Skip to main content
SpringerLink
Log in

A la Carte Treatment of Acute Variceal Bleeding

  • Conference paper
Book cover Portal Hypertension VI

Abstract

Failure to control bleeding remains challenging to define, despite many attempts of the community of experts. Even if it is associated with survival, regulatory agencies do not consider this endpoint as a reliable one for clinical trials. Moreover, identifying patients before early rebleeding or at risk of refractory bleeding is probably the most important issue. Mortality at 6 weeks seems to be a reasonable endpoint for RCTs. Refractory bleeding and its attendant mortality remain a challenging condition. Some therapeutic options, besides salvage TIPS, are currently developed but need to be tested in RCTs. As of today, most prognostic variables and scores lack external validation, and a majority include subjective or time-dependent variables and are, therefore, inconsistently evaluated. Identification of solid and unbiased predicting factors of treatment failure and rebleeding have become an urgent need, especially after the demonstration that placement of a TIPS improves survival in patients with acute variceal bleeding and high risk of failure. Identifying the best prognostic factors defining high risk should be our priority. The greatest improvement in the last years in the management of acute variceal bleeding is early TIPS in selected high-risk patients. Selection of patients needs to be refined.

This is a preview of subscription content, log in via an institution to check access.

Access this chapter

Log in via an institution
Chapter
USD 29.95
Price excludes VAT (USA)
  • Available as PDF
  • Read on any device
  • Instant download
  • Own it forever
eBook
USD 89.00
Price excludes VAT (USA)
  • Available as EPUB and PDF
  • Read on any device
  • Instant download
  • Own it forever
Softcover Book
USD 119.99
Price excludes VAT (USA)
  • Compact, lightweight edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info
Hardcover Book
USD 169.99
Price excludes VAT (USA)
  • Durable hardcover edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info

Tax calculation will be finalised at checkout

Purchases are for personal use only

Institutional subscriptions

References

  1. Garcia-Pagan JC, Caca K, Bureau C, Laleman W, Appenrodt B, Luca A, Abraldes JG et al (2010) Early use of TIPS in patients with cirrhosis and variceal bleeding. N Engl J Med 362:2370–2379

    Article  CAS  PubMed  Google Scholar 

  2. Garcia-Pagan JC, Di Pascoli M, Caca K, Laleman W, Bureau C, Appenrodt B, Luca A et al (2013) Use of early-TIPS for high-risk variceal bleeding: results of a post-RCT surveillance study. J Hepatol 58:45–50

    Article  PubMed  Google Scholar 

  3. D’Amico G, Garcia-Tsao G, Pagliaro L (2006) Natural history and prognostic indicators of survival in cirrhosis: a systematic review of 118 studies. J Hepatol 44:217–231

    Article  PubMed  Google Scholar 

  4. de Franchis R, Baveno VF (2010) Revising consensus in portal hypertension: report of the Baveno V consensus workshop on methodology of diagnosis and therapy in portal hypertension. J Hepatol 53:762–768

    Article  PubMed  Google Scholar 

  5. Abraldes JG, Villanueva C, Banares R, Aracil C, Catalina MV, Garci APJC, Bosch J (2008) Hepatic venous pressure gradient and prognosis in patients with acute variceal bleeding treated with pharmacologic and endoscopic therapy. J Hepatol 48:229–236

    Article  PubMed  Google Scholar 

  6. Augustin S, Muntaner L, Altamirano JT, Gonzalez A, Saperas E, Dot J, Abu-Suboh M et al (2009) Predicting early mortality after acute variceal hemorrhage based on classification and regression tree analysis. Clin Gastroenterol Hepatol 7:1347–1354

    Article  PubMed  Google Scholar 

  7. Reverter E, Tandon P, Augustin S, Turon F, Casu S, Bastiampillai R, Keough A et al (2014) A MELD-based model to determine risk of mortality among patients with acute variceal bleeding. Gastroenterology 146:412–419.e413

    Article  PubMed  Google Scholar 

  8. Monescillo A, Martinez-Lagares F, Ruiz-del-Arbol L, Sierra A, Guevara C, Jimenez E, Marrero JM et al (2004) Influence of portal hypertension and its early decompression by TIPS placement on the outcome of variceal bleeding. Hepatology 40:793–801

