Octreotide in acute bleeding esophageal varices: a prospective randomized study

BACKGROUND/AIMS: To assess the value of octreotide in the control of acute bleeding esophageal varices, in a prospective randomized study. METHODOLOGY: One hundred and ninety-seven patients admitted for variceal bleeding confirmed at endoscopy were recruited and divided into two groups: group I (n = 111) with endoscopic stigmata of recent bleeding; and group II (n = 86) with active bleeding at emergency endoscopy. Patients in group I were randomized to receive a continuous infusion of octreotide (n = 58) or emergency sclerotherapy (n = 53). Patients in group II were assigned to sclerotherapy (n = 42) or to sclerotherapy plus octreotide (n = 44). At the end of the period of study (48 hours), patients were submitted to sclerotherapy or band ligation until variceal obliteration was achieved. RESULTS: In group I, octreotide was found to be as effective as sclerotherapy regarding hemostasis at 48 hours and on day 7 after the index bleeding episode. Transfusion needs were not significantly different for the two treatment modalities. In group II, the association of octreotide with sclerotherapy was significantly better than sclerotherapy alone either in controlling acute active bleeding (P < 0.001) or in achieving hemostasis at 48 hours (P < 0.01). Transfusion needs were significantly fewer in patients treated with this therapeutic association as compared to sclerotherapy alone. CONCLUSIONS: These results suggest that octreotide infusion is effective in the treatment of variceal bleeding. In patients with recent bleeding, octreotide infusion is as effective as emergency sclerotherapy. In active variceal bleeding, it is a valuable adjuvant treatment in association with emergency sclerotherapy.     

Clinical management and patient outcomes of acute lower gastrointestinal bleeding. A multicenter,prospective, cohort study

Background & aimAlthough acute lower GI bleeding (LGIB) represents a significant healthcare burden, prospective real-life data on management and outcomes are scanty. Present multicentre, prospective cohort study was aimed at evaluating mortality and associated risk factors and at describing patient management.MethodsAdult outpatients acutely admitted for or developing LGIB during hospitalization were consecutively enrolled in 15 high-volume referral centers. Demographics, comorbidities, medications, interventions and outcomes were recorded.ResultsOverall 1,198 patients (1060 new admissions;138 inpatients) were included. Most patients were elderly (mean-age 74±15 years), 31% had a Charlson-Comorbidity-Index ≥3, 58% were on antithrombotic therapy. In-hospital mortality (primary outcome) was 3.4% (95%CI 2.5–4.6). At logistic regression analysis, independent predictors of mortality were increasing age, comorbidity, inpatient status, hemodynamic instability at presentation, and ICU-admission. Colonoscopy had a 78.8% diagnostic yield, with significantly higher hemostasis rate when performed within 24-hours than later (21.3% vs.10.8%, p = 0.027). Endoscopic hemostasis was associated with neither in-hospital mortality nor rebleeding. A definite or presumptive source of bleeding was disclosed in 90.4% of investigated patients.ConclusionMortality in LGIB patients is mainly related to age and comorbidities. Although early colonoscopy has a relevant diagnostic yield and is associated with higher therapeutic intervention rate, endoscopic hemostasis is not associated with improved clinical outcomes [ClinicalTrial.gov number: NCT 04364412].     

Improved patient survival after acute variceal bleeding: a multicenter,cohort study

