (R: 0.51 vs. 0.26; ICC: 0.65 vs. 0.41; p < 0.05). Conclusions: WHVP in patients with PA-HSOS did not estimate PP as accurately as in patients with virus- or alcohol-related cirrhosis, which was mainly due to PP overestimation.
Objectives: TIPS can decrease rebleeding in cirrhotic patients with variceal bleeding (VB), but it is controversial whether TIPS can improve survival. We aimed to assess whether TIPS improves survival in selected patients based on HVPG-related risk stratification in a long-term follow-up.Methods: Consecutive VB patients treated with endoscopic therapy+NSBBs or covered TIPS were retrospectively enrolled between January 2013 and December 2019. All patients had HVPG measurements by experienced personnel before therapy. Outpatient follow-up was performed regularly. The primary outcome was transplant-free survival. The secondary endpoints were rebleeding and OHE. Statistical analysis were performed.Results: According to the inclusion and exclusion criteria, 184 patients were analyzed (Mean age 55.27years ± 13.86, 107 males; 102 endoscopic therapy+NSBBs, 82 covered TIPS). Based on the HVPG-guided risk stratification, 70 patients had HVPGs lower than 16 mmHg, and 114 patients had HVPGs higher than 16 mmHg. The median follow-up time was 49.5 months. In the total cohort, the difference between the 2 therapies in terms of transplant-free survival was not statistically significant in the TIPS group (hazard ratio 0.6092, 95% CI 0.3546-1.046; p=0.0725). In the high-HVPG tier, transplant-free survival was higher in the TIPS group (hazard ratio 0.4385, 95% CI 0.2255-0.8525; p=0.0037). In the low-HVPG tier, transplant-free survival between the 2 treatments was similar without statistical significance (hazard ratio 0.8583, 95% CI 0.3301-0.232; p=0.7399). The difference in OHE between the two treatment groups was not statistically significant (P=0.0850; P=0.4791).Conclusions: TIPS can effectively improve transplant-free survival when HVPG is greater than 16 mmHg.
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