    Article  PubMed  Google Scholar 

  9. Bosch J, Thabut D, Albillos A, Carbonell N, Spicak J, Massard J, D’Amico G et al (2008) Recombinant factor VIIa for variceal bleeding in patients with advanced cirrhosis: a randomized, controlled trial. Hepatology 47:1604–1614

    Article  CAS  PubMed  Google Scholar 

  10. Augustin S, Altamirano J, Gonzalez A, Dot J, Abu-Suboh M, Armengol JR, Azpiroz F et al (2011) Effectiveness of combined pharmacologic and ligation therapy in high-risk patients with acute esophageal variceal bleeding. Am J Gastroenterol 106:1787–1795

    Article  CAS  PubMed  Google Scholar 

  11. D’Amico G, De Franchis R (2003) Upper digestive bleeding in cirrhosis. Post-therapeutic outcome and prognostic indicators. Hepatology 38:599–612

    Article  PubMed  Google Scholar 

  12. Al-Freah MA, Gera A, Martini S, McPhail MJ, Devlin J, Harrison PM, Shawcross D et al (2014) 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 39:1286–1300

    Article  CAS  PubMed  Google Scholar 

  13. Amitrano L, Guardascione MA, Manguso F, Bennato R, Bove A, DeNucci C, Lombardi G et al (2012) The effectiveness of current acute variceal bleed treatments in unselected cirrhotic patients: refining short-term prognosis and risk factors. Am J Gastroenterol 107:1872–1878

    Article  PubMed  Google Scholar 

  14. Chen PH, Chen WC, Hou MC, Liu TT, Chang CJ, Liao WC, Su CW et al (2012) Delayed endoscopy increases re-bleeding and mortality in patients with hematemesis and active esophageal variceal bleeding: a cohort study. J Hepatol 57:1207–1213

    Article  PubMed  Google Scholar 

  15. Bambha K, Kim WR, Pedersen R, Bida JP, Kremers WK, Kamath PS (2008) Predictors of early re-bleeding and mortality after acute variceal haemorrhage in patients with cirrhosis. Gut 57:814–820

    Article  CAS  PubMed  Google Scholar 

  16. de Franchis R (2000) Updating consensus in portal hypertension: report of the Baveno III Consensus Workshop on definitions, methodology and therapeutic strategies in portal hypertension. J Hepatol 33:846–852

    Article  PubMed  Google Scholar 

  17. de Franchis R (2005) Evolving consensus in portal hypertension. Report of the Baveno IV consensus workshop on methodology of diagnosis and therapy in portal hypertension. J Hepatol 43:167–176

    Article  PubMed  Google Scholar 

  18. Cales P, Masliah C, Bernard B, Garnier PP, Silvain C, Szostak-Talbodec N, Bronowicki JP et al (2001) Early administration of vapreotide for variceal bleeding in patients with cirrhosis. N Engl J Med 344:23–28

    Article  CAS  PubMed  Google Scholar 

  19. Burroughs AK (2001) Assessment of value of consensus definitions in acute variceal bleeding. Lancet 357:1147–1148

    Article  CAS  PubMed  Google Scholar 

  20. Cales P, Lacave N, Silvain C, Vinel JP, Besseghir K, Lebrec D (2000) Prospective study on the application of the Baveno II Consensus Conference criteria in patients with cirrhosis and gastrointestinal bleeding. J Hepatol 33:738–741

    Article  CAS  PubMed  Google Scholar 

  21. Thabut D, D’Amico G, Tan P, De Franchis R, Fabricius S, Lebrec D, Bosch J et al (2010) Diagnostic performance of Baveno IV criteria in cirrhotic patients with upper gastrointestinal bleeding: analysis of the F7 liver-1288 study population. J Hepatol 53:1029–1034

    Article  CAS  PubMed  Google Scholar 

  22. Ahn SY, Park SY, Tak WY, Lee YR, Kang EJ, Park JG, Lee WK et al (2015) Prospective validation of Baveno V definitions and criteria for failure to control bleeding in portal hypertension. Hepatology 61:1033–1040

    Article  PubMed  Google Scholar 

  23. Thabut D, Rudler M, Dib N, Carbonell N, Mathurin P, Saliba F, Mallet A et al (2015) Multicenter prospective validation of the Baveno IV and Baveno II/III criteria in cirrhosis patients with variceal bleeding. Hepatology 61:1024–1032