OBJECTIVE: Existing literature indicates that the mortality rate with each variceal bleeding episode is 30-50%. Over the past 2 decades, there have been significant developments in the management of variceal bleeding. The effect of these developments on the natural history of variceal bleeding is unclear. Therefore, a retrospective, multicenter study was conducted to define the outcomes of variceal bleeding and to describe the patterns of current practice in the management of variceal bleeding. METHODS: All patients with documented variceal bleeding hospitalized at four large county hospitals from January 1, 1997, to June 30, 2000, were included. Study outcomes were in-hospital, 6-wk, and overall mortality, rate of rebleeding, transfusion requirement, and length of stay. After discharge, patients were followed until death or study closure date, on June 30, 2000. RESULTS: A total of 231 subjects were included, and their in-hospital, 6-wk, and overall mortality rates were 14.2%, 17.5%, and 33.5%, respectively. The frequency of rebleeding during follow-up was 29%. Median length of total hospital stay was 8 days (0-34 days). Median number of packed red cell units transfused was 4 U (0-60 U). Upper endoscopy was performed in 95% of patients within 24 h, and endoscopic therapy was done in all but eight patients (ligation 64%, sclerotherapy 33%). Octreotide was administered in 74% of the patients. Portasystemic shunts were performed in 7.5% of the patients for controlling acute variceal bleeding. CONCLUSIONS: The mortality rate after variceal bleeding in this study was substantially lower than previously reported. This suggests that advances made in the management of variceal bleeding have improved outcomes after variceal bleeding.     

Surgical management of bleeding stomal varices

A retrospective chart review of nine patients with stomal varices and portal hypertension who required surgical management of bleeding varices from 1978 to 1986 was performed. The patient's mean age at stoma formation was 46 years (range, 36 to 70 years). Three were female, six were male, and all were Caucasian. Three patients had colostomies and six had ileostomies. Indications for creation of the ostomies included inflammatory bowel disease in six patients and carcinoma in three patients. The time from creation of the stoma to the first bleed was 11 to 196 months (mean, 82 months). The average time between this bleed and surgical treatment was six months. The operative procedures performed included nine mucocutaneous disconnections (MCD) in seven patients (one for recurrent bleeding) and two stoma relocations (one for recurrence). MCD is simple, quick, and associated with a lower morbidity and intraoperative blood loss than stomal relocation. Post-operative follow-up has ranged from 4 months to 4.6 years (mean, 2.5 years). During this period there were two episodes of recurrent varices that required surgery. In the select group of patients that cannot be managed conservatively, MCD is favored and relocation considered only if MCD is technically impossible. Read at the meeting of the American Society of Colon and Rectal Surgeons, Washington, D.C., April 5 to 10, 1987. The opinions expressed are those of the authors and do not reflect the opinions of the United States Air Force or the Department of Defense.     

The usage of comprehensive geriatric assessment in elderly patients with acute myeloid leukemia: a multicenter,prospective study

<正>Objective To evaluate the feasibility and potential value of comprehensive geriatric assessment (CGA) in elderly (≥60 years) patients with newly diagnosed acute myeloid leukemia (AML) in China. Methods The CGA results of 83 newly diagnosed AML (non-APL) patients     

Timing of colonoscopy in acute lower GI bleeding: a multicenter retrospective cohort study

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Oesophageal varices: assessment of the risk of bleeding and mortality

Patients with oesophageal varices run a high risk of bleeding and even death, however rates of bleeding and mortality vary greatly. Indeed, a number of patients with varices never bleed. Prophylactic therapy is effective, but can be associated with side-effects. It remains to be determined which patients are at high risk of bleeding and require treatment. In addition, since non-response to medical therapy has been reported to occur in 20-40% of patients, the effect of a given prophylactic drug, or combinations of drugs, needs to be tested. A review is given of available methods of assessment. The Hepatic Venous Pressure Gradient, and measurements of the variceal pressure, are two proven methods, and the latter has the advantages of being non-invasive and having value in presinusoidal portal hypertension.     

Left ventricular dysfunction after acute myocardial infarction: results of a prospective multicenter study

