Failure to Control Oesophago-Gastric Variceal Bleeding Associated With Increased Mortality

Close-up view of liver cirrhosis.
Failure to control oesophago-gastric variceal bleeding in patients with acute-on-chronic liver failure resulted in increased mortality risk.

Failure to control oesophago-gastric variceal bleeding (OGVB) in patients with acute-on-chronic liver failure (ACLF) resulted in increased mortality risk, according to results from a study of patients in a prospectively maintained intensive care unit published in the Journal of Hepatology.

Researchers collected data from 174 individuals with liver cirrhosis (n=119) or acute decompensation (n=55) admitted to the intensive care unit at the Royal Free Hospital in London, England between 2005 and 2015. All patients were categorized as failure to control OGVB, defined by the Baveno VI consensus as a failure to control bleeding after 2 endoscopic hemostasis attempts or 1 endoscopic hemostasis attempt using a rescue balloon tamponade of esophageal stent within 5 days of the first bleeding episode. Rescue transjugular intrahepatic stent-shunt (TIPSS) was considered successful when inserted within 72-hours of presenting with uncontrolled OGVB.

Compared with patients with acute decompensation, patients with ACLF were significantly older (P =.014), had more instances of organ failure (P <.001), and higher white cell counts (P =.025). The patients with ACLF also had significantly elevated mortality rates (P <.001) at 42-days (47.9% vs 9.1%) and 1-year (61.3% vs 12.7%) after their uncontrolled OGVB episode compared with patients with acute decompensation.

Mortality rates for patients with ACLF increased with ACLF grade (P <.001). The surviving patients had a lower scores for Child-Turcotte-Pugh class (P =.004), Model for End-Stage Liver Disease (P <.001), United Kingdom Model for End-Stage Liver Disease (P <.001), and Chronic Liver Failure (P <.001).

Rescue TIPSS were inserted in 78 patients (38.2% acute decompensation and 47.8% ACLF). The insertion of a rescue TIPSS resulted in a more favorable prognosis for patients with ACLF (P =.002) but not among patients with acute decompensation (P =.225). Both patient groups had similar numbers of endoscopies (median of 2 before inclusion), transfusions (median 8 units of packed red blood cells), and previous instances of OGVB (27.7% ACLF vs 41.8% acute decompensation; P =.064).

A potential limitation of this study is that the decision to insert a TIPSS was not protocolized but decided by the physician, which may have introduced some bias and inconsistency.

The researchers concluded that uncontrolled OGVB in patients with ACLF was associated with an increased risk for mortality compared with acute decompensation. They also noted that patients who received rescue TIPSS had more favorable outcomes.

Disclosure: Multiple authors declared affiliations with industry. Please refer to the original article for a full list of disclosures.

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Kumar R, Kerbert A J C, Sheikh M F, et al. Determinants of mortality in patients with cirrhosis and uncontrolled variceal bleeding. J Hepatol. 2020;S0168-8278(20)30381-0. doi:10.1016/j.jhep.2020.06.010