Risk of rebleeding from gastroesophageal varices after initial treatment with cyanoacrylate: a systematic review and pooled analysis.

Hu, Zixuan; Zhang, Decai; Swai, Joel; Liu, Tao; Liu, Shaojun

doi:10.21203/rs.3.rs-17635/v1

Cited by 2 publications

(5 citation statements)

References 9 publications

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“…Two more recent systematic reviews/meta-analyses have reported similar results. Hu et al, after correcting for study heterogeneity, reported that, when gastric varices were treated with cyanoacrylate alone (n = 309), the risk of rebleeding was 15 % (95 %CI 11 % to 18 %) 108 . Chirapongsathorn et al included seven RCTs (n = 583) comparing endoscopic injection of N‐butyl‐2‐cyanoacrylate glue with any other treatment approach not involving cyanoacrylate (propranolol only, EBL, or sclerotherapy with alcohol or ethanolamine).…”

Section: Endoscopic Managementmentioning

confidence: 99%

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Endoscopic diagnosis and management of esophagogastric variceal hemorrhage: European Society of Gastrointestinal Endoscopy (ESGE) Guideline

et al. 2022

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Main Recommendations 1 ESGE recommends that patients with compensated advanced chronic liver disease (ACLD; due to viruses, alcohol, and/or nonobese [BMI < 30 kg/m2] nonalcoholic steatohepatitis) and clinically significant portal hypertension (hepatic venous pressure gradient [HVPG] > 10 mmHg and/or liver stiffness by transient elastography > 25 kPa) should receive, if no contraindications, nonselective beta blocker (NSBB) therapy (preferably carvedilol) to prevent the development of variceal bleeding.Strong recommendation, moderate quality evidence. 2 ESGE recommends that in those patients unable to receive NSBB therapy with a screening upper gastrointestinal (GI) endoscopy that demonstrates high risk esophageal varices, endoscopic band ligation (EBL) is the endoscopic prophylactic treatment of choice. EBL should be repeated every 2–4 weeks until variceal eradication is achieved. Thereafter, surveillance EGD should be performed every 3–6 months in the first year following eradication.Strong recommendation, moderate quality evidence. 3 ESGE recommends, in hemodynamically stable patients with acute upper GI hemorrhage (UGIH) and no history of cardiovascular disease, a restrictive red blood cell (RBC) transfusion strategy, with a hemoglobin threshold of ≤ 70 g/L prompting RBC transfusion. A post-transfusion target hemoglobin of 70–90 g/L is desired.Strong recommendation, moderate quality evidence. 4 ESGE recommends that patients with ACLD presenting with suspected acute variceal bleeding be risk stratified according to the Child–Pugh score and MELD score, and by documentation of active/inactive bleeding at the time of upper GI endoscopy.Strong recommendation, high quality of evidence. 5 ESGE recommends the vasoactive agents terlipressin, octreotide, or somatostatin be initiated at the time of presentation in patients with suspected acute variceal bleeding and be continued for a duration of up to 5 days.Strong recommendation, high quality evidence. 6 ESGE recommends antibiotic prophylaxis using ceftriaxone 1 g/day for up to 7 days for all patients with ACLD presenting with acute variceal hemorrhage, or in accordance with local antibiotic resistance and patient allergies.Strong recommendation, high quality evidence. 7 ESGE recommends, in the absence of contraindications, intravenous erythromycin 250 mg be given 30–120 minutes prior to upper GI endoscopy in patients with suspected acute variceal hemorrhage.Strong recommendation, high quality evidence. 8 ESGE recommends that, in patients with suspected variceal hemorrhage, endoscopic evaluation should take place within 12 hours from the time of patient presentation provided the patient has been hemodynamically resuscitated.Strong recommendation, moderate quality evidence. 9 ESGE recommends EBL for the treatment of acute esophageal variceal hemorrhage (EVH).Strong recommendation, high quality evidence. 10 ESGE recommends that, in patients at high risk for recurrent esophageal variceal bleeding following successful endoscopic hemostasis (Child–Pugh C ≤ 13 or Child–Pugh B > 7 with active EVH at the time of endoscopy despite vasoactive agents, or HVPG > 20 mmHg), pre-emptive transjugular intrahepatic portosystemic shunt (TIPS) within 72 hours (preferably within 24 hours) must be considered.Strong recommendation, high quality evidence. 11 ESGE recommends that, for persistent esophageal variceal bleeding despite vasoactive pharmacological and endoscopic hemostasis therapy, urgent rescue TIPS should be considered (where available).Strong recommendation, moderate quality evidence. 12 ESGE recommends endoscopic cyanoacrylate injection for acute gastric (cardiofundal) variceal (GOV2, IGV1) hemorrhage.Strong recommendation, high quality evidence. 13 ESGE recommends endoscopic cyanoacrylate injection or EBL in patients with GOV1-specific bleeding.Strong recommendations, moderate quality evidence. 14 ESGE suggests urgent rescue TIPS or balloon-occluded retrograde transvenous obliteration (BRTO) for gastric variceal bleeding when there is a failure of endoscopic hemostasis or early recurrent bleeding.Weak recommendation, low quality evidence. 15 ESGE recommends that patients who have undergone EBL for acute EVH should be scheduled for follow-up EBLs at 1- to 4-weekly intervals to eradicate esophageal varices (secondary prophylaxis).Strong recommendation, moderate quality evidence. 16 ESGE recommends the use of NSBBs (propranolol or carvedilol) in combination with endoscopic therapy for secondary prophylaxis in EVH in patients with ACLD.Strong recommendation, high quality evidence.