In a multicenter prospective study of 866 patients who survived the coronary care unit phase of an acute myocardial infarction, variables reflecting left ventricular function were examined to assess their impact on 2 year survival. Single variables that reflected left ventricular dysfunction before infarction and in the acute and recovery phases were, respectively, history of prior myocardial infarction, rales in the coronary care unit dichotomized at greater than bibasilar and predischarge radionuclide ejection fraction dichotomized at less than 0.40. When combined in a stepwise fashion, patients lacking these three risk characteristics had a 2 year 4.2% mortality rate, whereas patients possessing all three characteristics had a 45% mortality rate. Rales in the coronary care unit and predischarge ejection fraction act independently, and each contributes to mortality. Fifty-two patients with advanced rales but an ejection fraction of 0.40 or greater had a 21% mortality rate. Similarly, 208 patients with few rales but an ejection fraction of less than 0.40 had a 15% mortality rate. These data suggest that the mortality risk imposed by those factors that assess permanent left ventricular damage is independent of and additive to the mortality risk contributed by dynamic, acute phase dysfunction. These data fit the hypothesis that acute phase dysfunction is, in part, due to transient ischemia that, on reversal, can restore function toward normal. The results suggest 1) that assessment of left ventricular function during the acute and recovery phases of myocardial infarction is necessary to define prognostic characteristics of an individual patient, and 2) that of particular importance is the identification of patients whose postinfarction course is consistent with reversible ischemia.     

肥胖者重症急性胰腺炎发生率的多中心前瞻性对照研究

目的 观察肥胖的急性胰腺炎(AP)患者在基础内科治疗过程中发展为重症急性胰腺炎(SAP)的概率,探讨肥胖对AP病情发展的影响.方法 采用多中心、前瞻性研究,以APACHEⅡ评分评估AP严重程度,共纳入轻症急性胰腺炎(MAP)患者161例,以体重指数25 kg/m2为标准,分为肥胖组(79例)和非肥胖组(82例).在相同的基础内科治疗条件下观察两组患者血C-反应蛋白(CRP)和三酰甘油水平、并发症发生率、SAP的发生率及病死率.结果 肥胖组的CRP水平为(117±109)mg/L,显著高于非肥胖组的(35±36)mg/L(P＜0.01);肥胖组高三酰甘油血症患者的例数是非肥胖组的1倍,但无显著性差异.两组均无局部并发症,但肥胖组各系统并发症发生率(20.3%)显著高于非肥胖组(6.1%,P＜0.01).肥胖组有16例(20.3%)发展为SAP,显著高于非肥胖组(5例,6.1%,P＜0.01).肥胖组有1例(1.3%)病死,非肥胖组无病死.在APACHEⅡ4-7分的MAP患者中,肥胖组的SAP发生率(43.3%)明显高于非肥胖组(18.5%,P＜0.05).结论 肥胖且 APACHEⅡ评分为4-7分的MAP 患者更易进展为SAP,应给予更积极的临床干预措施.     

Acetaminophen-induced acute liver failure: results of a United States multicenter, prospective study

Severe acetaminophen hepatotoxicity frequently leads to acute liver failure (ALF). We determined the incidence, risk factors, and outcomes of acetaminophen-induced ALF at 22 tertiary care centers in the United States. Detailed prospective data were gathered on 662 consecutive patients over a 6-year period fulfilling standard criteria for ALF (coagulopathy and encephalopathy), from which 275 (42%) were determined to result from acetaminophen liver injury. The annual percentage of acetaminophen-related ALF rose during the study from 28% in 1998 to 51% in 2003. Median dose ingested was 24 g (equivalent to 48 extra-strength tablets). Unintentional overdoses accounted for 131 (48%) cases, intentional (suicide attempts) 122 (44%), and 22 (8%) were of unknown intent. In the unintentional group, 38% took two or more acetaminophen preparations simultaneously, and 63% used narcotic-containing compounds. Eighty-one percent of unintentional patients reported taking acetaminophen and/or other analgesics for acute or chronic pain syndromes. Overall, 178 subjects (65%) survived, 74 (27%) died without transplantation, and 23 subjects (8%) underwent liver transplantation; 71% were alive at 3 weeks. Transplant-free survival rate and rate of liver transplantation were similar between intentional and unintentional groups. In conclusion, acetaminophen hepatotoxicity far exceeds other causes of acute liver failure in the United States. Susceptible patients have concomitant depression, chronic pain, alcohol or narcotic use, and/or take several preparations simultaneously. Education of patients, physicians, and pharmacies to limit high-risk use settings is recommended.     

An assessment of endoscopic and concomitant management of acute variceal bleeding at a tertiary care centre.

