Early rebleeding increases mortality of variecal bleeders on secondary prophylaxis with β-blockers and ligation. Issue 9 (September 2020)

• Record Type: Journal Article
• Authors: Ardevol, Alba; Alvarado-Tapias, Edilmar; Garcia-Guix, Marta; Brujats, Anna; Gonzalez, Laura; Hernández-Gea, Virginia; Aracil, Carles; Pavel, Oana; Cuyas, Berta; Graupera, Isabel; Colomo, Alan; Poca, Maria; Torras, Xavier; Concepción, Mar; Villanueva, Càndid
• Is Part Of: Digestive and liver disease. Volume 52:Issue 9(2020)
• Page Start: 1017
• Page End: 1025
• Publication Date: 2020-09
• Subjects: β-blockers -- Complications of cirrhosis -- Endoscopic variceal ligation -- Portal hypertension -- Variceal bleeding; AKI acute kidney injury -- ACLF acute on chronic liver failure -- CART classification-and-regression-tree analysis -- CI confidence interval -- EVL endoscopic variceal ligation -- HCC Hepatocellular carcinoma -- HR hazard ratio -- HVPG hepatic venous pressure gradient -- IQR interquartile range -- ISMN Isosorbide Mononitrate -- MELD Model for End-Stage Liver Disease -- NSBBs non selective β-blockers -- NPV negative predictive value -- OLT orthotopic liver transplantation -- PHT portal hypertension -- PPV positive predictive value -- RCT randomized controlled trial -- SBP systolic blood pressure -- TIPS transjugular intrahepatic portosystemic shunt; Digestive organs -- Diseases -- Periodicals; Liver -- Diseases -- Periodicals; 616.33005
• DOI: 10.1016/j.dld.2020.06.005
• Languages: English
• ISSNs: 1590-8658

Abstract

Abstract: Background/aims: Despite secondary-prophylaxis with β-blockers and endoscopic-variceal-ligation rebleeding is frequent, particularly within the first-6-weeks. Early-rebleeding may have greater impact on death-risk than late rebleeding, which may affect therapy. We assessed whether the influence of rebleeding on long-term survival of patients on secondary-prophylaxis is greater in patients with early-rebleeding. Methods: 369 patients with cirrhosis were consecutively included once recovered from first variceal-bleeding. The impact of rebleeding on survival was investigated according to whether it occurred within 6-weeks (early-rebleeding) or later (late-rebleeding). Results: During 46-months of follow-up (IQR: 14-61), 45 patients (12%) had early-rebleeding, 74(20%) had late-rebleeding and 250(68%) had not rebleeding. Mortality risk was higher in early-rebleeding group vs. late-rebleeding (HR = 0.476, 95%CI = 0.318–0.712, p < 0.001) and was similar in late-rebleeding group vs. no-rebleeding (HR = 0.902, 95%CI = 0.749–1.086, p = 0.271). Adjusting for baseline risk-factors, early-rebleeding was independently associated with mortality-risk (HR = 1.58, 95%CI = 1.02–2.45; p = 0.04). Child-Pugh&MELD scores improved at 3rd-4th-week only in patients without early-rebleeding ( p < 0.05). Presence of ascites or encephalopathy, MELD-score>12 and HVPG>20 mmHg identified patients at risk of early-rebleeding. Conclusions: Patients with early-rebleeding have higher risk of death than patients without rebleeding and even than those rebleeding later. Our results suggest that patients at risk of early rebleeding might benefit from preemptive therapies such as early-TIPS.