Cost-effectiveness analysis of beta-blockers vs endoscopic surveillance in patients with cirrhosis and small varices

AIM:To evaluate the most cost-effectiveness strategy for preventing variceal growth and bleeding in patients with cirrhosis and small esophageal varices.METHODS:A stochastic analysis based on decision trees was performed to compare the cost-effectiveness of beta-blockers therapy starting from a diagnosis of small varices(Strategy 1)with that of endoscopic surveillance followed by beta-blockers treatment when large varices are demonstrated(Strategy 2),for preventing variceal growth,bleeding and death in patients with cirrhosis and small esophageal varices.The basic nodes of the tree were gastrointestinal endoscopy,inpatient admission and treatment for bleeding,as required.All estimates were performed using a Monte Carlo microsimulation technique,consisting in simulating observations from known probability distributions depicted in the model.Eight-hundred-thousand simulations were performed to obtain the final estimates.All estimates were then subjected to Monte Carlo Probabilistic sensitivity analysis,to assess the impact of the variability of such estimates on the outcome distributions.RESULTS:The event rate(considered as progression of varices or bleeding or death)in Strategy 1[24.09%(95%CI:14.89%-33.29%)]was significantly lower than in Strategy 2[60.00%(95%CI:48.91%-71.08%)].The mean cost(up to the first event)associated with Strategy 1[823￡(95%CI:106￡-2036￡)]was not significantly different from that of Strategy 2[799￡(95%CI:0￡-3498￡)].The cost-effectiveness ratio with respect to this endpoint was equal to 50.26￡(95%CI:-504.37￡-604.89￡)per event avoided over the four-year follow-up.When bleeding episodes/deaths in subjects whose varices had grown were included,the mean cost associated with Strategy 1 was 1028￡(95%CI:122￡-2581￡),while 1699￡(95%CI:171￡-4674￡)in Strategy 2.CONCLUSION:Beta-blocker therapy turn out to be more effective and less expensive than endoscopic surveillance for primary prophylaxis of bleeding in patients with cirrhosis and small varices.     

Oesophageal capsule endoscopy versus oesophago-gastroduodenoscopy for the diagnosis of recurrent varices: A prospective multicentre study

BackgroundOesophago-gastroduodenoscopy is the standard method for the diagnosis of recurrent oesophago-gastric varices after endoscopic treatment and eradication. The aim of this study was to evaluate the PillCam^®Eso capsule endoscopy in this setting.MethodsProspective, multicentre study in which patients with history of oesophageal varices treated by band ligation underwent PillCam^®Eso capsule and oesophago-gastroduodenoscopy. Capsule recordings were blindly read by two endoscopists. Indication for a new prophylactic treatment and patient satisfaction were determined for both procedures.Results80 patients (80% males, mean age: 57 ± 12 years) were included, after a median delay of 16 months from last endoscopic treatment. Recurrent oesophageal varices requiring a new prophylactic treatment were detected in 26 patients (32.5%). The mean oesophageal transit time of the capsule was 153 s (range 2–930 s). Capsule sensitivity, specificity, negative and positive predictive values for indication of new prophylactic treatments were 65%, 83%, 83%, and 65%, respectively. Capsule adequately classified 77.5% of the patients for prophylaxis indication. Inter-observer concordance for capsule readings was 88% for the prophylaxis indication.ConclusionThis study demonstrates that accuracy of PillCam^®Eso capsule for the diagnosis of recurrent oesophageal varices after endoscopic eradication is suboptimal. PillCam^®Eso capsule might therefore be proposed in patients unable or unwilling to undergo oesophago-gastroduodenoscopy.     

A pilot study of capsule endoscopy after a standard meal for the detection and grading of oesophageal varices in cirrhotic patients

Background

Capsule endoscopy has been proposed as an alternative to fibreoptic endoscopy for oesophageal varices evaluation in cirrhotics. However, it shows only moderate sensitivity compared to fibreoptic endoscopy.

Aim

To compare post-meal capsule endoscopy to fibreoptic endoscopy, based on the hypothesis that meal-induced increase of portal pressure can enhance its sensitivity.

Methods

Twenty-five patients were submitted to fibreoptic endoscopy and, after a standard meal, capsule endoscopy.

Results

Post-meal capsule endoscopy detected varices in the 18 patients in whom fibreoptic endoscopy detected varices plus 3 more subjects (sensitivity 100%, specificity 70%); large varices in the 4 patients in whom fibreoptic endoscopy graded varices as large, plus 5 more subjects; red markers in the 5 patients in whom fibreoptic endoscopy detected red markers, plus 3 more subjects. High-risk varices were identified in 11 patients by post-meal capsule endoscopy and in 10 by fibreoptic endoscopy (sensitivity 100%, specificity 93.8%).

Conclusions

Post-meal capsule endoscopy identified more varices, large varices and red markers than fibreoptic endoscopy. The two methods detected similar proportions of high-risk varices. These data suggest that a standard meal can enhance the sensitivity of capsule endoscopy in the detection and grading of oesophageal varices in cirrhotics.     