BACKGROUND: Several therapies have been demonstrated to be beneficial in the management of acute variceal bleeding (AVB). The aim of the present study was to characterize the use of these therapies at a Canadian tertiary care centre. PATIENTS AND METHODS: A comprehensive chart review was performed to assess the management of all adult cirrhotic patients with AVB who were admitted to a university-affiliated, tertiary care centre between April 2001 and March 2004. RESULTS: A total of 81 AVB patients were identified with a mean age of 53.7+/-13.2 years and a median model for end-stage liver disease score of 14. Endoscopy was performed within 8.2+/-7.6 h of admission. Variceal banding was performed for 87% of patients with esophageal varices, which were the most common source of bleeding (80%). Octreotide was used in 82% of patients for a mean duration of 74.3+/-35.4 h; prophylactic antibiotics were used in 25% of patients and beta-blockers were used in 24% of patients without any contraindications. Follow-up endoscopy was arranged for 46 of 71 (65%) survivors. Prophylactic antibiotic use was associated with the presence of ascites, while beta-blockers were used more often in the last year of the study. CONCLUSIONS: There is a disconnection between the use of evidence-based recommendations and routine clinical practices in the management of AVB. Deficiencies identified include the lack of use of prophylactic antibiotics and beta-blockers, variable use of octreotide and inadequate follow-up recommendations. There is a need to identify measures to improve the process of care for patients with AVB which would ensure optimal management of these patients.     

Terlipressin in bleeding esophageal varices: a placebo-controlled, double-blind study

The effect of terlipressin (N-alpha-triglycyl-8-lysine-vasopressin) in bleeding esophageal varices was evaluated in a prospective placebo-controlled study. Fifty bleeding episodes from esophageal varices in 34 patients were randomized. Standard therapy with transfusions, fluid and electrolyte correction, and lactulose was performed in both groups. Balloon tamponade was used in 20 bleeding episodes in the terlipressin group and in 19 bleeding episodes in the control group. In the terlipressin group, hemorrhage was controlled in all bleeding episodes (25/25) whereas in the placebo group, only 20 of 25 bleeding episodes could be stopped within 36 hr (p less than 0.05). Sclerotherapy was performed in five bleeding episodes in the terlipressin group and in seven bleeding episodes in the placebo group. Treatment failures, including patients who required sclerotherapy, occurred in five bleedings in the terlipressin group and in 12 in the control group (p less than 0.05). The hospital mortality rate was 12% (3/25) in the terlipressin group and 32% (8/25) in the control group. Patients in the terlipressin group required fewer transfusions, the balloon needed to be inflated for a shorter time and the duration of bleeding was shorter than in the control group. However, these differences were not significant. These data do not allow conclusions concerning monotherapy with terlipressin, but they indicate that the addition of terlipressin to standard therapy may increase the control rate in acute variceal hemorrhage.     

An 8-year prospective experience with balloon tamponade in emergency control of bleeding esophageal varices

The use of balloon tamponade in the emergency control of bleeding from esophageal varices is controversial. This paper reports a prospective study over an 8-year period in which balloon tamponade has been the sole means employed for the early control of bleeding varices. During 1972–1980 all patients referred to Prince Henry's Hospital with upper gastrointestinal bleeding were admitted to a special unit. Ninety-one had bleeding esophageal varices, and 17 were admitted on one or more occasions for bleeding for a total of 132 admissions. After early endoscopy, balloon tamponade was used during 103 of these admissions with failure to control bleeding on six occasions; five of these patients died from hemorrhage and the sixth recovered after emergency portacaval shunt. Another patient died from rebleeding not treated by tamponade. Reinsertion of the balloon for rebleeding was necessary on 28 occasions with successful control in all cases. Balloon tamponade was not used during 29 admissions because bleeding had ceased or the patient was considered to have terminal liver disease. In this group there were four deaths from severe liver disease and hemorrhage. Balloon tamponade was used in 78% of admissions and controlled bleeding in more than 90% of patients. This suggests that tamponade may be the method of choice for early control of bleeding from esophageal varices.