The Diagnostic And Therapeutic Values Of Emergency Endoscopy In Liver Cirrhotic Patients With Upper Gastrointestinal Hemorrhage

Objective: Upper gastrointestinal hemorrhage is a common complication of liver cirrhosis. Endoscopy is not only diagnosis methods of bleeding etiology, but also the main method of hemostasis and preventing rebleeding. However, the timing of the endoscopic procedure is controversial in upper gastrointestinal hemorrhage of liver cirrhotic patient. The current international guidelines recommend that upper endoscopy should have performed within 12 h after admission. In this paper, 368 cases of liver cirrhosis with upper gastrointestinal hemorrhage patients were studied retrospectively. We compared the treatment outcomes, rebleeding rate and survival during 1 year follow-up between patients endoscopically examined at different time, aiming to explore the diagnostic and therapeutic values of emergency endoscopy in liver cirrhotic patients with upper gastrointestinal hemorrhage.Methods: We performed a retrospective analysis of data from 368 liver cirrhotic patients with upper gastrointestinal hemorrhage hospitalized in the Second Hospital of Hebei Medical University from December 2008 to December 2013. The patients were divided into 4 groups as follows based on the initial endoscopy timing: â‘ Group A(emergency endoscopy within 48 h): Endoscopy was performed within 48 hours after hemorrhage, and patients had no signs of active hemorrhage(frequent hematemesis/hematochezia or continued descenting in the level of blood pressure and hemoglobin); â‘¡Group B(selective endoscopy): Active hemorrhage was controlled successfully by pharmacotherapy and endoscopy was performed after 48 hours since hemorrhage; â‘¢ Group C(emergency endoscopy with active hemorrhage): Active hemorrhage could not be controlled by pharmacotherapy, and emergency endoscopic treatments were needed; â‘£Group D(conservative treatment): Endoscopy was not performed in this group. Follow-up period is one year.Results:1 Groups: There were 52 cases(14.1%) in Group A, 205 cases(55.7%) in Group B, 47 cases(12.8%) in Group C, and 64 cases(17.4%) in Group D.2 The endoscopic manifestations and cause of hemorrhage: Only 133 cases presented with active hemorrhage signs at endoscopy such as acute bleeding(active spurting bleeding, active oozing bleeding), red/white thrombosis on variceal surface, erosion, hemorrhage spot. The most common cause of active hemorrhage was esophageal varices(66.9%), followed by gastric varices(26.3%), portal hypertension gastropathy(4.5%), duodenal varices(0.8%), hemorrhage located below the anastomotic stoma(0.8%), and esophageal ulcer(0.7%).3 The detective efficacy of hemorrhage location: Statistical significance was found in the detective efficacy of hemorrhage location between 3 groups at endoscopy: Group C(83.0%)>Group A(57.7%)>Group B(31.2%). The rate of acute bleeding(active spurting/oozing bleeding) at endosopy was 48.9% in Group C, followed by 21.2% in Group A, and 1.5% in Group B, with statistical significance.4 The efficacy of endoscopic therepy in the management of acute bleeding: Acute bleeding(active spurting/oozing bleeding) from esophageal varices was controlled successfully by initial endoscopy at the rate of 100%(21/21), and ligation was the main endoscopic therapy followed by sclerotherapy. 86.7%(13/15) acute bleeding from gastric variceal rupture was controlled successfully by initial endoscopy, and tissue adhesive injection was the main endoscopic therapy, the rate of successful hemostasis was 90%.5 The efficacy of emergency endoscopy: Among the 368 liver cirrhotic patients with upper gastrointestinal hemorrhage, 356(96.7%) cases achieved hemostasis, 6 cases(1.6%) died in hospital, and 2.7%(10/368) severe cases left hospital voluntarily without any treatment. During the follow-up period, early rebleeding(72 h-6 w) was found in 15.4%(47/306) cases, delayed rebleeding(6 w-1 year) was found in 35.9%(110/306) cases, and the 1-year mortality rate was 20.0%(59/295).There was no significant difference between Group A and B in the rate of successful hemostasis(98.1% vs. 99.5%, P=0.364), the delayed rebleeding rate(34.0% vs. 35.3%, P=0.362), and the 1-year mortality rate(11.1% vs 16.8%,P=0.351). The early rebleeding rate was higher in Group A compared with that in Group B(23.4% vs. 7.1%, P=0.003). Patients in Group A had shorter lengths of stay in hospital than those in Group B.In Group C, 93.6%(44/47) cases achieved hemostasis, early rebleeding was found in 14.6%(6/41) cases, delayed rebleeding was found in 41.5%(17/41) cases, and the 1-year mortality rate was 23.7%(9/38). The rate of successful hemostasis in Group C was lower than that in Group B(P=0.021<0.025), indicating that the rate of successful hemostasis in patients endoscopically examined with active hemorrhage was lower than those without active hemorrhage, but there was no significant difference in the early rebleeding rate, delayed rebleeding rate, and 1-year mortality rate between these two groups.Patients in Group D achieved hemostasis by pharmacotherapy at the rate of 89.1%(57/64). The early rebleeding rate was 50.0%(17/34) in this group, the delayed rebleeding rate was 35.3%(12/34), and 1-year mortality rate was 45.5%(15/33). The early rebleeding rate in Group D was significantly higher than that of other three groups, but there was no significant difference in the delayed rebleeding rate among the 4 groups. The 1-year mortality rate in Group D was significantly higher than that of Group A and B, while no difference was found between Group D and C.6 Short-term complications(within 1 w) after endoscopic therapy: Among the 216 patients with gastroesophageal varices treated endoscopicly, short-term complications were found in 6.1%(13/216) cases. The incidence of short-term complications in Group A, Group B, Group C respectively were 7.3%(3/41), 6.7%(9/134), 2.4%(1/41), and there was no significent difference among the three groups.Conclusion:1 The most common cause of upper gastrointestinal hemorrhage in liver cirrhotic patients is gastroesophageal varices, followed by the portal hypertension gastropathy, ectopic varices and hepatogenic ulcer are the rare causes.2 Ligation(EVL) is the main endoscopic therapy for acute esophageal variceal bleeding, followed by sclerotherapy, with an overall effective rate of 100%. Most of gastric variceal bleeding is treated with tissue adhesive injection, and the effective rate is 90%.3 For liver cirrhotic patients who have no signs of active hemorrhage, endoscopy performed within 48 h after hemorrhage is associated with shorter lengths of hospitalization compared with those performed after 48 h and the cause and location of hemorrhage can be better identified if patients underwent endoscopy within 48 h after hemorrhage. While the rate of successful hemostasis, delayed rebleeding rate and 1-year mortality rate are not affected by the timing of endoscopy.4 Emergency endoscopy is essential for patients with active hemorrhage since hemostasis can be achieved successfully by this procedure with the effective rate of 93.6%, although the effective rate is lower in those without active hemorrhage. There is no significant difference in the early rebleeding rate, delayed rebleeding rate, and 1-year mortality rate between patients with and without active hemorrhage.5 Early rebleeding rate and 1-year mortality rate can be decreased by emergency endoscopic therapy, but delayed rebleeding rate is not significant different compared with those treated with pharmacotherapy.6 The incidence of short-term complications after endoscopic therepy shows no difference between patients treated with emergency endoscopy and selective endoscopy.