EARLY INITIATION OF BETA BLOCKERS FOLLOWING PRIMARY ENDOSCOPIC THERAPY FOR BLEEDING ESOPHAGEAL VARICES IN CIRRHOTICS

Adnan Salim, Kashif Malik, Muhammad Omer Farooq, Umair Butt, Arshad Kamal Butt, Altaf Alam

Abstract


Background and Aims: Beta-blockers provide secondary prophylaxis following endoscopic therapy for variceal bleeding. Guidelines recommend starting beta-blockers 6 days after endoscopy to prevent masking hemodynamic signs of rebleeding. We aimed to see safety of earlier initiation of beta-blockers.

Methods: Cirrhotic patients with upper GI bleed were given I.V vasoactive agents until undergoing endoscopy. Patients with only esophageal varices as source of bleed were recruited. Vasoactive agents were discontinued following variceal banding. The patients were observed for 12-18 hours, discharged on oral carvedilol 6.25mg BID and monitored for 6 weeks for rebleeding and mortality.

Results: 50 patients were included, 27 (54%) male and 23 (46%) female. Average age was 43+3 years. Etiology of cirrhosis was HCV in 42 (84%), HBV in 6 (12%), HCV & HBV in 2 (4%) and indeterminate
in 1 (2%) patient. 17 (34%) patients had Child A, 22 (44%) Child B and 11 (22%) had Child C disease. Hospital stay was under 24 hours in 24 (48%), 24-48 hours in 15 (30%) and 48-72 hours in 11 (22%) patients. 5 (10%) patients underwent EGD within 6 hours of admission, 28 (56%) within 12 hours, 14 (28%) within 24 hours and 3 (6%) within 36 hours. No rebleeding, mortality or drug related adverse effects were noted during 6 weeks after discharge.

Conclusions:Our study proves possibility of shorter management of variceal bleeding by having a 12-18 hour monitoring after endoscopic banding, followed by beta-blocker initiation and discharge. This will safely reduce physical and financial burden on health services. 

Background: Beta-blockers provide secondary prophylaxis following endoscopic therapy for variceal bleeding. Guidelines recommend starting beta-blockers 6 days after endoscopy to prevent masking hemodynamic signs of re-bleeding. We aimed to see safety of earlier initiation of beta-blockers. Methods: Cirrhotic patients with upper GI bleed were given intravenous vasoactive agents until undergoing endoscopy. Patients with only oesophageal varices as source of bleed were recruited. Vasoactive agents were discontinued following variceal banding. The patients were observed for 12–18 hours, discharged on oral carvedilol 6.25 mg BID and monitored for 6 weeks for re-bleeding and mortality. Results: Fifty patients were included, 27 (54%) male and 23 (46%) female. Average age was 43±3 years. Aetiology of cirrhosis was HCV in 42 (84%), HBV in 6 (12%), HCV & HBV in 2 (4%) and indeterminate
in 1 (2%) patient. Seventeen (34%) patients had Child A, 22 (44%) Child B and 11 (22%) had Child C disease. Hospital stay was under 24 hours in 24 (48%), 24–48 hours in 15 (30%) and 48–72 hours in 11 (22%) patients. Five (10%) patients underwent EGD within 6 hours of admission, 28 (56%) within 12 hours, 14 (28%) within 24 hours and 3 (6%) within 36 hours. No re-bleeding, mortality or drug related adverse effects were noted during 6 weeks after discharge. Conclusions: Our study proves possibility of shorter management of variceal bleeding by having a 12–18 hour monitoring after endoscopic banding, followed by beta-blocker initiation and discharge. This will safely reduce physical and financial burden on health services.

Keywords: liver cirrhosis; Portal hypertension; variceal bleeding; beta-blockers


Full Text:

PDF

References


Krige JE, Beckingham IJ. ABC of diseases of liver, pancreas, and biliary system. Portal hypertension-1: varices. BMJ 2001;322(7282):348–51.

Biecker E. Diagnosis and therapy of ascites in liver cirrhosis. World J Gastroenterol 2011;17(10):1237–48.

Obara K. Hemodynamic mechanism of esophageal varices. Dig Endosc 2006;18(1):6–9.

Hong WD, Dong LM, Jiang ZC, Zhu QH, Jin SQ. Prediction of large esophageal varices in cirrhotic patients using classification and regression tree analysis. Clinics (Sao Paulo) 2011;66(1):119–24.

Merli M, Nicolini G, Angeloni S, Rinaldi V, De Santis A, Merkel C, et al. Incidence and natural history of small esophageal varices in cirrhotic patients. J Hepatol 2003;38(3):266–72.

Madhotra R, Mulcahy HE, Willner I, Reuben A. Prediction of esophageal varices in patients with cirrhosis. J Clin Gastroenterol 2002;34(1):81–5.

Cremers I, Ribeiro S. Management of variceal and nonvariceal upper gastrointestinal bleeding in patients with cirrhosis. Therap Adv Gastroenterol 2014;7(5):206–16.

Imperiale TF, Chalasani N. A meta-analysis of endoscopic variceal ligation for primary prophylaxis of esophageal variceal bleeding. Hepatology 2001;33(4):802–7.

de Franchis R; Baveno VI Faculty. Expanding consensus in portal hypertension: Report of the Baveno VI Consensus Workshop: Stratifying risk and individualizing care for portal hypertension. J Hepatol 2015;63(3):743–52.

Reiberger T, Ulbrich G, Ferlitsch A, Payer BA, Schwabl P, Pinter M, et al. Carvedilol for primary prophylaxis of variceal bleeding in cirrhotic patients with haemodynamic non-response to propranolol. Gut 2013;62(11):1634–41.

Lo GH, Chen WC, Wang HM, Yu HC. Randomized, controlled trial of carvedilol versus nadolol plus isosorbide mononitrate for the prevention of variceal rebleeding. J Gastroenterol Hepatol 2012;27(11):1681–7.

Tripathi D, Stanley AJ, Hayes PC, Patch S, Millison C, Mehrzad H, et al. UK guidelines on the management of variceal haemorrhage in cirrhotic patients. Gut 2015;64(11):1680–704.

Lopera JE. Role of Emergency Transjugular Intrahepatic Portosystemic Shunts. Semin Intervent Radiol 2005;22(4):253–65.

Rudolph SJ, Landsverk BK, Freeman ML. Endotracheal intubation for airway protection during endoscopy for severe upper GI hemorrhage. Gastrointest Endosc 2003;57(1):58–61.

Rahimi RS, Rockey DC. Complications of cirrhosis. Curr Opin Gastroenterol 2012;28(3):223–9.

Poordad FF. Presentation and complications associated with cirrhosis of the liver. Curr Med Res Opin. 2015;31(5):925–37.

Hepatic Encephalopathy in Chronic Liver Disease: 2014 Practice Guideline by the European Association for the Study of the Liver and the American Association for the Study of Liver Diseases. J Hepatol 2014;61(3):642–59.


Refbacks

  • There are currently no refbacks.


Contact Number: +92-992-382571

email: [jamc] [@] [ayubmed.edu.pk]