    Article  CAS  PubMed  Google Scholar 

  24. U.S. Food and Drug Administration (FDA). FDA gastrointestinal drugs advisory committee, In 19 May 2009

    Google Scholar 

  25. Carbonell N, Pauwels A, Serfaty L, Fourdan O, Levy VG, Poupon R (2004) Improved survival after variceal bleeding in patients with cirrhosis over the past two decades. Hepatology 40:652–659

    Article  PubMed  Google Scholar 

  26. Goulis J, Armonis A, Patch D, Sabin C, Greenslade L, Burroughs AK (1998) Bacterial infection is independently associated with failure to control bleeding in cirrhotic patients with gastrointestinal hemorrhage. Hepatology 27:1207–1212

    Article  CAS  PubMed  Google Scholar 

  27. Levacher S, Letoumelin P, Pateron D, Blaise M, Lapandry C, Pourriat JL (1995) Early administration of terlipressin plus glyceryl trinitrate to control active upper gastrointestinal bleeding in cirrhotic patients. Lancet 346:865–868

    Article  CAS  PubMed  Google Scholar 

  28. Schmidt ML, Barritt AS, Orman ES, Hayashi PH (2015) Decreasing mortality among patients hospitalized with cirrhosis in the United States from 2002 through 2010. Gastroenterology 148:967–977

    Article  PubMed  Google Scholar 

  29. Avgerinos A, Klonis C, Rekoumis G, Gouma P, Papadimitriou N, Raptis S (1991) A prospective randomized trial comparing somatostatin, balloon tamponade and the combination of both methods in the management of acute variceal hemorrhage. J Hepatol 13:78–83

    Article  CAS  PubMed  Google Scholar 

  30. Chong C-F (2005) Esophageal rupture due to Sengstaken-Blakemore tube misplacement. World J Gastroenterol 11:6563–6565

    Article  PubMed  PubMed Central  Google Scholar 

  31. Panes J, Teres J, Bosch J, Rodes J (1988) Efficacy of baloon tamponade in treatment of bleeding gastric and esophageal varices- results in 151 consecutive episodes. Dig Dis Sci 33:454–459

    Article  CAS  PubMed  Google Scholar 

  32. Azoulay D, Castaing D, Majno P, Saliba F, Ichai P, Smail A, Delvart V et al (2001) Salvage transjugular intrahepatic portosystemic shunt for uncontrolled variceal bleeding in patients with decompensated cirrhosis. J Hepatol 35:590–597

    Article  CAS  PubMed  Google Scholar 

  33. Roessle M (2013) TIPS: 25 years later. J Hepatol 59:1081–1093

    Article  Google Scholar 

  34. Rudler M, Rousseau G, Thabut D (2013) Salvage transjugular intrahepatic portosystemic shunt followed by early transplantation in patients with Child C14-15 cirrhosis and refractory variceal bleeding: a strategy improving survival. Transpl Int 26:E50–E51

    Article  PubMed  Google Scholar 

  35. Benko L, Danis J, Hubmann R, Kasza G, Gomori E, Roth E, Lorinczy D (2009) DSC examination of the esophagus after implantation of special stents, designed for the management of acute esophagus variceal bleeding: experimental study. J Therm Anal Calorimetry 95:763–768

    Article  CAS  Google Scholar 

  36. Hubmann R, Bodlaj G, Czompo M, Benkoe L, Pichler P, Al-Kathib S, Kiblboeck P et al (2006) The use of self-expanding metal stents to treat acute esophageal variceal bleeding. Endoscopy 38:896–901

    Article  CAS  PubMed  Google Scholar 

  37. Zehetner J, Shamiyeh A, Wayand W, Hubmann R (2008) Results of a new method to stop acute bleeding from esophageal varices: implantation of a self-expanding stent. Surg Endosc Other Interv Techn 22:2149–2152

    Article  CAS  Google Scholar 

  38. Wright G, Lewis H, Hogan B, Burroughs A, Patch D, O’Beirne J (2010) A self-expanding metal stent for complicated variceal hemorrhage: experience at a single center. Gastrointest Endosc 71:71–78

    Article  PubMed  Google Scholar 

  39. Dechene A, El Fouly AH, Bechmann LP, Jochum C, Saner FH, Gerken G, Canbay A (2012) Acute management of refractory variceal bleeding in liver cirrhosis by self-expanding metal stents. Digestion 85:185–191

