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      UK guidelines on the management of variceal haemorrhage in cirrhotic patients

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          Abstract

          These updated guidelines on the management of variceal haemorrhage have been commissioned by the Clinical Services and Standards Committee (CSSC) of the British Society of Gastroenterology (BSG) under the auspices of the liver section of the BSG. The original guidelines which this document supersedes were written in 2000 and have undergone extensive revision by 13 members of the Guidelines Development Group (GDG). The GDG comprises elected members of the BSG liver section, representation from British Association for the Study of the Liver (BASL) and Liver QuEST, a nursing representative and a patient representative. The quality of evidence and grading of recommendations was appraised using the AGREE II tool.

          The nature of variceal haemorrhage in cirrhotic patients with its complex range of complications makes rigid guidelines inappropriate. These guidelines deal specifically with the management of varices in patients with cirrhosis under the following subheadings: (1) primary prophylaxis; (2) acute variceal haemorrhage; (3) secondary prophylaxis of variceal haemorrhage; and (4) gastric varices. They are not designed to deal with (1) the management of the underlying liver disease; (2) the management of variceal haemorrhage in children; or (3) variceal haemorrhage from other aetiological conditions.

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          AGREE II: advancing guideline development, reporting and evaluation in health care.

          M. Brouwers, M E Kho, G P Browman … (2010)
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            A model to predict survival in patients with end-stage liver disease.

            P S Kamath, R H Wiesner, M Malinchoc … (2001)
            A recent mandate emphasizes severity of liver disease to determine priorities in allocating organs for liver transplantation and necessitates a disease severity index based on generalizable, verifiable, and easily obtained variables. The aim of the study was to examine the generalizability of a model previously created to estimate survival of patients undergoing the transjugular intrahepatic portosystemic shunt (TIPS) procedure in patient groups with a broader range of disease severity and etiology. The Model for End-Stage Liver Disease (MELD) consists of serum bilirubin and creatinine levels, International Normalized Ratio (INR) for prothrombin time, and etiology of liver disease. The model's validity was tested in 4 independent data sets, including (1) patients hospitalized for hepatic decompensation (referred to as "hospitalized" patients), (2) ambulatory patients with noncholestatic cirrhosis, (3) patients with primary biliary cirrhosis (PBC), and (4) unselected patients from the 1980s with cirrhosis (referred to as "historical" patients). In these patients, the model's ability to classify patients according to their risk of death was examined using the concordance (c)-statistic. The MELD scale performed well in predicting death within 3 months with a c-statistic of (1) 0.87 for hospitalized patients, (2) 0.80 for noncholestatic ambulatory patients, (3) 0.87 for PBC patients, and (4) 0.78 for historical cirrhotic patients. Individual complications of portal hypertension had minimal impact on the model's prediction (range of improvement in c-statistic: <.01 for spontaneous bacterial peritonitis and variceal hemorrhage to ascites: 0.01-0.03). The MELD scale is a reliable measure of mortality risk in patients with end-stage liver disease and suitable for use as a disease severity index to determine organ allocation priorities.
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              Transfusion strategies for acute upper gastrointestinal bleeding.