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Section: Endoscopic Managementmentioning

confidence: 99%

“…Several systematic reviews/meta-analyses have evaluated the efficacy of cyanoacrylate injection for the treatment of GVH 105 106 107 108 109 . Qiao et al reported on three RCTs, which included 194 patients with active gastric variceal bleeding, comparing endoscopic cyanoacrylate injection versus EBL 106 .…”

Section: Endoscopic Managementmentioning

confidence: 99%

Endoscopic diagnosis and management of esophagogastric variceal hemorrhage: European Society of Gastrointestinal Endoscopy (ESGE) Guideline

et al. 2022

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“…BL or rubber-band ligation represents one of the oldest techniques in the treatment of gastrointestinal varices [8]. It is inferior to cyanoacrylate injection and embolization coils in terms of the overall success rate and rebleeding risk [3]. However, BL is cost-effective, less technically demanding than the aforementioned techniques.…”

Section: Introductionmentioning

confidence: 99%

“…Oesophageal varices result from portal hypertension as a frequent manifestation of liver cirrhosis [1]. About 60%-80% of liver cirrhosis patients develop gastrointestinal varices, with oesophageal varices constituting 17% [2,3]. The frequency of developing oesophageal varices is rmly attributed to the severity of liver disease.…”

Section: Introductionmentioning

confidence: 99%

“…Common interventions include pharmacological (i.e. somatostatin, octreotide, proton pump inhibitors [PPIs] and beta-blockers) and procedural interventions, such as cyanoacrylate injection, balloon tamponade, embolization coils, sclerotherapy and band ligation (BL), among others [3,5]. BL or rubber-band ligation represents one of the oldest techniques in the treatment of gastrointestinal varices [8].…”

Section: Introductionmentioning

confidence: 99%

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Bleeding from band ligation-induced ulcers following the treatment of oesophageal varices: a retrospective case–control study.

Swai²

2020

Preprint

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Background Band ligation (BL) plays a vital role in the treatment of oesophageal varices; however, the procedure carries a considerable risk of band slippage, variceal site ulcer formation and post-treatment bleeding. Our study aimed to explore the incidence of post-BL ulcer bleeding and to identify possible associated factors.Methods We retrospectively reviewed the records of patients with oesophageal varices who underwent endoscopic haemostasis by BL at our institution between 2015 and 2020. We statistically compared the patients with post-BL ulcer bleeding and those without (controls). The outcome variable was the development of BL-induced ulcer bleeding. The patients’ demographics, clinical and laboratory parameters, BL procedure outcomes and experts’ opinions were used as the independent variables and possible associated factors. Results Of the 4579 eligible patients 388 (8.5%) presented with post-BL ulcer bleeding. Proton pump inhibitor (PPI) use was associated with a lower risk of post-BL ulcer bleeding (odds ratio, 0.77; 95% confidence interval [CI]: 0.603–0.983). The presence of high-risk stigmata indicated a 1.276 times higher risk of bleeding (CI: 1.024–1.592), and a greater number of varices was associated with an increased risk of post-BL ulcer bleeding (P = 0.007). The use of fewer bands per variceal site was associated with fewer bleeding incidents (P = 0.008), while lower haemoglobin levels were associated with a higher probability of bleeding (P = 0.007).Conclusions The overall incidence of post-BL ulcer bleeding was 8.5%. The presence of high-risk stigmata and a higher number of varices and bands per variceal site were associated with an increased risk of bleeding. Adequate haemoglobin levels and the use of adjuvant PPIs and having were protective factors.

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Risk of rebleeding from gastroesophageal varices after initial treatment with cyanoacrylate: a systematic review and pooled analysis.

Cited by 2 publications

References 9 publications

Endoscopic diagnosis and management of esophagogastric variceal hemorrhage: European Society of Gastrointestinal Endoscopy (ESGE) Guideline

Endoscopic diagnosis and management of esophagogastric variceal hemorrhage: European Society of Gastrointestinal Endoscopy (ESGE) Guideline

Bleeding from band ligation-induced ulcers following the treatment of oesophageal varices: a retrospective case–control study.

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