    Article  CAS  PubMed  Google Scholar 

  40. Escorsell A, Cardenas A, Pavel O, Maria Morillas R, Albillos A, Llop E, de la Pena J et al (2013) Self-expandable esophageal metal stent vs balloon tamponade in esophageal variceal bleeding refractory to medical and endoscopic treatment: a multicenter randomized controlled trial. Hepatology 58:1386A–1387A

    Google Scholar 

  41. Fierz FC, Kistler W, Stenz V, Gubler C (2013) Treatment of esophageal variceal hemorrhage with self-expanding metal stents as a rescue maneuver in a swiss multicentric cohort. Case Rep Gastroenterol 7:97–105

    Article  PubMed  PubMed Central  Google Scholar 

  42. Zakaria MS, Hamza IM, Mohey MA, Hubamnn RG (2013) The first Egyptian experience using new self-expandable metal stents in acute esophageal variceal bleeding: Pilot study. Saudi J Gastroenterol 19:177–181

    Article  PubMed  PubMed Central  Google Scholar 

  43. Vangeli M, Patch D, Burroughs AK (2002) Salvage tips for uncontrolled variceal bleeding. J Hepatol 37:703–704

    Article  CAS  PubMed  Google Scholar 

  44. Vinel JP, Cassigneul J, Louis A, Levade M, Pascal JP (1982) Clinical and prognostic significance of portohepatic gradient in patients with cirrhosis. Surg Gynecol Obstet 155:347–352

    CAS  PubMed  Google Scholar 

  45. Bureau C, Garcia-Pagan JC, Otal P, Pomier-Layrargues G, Chabbert V, Cortez C, Perreault P et al (2004) Improved clinical outcome using polytetrafluoroethylene-coated stents for TIPS: results of a randomized study. Gastroenterology 126:469–475

    Article  PubMed  Google Scholar 

  46. Thabut D, Remy A, Carbonell N, Causse X, Coelho J, Cadranel JF, Cervoni JP, Bramli S, Archambeaud I, Ahsoune P, Ehrhard F, Pariente A, Bureau C, Dupuychaffray J, Rostain F, Skinazi F, Vergniol J, Vitte RI, Pelletier AL, Henrion J, Guillygomarc’h A, Combet S, Pauwels A, Club Francophone pour l’Etude de l’Hypertension Portale, Association Nationale desHepato-Gastroentérologues des Hôpitaux Généraux. Prospective observational study of portal-hypertensive bleeding in 914 cirrhotic patients in France (CHOC study) : high proportion of high-risk patients but limited access to TIPS. AASLD 2014.

    Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Gastrointestinal Bleeding Unit, Department of Gastroenterology, Hospital de Sant Pau, Barcelona, Autonomous University, Barcelona, Spain

    Càndid Villanueva

  2. (CIBERehd), Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Barcelona, Spain

    Càndid Villanueva

  3. The Royal Free Sheila Sherlock Liver Centre, Royal Free Hospital, London, UK

    James O’Beirne

  4. Service d’Hépato-Gastroentérologie, CHU de Toulouse, Toulouse, France

    Christophe Bureau

  5. Liver ICU, Service d’Hépato-Gastroentérologie, Hôpital de la Pitié-Salpétrière, APHP, UPMC, Paris, France

    Dominique Thabut

Authors
  1. Càndid Villanueva
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. James O’Beirne
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Christophe Bureau
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Dominique Thabut
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Dominique Thabut .

Editor information

Editors and Affiliations

  1. Gastroenterology Unit, Luigi Sacco University Hospital, Milan, Italy

    Roberto de Franchis

Rights and permissions

Reprints and permissions

Copyright information

© 2016 Springer International Publishing Switzerland

About this paper

Cite this paper

Villanueva, C., O’Beirne, J., Bureau, C., Thabut, D. (2016). A la Carte Treatment of Acute Variceal Bleeding. In: de Franchis, R. (eds) Portal Hypertension VI. Springer, Cham. https://doi.org/10.1007/978-3-319-23018-4_27

Download citation

  • DOI: https://doi.org/10.1007/978-3-319-23018-4_27

  • Publisher Name: Springer, Cham

  • Print ISBN: 978-3-319-23017-7

  • Online ISBN: 978-3-319-23018-4

  • eBook Packages: MedicineMedicine (R0)

Publish with us

Policies and ethics

Search

Navigation