Transjugular intrahepatic portosystemic shunt in cirrhosis: An exhaustive critical update

More than five decades after it was originally conceptualized as rescue therapy for patients with intractable variceal bleeding, the transjugular intrahepatic portosystemic shunt(TIPS) procedure continues to remain a focus of intense clinical and biomedical research. By the impressive reduction in portal pressure achieved by this intervention, coupled with its minimally invasive nature, TIPS has gained increasing acceptance in the treatment of complications of portal hypertension. The early years of TIPS were plagued by poor long-term patency of the stents and increased incidence of hepatic encephalopathy. Moreover, the diversion of portal flow after placement of TIPS often resulted in derangement of hepatic functions, which was occasionally severe. While the incidence of shunt dysfunction has markedly reduced with the advent of covered stents, hepatic encephalopathy and instances of early liver failure continue to remain a significant issue after TIPS. It has emerged over the years that careful selection of patients and diligent post-procedural care is of paramount importance to optimize the outcome after TIPS. The past twenty years have seen multiple studies redefining the role of TIPS in the management of variceal bleeding and refractory ascites while exploring its application in other complications of cirrhosis like hepatic hydrothorax, portal hypertensive gastropathy, ectopic varices, hepatorenal and hepatopulmonary syndromes, non-tumoral portal vein thrombosis and chylous ascites. It has also been utilized to good effect before extrahepatic abdominal surgery to reduce perioperative morbidity and mortality. The current article aims to review the updated literature on the status of TIPS in the management of patients with liver cirrhosis.     

三腔二囊管和（或）内镜下注射聚桂醇治疗不宜套扎的重度食管胃底静脉曲张出血的疗效观察

目的探讨三腔二囊管和(或)内镜下注射聚桂醇治疗不宜套扎的食管胃底静脉曲张破裂出血(Esophageal gastric variceal bleeding,EGVB)的疗效。方法回顾性分析我院2008年1月～2018月10月不宜套扎的重度食管胃底静脉曲张出血患者180例,分成四组:保守治疗组、三腔二囊管组、内镜下注射聚桂醇组、三腔二囊管+内镜下注射聚桂醇组,比较四组止血率、治疗后生活质量评分、治疗后1个月、3个月和6个月静脉曲张缓解情况、副作用发生率。结果三腔二囊管+内镜下注射聚桂醇组、内镜下注射聚桂醇组、三腔二囊管组与保守治疗组比较,止血率、生活质量评分、治疗后1个月、3个月和6个月静脉曲张缓解率均显著性升高(P0.05);三腔二囊管+内镜下注射聚桂醇组、内镜下注射聚桂醇组与三腔二囊管组止血率比较,差异无统计学意义,生活质量评分、治疗后1个月、3个月和6个月静脉曲张缓解率显著性升高(P0.05);三腔二囊管+内镜下注射聚桂醇组与内镜下注射聚桂醇组止血率比较,差异无统计学意义,生活质量评分、治疗后1个月、3个月和6个月静脉曲张缓解率显著性升高(P0.05);内镜下注射聚桂醇组的副作用发生率高于三腔二囊管组,差异有统计学意义(P0.05)。结论三腔二囊管和内镜下注射聚桂醇均能有效治疗不宜套扎的重度食管胃底静脉曲张出血,聚桂醇效果更佳,联用后能增强疗效。     

2015—2017年天津市津南区咸水沽医院消化性溃疡和胃食管反流病药物使用情况分析

目的 了解天津市津南区咸水沽医院消化性溃疡和胃食管反流病药物的使用情况和变化趋势,为促使临床合理用药提供依据。方法 对2015—2017年天津市津南区咸水沽医院消化性溃疡和胃食管反流病药物的使用数量、销售金额、用药频度（DDDs）和日均用药费用（DDC）等进行统计和分析。结果 2015—2017年消化性溃疡和胃食管反流病药物的销售总金额基本呈现先上升后下降趋势,浮动不明显。在2016年其构成比达到了3.62%。胃酸分泌抑制剂的销售总金额始终居首位,胃肠动力药的销售总金额居第2位。2015—2017年,雷贝拉唑钠肠溶胶囊的排名始终排名浮动在前两位,2017年跃居首位。米索前列醇片的DDDs始终保持在第1位,兰索拉唑肠溶片和盐酸苯海拉明注射液的DDDs排名稳定。除了注射用艾司奥美拉唑钠,2015—2016年的注射用兰索拉唑,2015年的盐酸阿扎司琼氯化钠注射液,其他所有消化性溃疡和胃食管反流病药物的DDC都在100以下。结论 天津市津南区咸水沽医院消化性溃疡和胃食管反流病药物应用基本合理,但仍存在一些不足,还需进一步加强消化性溃疡和胃食管反流病药物管理。