              Càndid Villanueva, Alan Colomo, Alba Bosch … (2013)
              The hemoglobin threshold for transfusion of red cells in patients with acute gastrointestinal bleeding is controversial. We compared the efficacy and safety of a restrictive transfusion strategy with those of a liberal transfusion strategy. We enrolled 921 patients with severe acute upper gastrointestinal bleeding and randomly assigned 461 of them to a restrictive strategy (transfusion when the hemoglobin level fell below 7 g per deciliter) and 460 to a liberal strategy (transfusion when the hemoglobin fell below 9 g per deciliter). Randomization was stratified according to the presence or absence of liver cirrhosis. A total of 225 patients assigned to the restrictive strategy (51%), as compared with 61 assigned to the liberal strategy (14%), did not receive transfusions (P<0.001) [corrected].The probability of survival at 6 weeks was higher in the restrictive-strategy group than in the liberal-strategy group (95% vs. 91%; hazard ratio for death with restrictive strategy, 0.55; 95% confidence interval [CI], 0.33 to 0.92; P=0.02). Further bleeding occurred in 10% of the patients in the restrictive-strategy group as compared with 16% of the patients in the liberal-strategy group (P=0.01), and adverse events occurred in 40% as compared with 48% (P=0.02). The probability of survival was slightly higher with the restrictive strategy than with the liberal strategy in the subgroup of patients who had bleeding associated with a peptic ulcer (hazard ratio, 0.70; 95% CI, 0.26 to 1.25) and was significantly higher in the subgroup of patients with cirrhosis and Child-Pugh class A or B disease (hazard ratio, 0.30; 95% CI, 0.11 to 0.85), but not in those with cirrhosis and Child-Pugh class C disease (hazard ratio, 1.04; 95% CI, 0.45 to 2.37). Within the first 5 days, the portal-pressure gradient increased significantly in patients assigned to the liberal strategy (P=0.03) but not in those assigned to the restrictive strategy. As compared with a liberal transfusion strategy, a restrictive strategy significantly improved outcomes in patients with acute upper gastrointestinal bleeding. (Funded by Fundació Investigació Sant Pau; ClinicalTrials.gov number, NCT00414713.).
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                Author and article information

                Journal
                Journal ID (nlm-ta): Gut
                Journal ID (iso-abbrev): Gut
                Journal ID (hwp): gutjnl
                Journal ID (publisher-id): gut
                Title: Gut
                Publisher: BMJ Publishing Group (BMA House, Tavistock Square, London, WC1H 9JR )
                ISSN (Print): 0017-5749
                ISSN (Electronic): 1468-3288
                Publication date (Print): November 2015
                Publication date (Electronic): 17 April 2015
                Volume: 64
                Issue: 11
                Pages: 1680-1704
                Affiliations
                [1 ]Liver Unit, University Hospitals Birmingham NHS Foundation Trust , Birmingham, UK
                [2 ]GI Unit, Glasgow Royal Infirmary , Glasgow, UK
                [3 ]Liver Unit, Royal Infirmary of Edinburgh , Edinburgh, UK
                [4 ]The Royal Free Sheila Sherlock Liver Centre, Royal Free Hospital and University College London , London, UK
                [5 ]Gastrointestinal and Liver Services, York Teaching Hospitals NHS Foundation Trust , York, UK
                [6 ]Department of Interventional Radiology, University Hospitals Birmingham NHS Foundation Trust , Birmingham, UK
                [7 ]Department of Gastroenterology, Derby Hospitals NHS Foundation Trust , Derby, UK
                [8 ]Liver Unit, Freeman Hospital , Newcastle upon Tyne, UK
                [9 ]Department of Gastroenterology, Royal Devon and Exeter Hospital , Devon, UK
                Author notes
                [Correspondence to ] Dr Dhiraj Tripathi, Liver Unit, Queen Elizabeth Hospital, Edgbaston, Birmingham B15 2TH, UK; Dhiraj.Tripathi@ 123456uhb.nhs.uk , d.tripathi@ 123456bham.ac.uk
                Article
                Publisher ID: gutjnl-2015-309262
                DOI: 10.1136/gutjnl-2015-309262
                PMC ID: 4680175
                PubMed ID: 25887380
                SO-VID: 36c9a3c5-3a99-44aa-89ed-8c4b99e2b95d
                Copyright © Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions
                License:

                This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/

                History
                Date received : 28 January 2015
                Date revision received : 11 March 2015
                Date accepted : 17 March 2015
                Categories
                Subject: 1506
                Subject: Guidelines
                Custom metadata
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                ScienceOpen disciplines: Gastroenterology & Hepatology
                Keywords: bleeding,cirrhosis,gastrointestinal haemorrhage,oesophageal varices,portal hypertension
                Data availability:
                ScienceOpen disciplines: Gastroenterology & Hepatology
                Keywords: bleeding, cirrhosis, gastrointestinal haemorrhage, oesophageal varices, portal hypertension

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