Clinical Significance of Variceal Bleeding
Clinical Significance of Variceal Bleeding
Background and Aims: Recent progress in the treatment of variceal bleeding might have reduced the impact of variceal bleeding on survival in patients with esophageal varices. We conducted a retrospective cohort study in an attempt to re-evaluate the clinical significance of variceal bleeding.
Methods: A cohort of 304 patients with liver cirrhosis and esophageal varices, who had no previous history of variceal bleeding and no prophylactic therapy, was studied.
Results: During a median follow-up period of 32 months, 55 patients (18%) bled from varices and 111 (37%) died. Variceal hemorrhages accounted for 15% of total deaths. The mortality of first variceal bleeding was 25% in the whole group, but was remarkably different depending on liver function at the time of bleeding (0% in grade Child Avs55% in grade C;P < 0.05). Among the survivors of first bleeding, 30% experienced rebleeding. Form of varix, red color sign and heavy drinking were the independent risk factors for first variceal bleeding. Multivariate analysis revealed that variceal bleeding still had a significant (P < 0.001) impact on death in the whole cohort, when other independent prognostic factors such as age, ascites, encephalopathy, platelet count, serum albumin level and hepatocellular carcinoma were adjusted. Furthermore, in subgroup analyses, variceal bleeding was more strongly (P < 0.001) linked to death in patients with alcoholic cirrhosis than in those with non-alcoholic cirrhosis, and showed a significant association with survival only for the patients in Child grade B.
Conclusions: Variceal bleeding has various prognostic impacts depending on the etiology of cirrhosis or on the degree of liver dysfunction, and this needs to be taken into account in the prophylaxis against first variceal bleeding.
Esophageal varices are the most common clinical manifestation of portal hypertension in patients with liver cirrhosis. It is known that once bleeding occurs in patients with varices the prognosis is extremely poor, with 30-50% of patients dying within 6 weeks of the first variceal hemorrhage. Among those who survive the first hemorrhage, 47-84% show recurrent bleeding and 70% die within the first year. Thus, various prophylactic measures such as shunt operation, use of beta-blockers, endoscopic sclerotherapy and endoscopic variceal ligation have been attempted to increase the survival rate by preventing the first variceal hemorrhage. Based on the results of these trials, oral administration of beta-blockers is widely used as a primary prophylactic method against first variceal bleeding. The effectiveness, however, of each prophylactic measure is still controversial, and the survival benefit of prophylaxis has not yet been clearly shown. In one study, beta-blockade was shown to increase the bleeding-free survival only in patients without ascites, whereas in another study it was only effective in patients with ascites. Notable progress in the treatment of variceal bleeding has possibly reduced the fatality rate of variceal hemorrhage and might weaken the necessity for prophylaxis. In the present study, we re-evaluated the clinical significance of variceal bleeding throughout the natural history of cirrhotic patients, who were managed in our department during the last decade, and tried to determine the impact of variceal bleeding on survival.
Background and Aims: Recent progress in the treatment of variceal bleeding might have reduced the impact of variceal bleeding on survival in patients with esophageal varices. We conducted a retrospective cohort study in an attempt to re-evaluate the clinical significance of variceal bleeding.
Methods: A cohort of 304 patients with liver cirrhosis and esophageal varices, who had no previous history of variceal bleeding and no prophylactic therapy, was studied.
Results: During a median follow-up period of 32 months, 55 patients (18%) bled from varices and 111 (37%) died. Variceal hemorrhages accounted for 15% of total deaths. The mortality of first variceal bleeding was 25% in the whole group, but was remarkably different depending on liver function at the time of bleeding (0% in grade Child Avs55% in grade C;P < 0.05). Among the survivors of first bleeding, 30% experienced rebleeding. Form of varix, red color sign and heavy drinking were the independent risk factors for first variceal bleeding. Multivariate analysis revealed that variceal bleeding still had a significant (P < 0.001) impact on death in the whole cohort, when other independent prognostic factors such as age, ascites, encephalopathy, platelet count, serum albumin level and hepatocellular carcinoma were adjusted. Furthermore, in subgroup analyses, variceal bleeding was more strongly (P < 0.001) linked to death in patients with alcoholic cirrhosis than in those with non-alcoholic cirrhosis, and showed a significant association with survival only for the patients in Child grade B.
Conclusions: Variceal bleeding has various prognostic impacts depending on the etiology of cirrhosis or on the degree of liver dysfunction, and this needs to be taken into account in the prophylaxis against first variceal bleeding.
Esophageal varices are the most common clinical manifestation of portal hypertension in patients with liver cirrhosis. It is known that once bleeding occurs in patients with varices the prognosis is extremely poor, with 30-50% of patients dying within 6 weeks of the first variceal hemorrhage. Among those who survive the first hemorrhage, 47-84% show recurrent bleeding and 70% die within the first year. Thus, various prophylactic measures such as shunt operation, use of beta-blockers, endoscopic sclerotherapy and endoscopic variceal ligation have been attempted to increase the survival rate by preventing the first variceal hemorrhage. Based on the results of these trials, oral administration of beta-blockers is widely used as a primary prophylactic method against first variceal bleeding. The effectiveness, however, of each prophylactic measure is still controversial, and the survival benefit of prophylaxis has not yet been clearly shown. In one study, beta-blockade was shown to increase the bleeding-free survival only in patients without ascites, whereas in another study it was only effective in patients with ascites. Notable progress in the treatment of variceal bleeding has possibly reduced the fatality rate of variceal hemorrhage and might weaken the necessity for prophylaxis. In the present study, we re-evaluated the clinical significance of variceal bleeding throughout the natural history of cirrhotic patients, who were managed in our department during the last decade, and tried to determine the impact of variceal bleeding on survival.
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