Predictors of variceal rebleeding in liver cirrhosis

Year 2023, Volume: 7 Issue: 1, 5 - 9, 21.06.2023

İbrahim Vasi , Hava Üsküdar Teke , Tuncer Temel

https://doi.org/10.30565/medalanya.1119439

Abstract

Aim: Cirrhotic patients with acute variceal bleeding are characterized by a high mortality and rebleeding rate. The aim of this study was to explore predictors of rebleeding in cirrhotic patients.

Methods: Cirrhotic patients who were admitted to the hospital were retrospectively analyzed. Rebleeding was defined as a new onset of hematemesis, hematochezia or melena after endoscopic therapy, and a period of stable vital signs and hemoglobin. Medical records as laboratory data include hemoglobin and platelet level, prothrombin time, creatinine, bilirubin, albumin level, vital signs, need of blood transfusions, comorbidities, medications, clinical findings as presence of ascites and hepatic encephalopathy, and endoscopic findings of varices were recorded and entered a computer-based database. Child-Pugh stage was also calculated and recorded.

Results: 20 patients (21%) with recurrent hemorrhage after control of the variceal bleeding during the six-week follow-up period were included in this study. The level of albumin and hemoglobin in the rebleeding group were significantly lower than those in non-rebleeding group. The mean level of albumin was 2.45 mg/dL (vs. 3.05 mg/dL, p=0.01) and hemoglobin was 7.96 g/dL (vs. 9.92 g/dL, p=0.001). Ascites was seen to be significantly higher in the rebleeding group (50% vs. 14%, p=0.002). After multivariate regression analysis, we found that lower hemoglobin level and Child-Pugh grade were the only independent significant predictors for variceal rebleeding.

Conclusion: Since factors such as the Child-Pugh grade, hypoalbuminemia and presence of ascites are associated with portal hypertension and hepatic failure, we found that lower hemoglobin level and Child-Pugh grade were the only independent significant predictors for variceal rebleeding.

Keywords

varices, hemorrhage, mortality

Sirotik Varis Kanamalarında Tekrar Kanama Belirleyicileri

Abstract

Amaç: Sirotik varis kanamaları yüksek mortalite ve tekrar kanama oranları ile karakterizedir. Bu çalışmada tekrar kanama belirleyicilerinin saptanması amaçlanmıştır.

Yöntem: Hastaneye başvuran siroz hastaları retrospektif olarak değerlendirilmiştir. Endoskopik müdahale ve vital bulguların stabil hale gelmesi sonrasında yeni gelişen hematemez, melena, hematokezya bulguları ve hemoglobin düzeyinde düşme görülmesi tekrar kanama olarak tanımlanmıştır. Hastaların hemoglobin ve trombosit düzeyi, protrombin zamanı, kreatinin, bilirubin, albümin düzeyi, vital bulguları, kan transfüzyonu ihtiyacı durumu, komorbiditeleri, ilaçları, asit varlığı ve hepatik ensefalopati varlığı gibi klinik bulguları ve varislerin endoskopik bulguları bilgisayar tabanlı bir veritabanına kaydedilmiştir. Child-Pugh evresi de kaydedilmiştir.

Bulgular: Varis kanamalarının kontrolünden sonraki altı haftalık dönemlerinde tekrarlayan kanaması olan 20 hasta (%21) saptanmıştır. Tekrar kanaması olan grupta albümin ve hemoglobin düzeyi, tekrar kanamayan gruba göre anlamlı derecede düşüktü. Albümin seviyesi (2.45 & 3,05 mg/dl, p=0.01) ve hemoglobin 7.96 & 9.92 g/dl'ydi, p=0.001). Tekrar kanaması olan grupta asit sıklığı, tekrar kanamayan gruba göre anlamlı olarak daha yüksekti (%50 & %14, p=0,002). Çok değişkenli regresyon analizden sonra, düşük hemoglobin seviyesi ve Child-Pugh evresinin varislerde tekrar kanama için tek bağımsız anlamlı risk faktörleri olduğu saptanmıştır.

Sonuç: Child-Pugh evresi, hipoalbüminemi ve asit varlığı gibi faktörler portal hipertansiyon ve karaciğer yetmezliği ile ilişkili olduğundan, düşük hemoglobin düzeyi ve Child-Pugh evresinin tekrarlayan varis kanaması için tek bağımsız anlamlı risk faktörleri olduğu saptanmıştır.

Keywords

varis, kanama, mortalite

References

• 1. Sarin SK, Kumar A, Angus PW, Baijal SS, Baik SK, Bayraktar Y, et al. Diagnosis and management of acute variceal bleeding: Asian Pacific Association for Study of the Liver recommendations. Hepatol Int. 2011;5(2):607–24. DOI: 10.1007/s12072-010-9236-9
• 2. Li L, Yu C, Li Y. Endoscopic band ligation versus pharmacological therapy for variceal bleeding in cirrhosis: A meta-analysis. Can J Gastroenterol. 2011;25(3):147–55. DOI: 10.1155/2011/346705
• 3. Romcea A, Tantau M, Seicean A, Pascu O. Variceal bleeding in cirrhotic patients: risk factors, evolution, treatment. Clujul Med. 2013;86(2):107–10. PMID: 26527928
• 4. Habib A, Sanyal AJ. Acute variceal hemorrhage. Gastrointest Endosc Clin N Am. 2007;17(2):223–52, v. DOI: 10.1016/j.giec.2007.03.005
• 5. Rahimi RS, Rockey DC. Complications of cirrhosis. Curr Opin Gastroenterol. 2012;28(3):223–9. DOI: 10.1097/MOG.0b013e328351d003
• 6. Nevens F, Bustami R, Scheys I, Lesaffre E, Fevery J. Variceal pressure is a factor predicting the risk of a first variceal bleeding: a prospective cohort study in cirrhotic patients. Hepatology. 1998;27(1):15–9. DOI: 10.1002/hep.510270104
• 7. Predicción de resangrado precoz en cirróticos con hemorragia varicosa aguda. Función del análisis con árboles de clasificación y regresión (CART) | Revista de Gastroenterología de México.2010;75(1):12-21 Available from: http://www.revistagastroenterologiamexico.org/es-prediccion-resangrado-precoz-cirroticos-con-articulo-X0375090610498378
• 8. Krige JEJ, Kotze UK, Sayed R, Burmeister S, Bernon M, Chinnery G. Outcome in decompensated alcoholic cirrhotic patients with acute variceal bleeding. South Afr Med J. 2012;102(6):554–7. DOI: 10.7196/samj.5493
• 9. Al-Freah M a. B, Gera A, Martini S, McPhail MJW, Devlin J, Harrison PM, et al. Comparison of scoring systems and outcome of patients admitted to a liver intensive care unit of a tertiary referral centre with severe variceal bleeding. Aliment Pharmacol Ther. 2014;39(11):1286–300. DOI: 10.1111/apt.12744
• 10. Hobolth L, Krag A, Bendtsen F. The recent reduction in mortality from bleeding oesophageal varices is primarily observed from Days 1 to 5. Liver Int. 2010;30(3):455–62. DOI: 10.1111/j.1478-3231.2009.02169.x
• 11. Bambha K, Kim WR, Pedersen R, Bida JP, Kremers WK, Kamath PS. Predictors of early re-bleeding and mortality after acute variceal haemorrhage in patients with cirrhosis. Gut. 2008;57(6):814–20. DOI: 10.1136/gut.2007.137489