Prognosis still poor for EVB in cirrhosis

The current standard of care for esophageal variceal bleeding (EVB) in liver cirrhosis is very effective at controlling bleeding but patient prognosis remains poor, say the authors of an Italian study.

Furthermore, they show that liver failure severity is the most reliable indicator of short-term prognosis during the critical 5 days after bleeding starts.

The study included 185 patients with liver cirrhosis who were admitted for upper gastrointestinal bleeding between January 2010 and July 2011. The average patient age was 63 years, and 78% had advanced disease, of Child-Pugh B or C class. Overall, 92.4% received band ligations as the primary endoscopic treatment.

In total, 5-day failure ‑ defined as uncontrolled bleeding, rebleeding, or death ‑ occurred in 16.8% of patients. Of these patients, 87.1% died, with the majority of deaths due to infections and complications, rather than bleeding.

Lucio Amitrano (AORN A. Cardarelli, Naples, Italy) and colleagues showed that a white blood cell count of more than 10.3x10⁹/L significantly raised the risk for 5-day failure 8.7-fold and a Child-Pugh score of more than 10 lead to a significant 13.6-fold increase in risk. Portal venous thrombosis (PVT) was also associated with negative short-term outcomes; however, this did not reach statistical significance.

Outcomes were particularly poor among patients in Child-Pugh C class, of whom 45.9% experienced 5-day failure and 64.9% died within 6 weeks. The authors also identified a subgroup of these patients with advanced hepatocellular carcinoma, occlusive PVT, creatinine levels of more than 3 mg/dL, or white blood counts greater than 10.3x10⁹/L that had a mortality rate of 80%.

"In these patients, control of acute bleeding should always be attempted even if it will scarcely influence the overall prognosis," they write in the American Journal of Gastroenterology.

An important feature of the study was that it included patients with more severe disease, who are typically excluded from trials.

The authors say that their results show that the current approach of band ligation is effective in controlling bleeding, even in high-risk patients. Overall, only 6.5% of patients experienced uncontrolled bleeding or early rebleeding.

However, they conclude that further studies are needed in moderate and advanced disease to find treatments that will improve survival among these patients.

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