Practice guideline-recommended care reduces bleeding in cirrhosis patients

Compliance with practice guideline-recommended treatment for cirrhosis is associated with a reduction in first esophageal variceal hemorrhage (EVH; bleeding), according to a new study in Clinical Gastroenterology and Hepatology, the official journal of the American Gastroenterological Association (AGA) Institute. Cirrhosis is a condition in which the liver is permanently scarred or injured.

"Esophageal variceal hemorrhage is a serious complication of cirrhosis, and the mortality rate associated with it is high at 20 percent," said Jayavani Moodley, MD, of the Cleveland Clinic Foundation and lead author of the study. "This high mortality rate makes primary prevention of bleeding the best approach to improving outcomes for these patients."

In this study, doctors conducted an Institutional Review Board-approved retrospective chart review on 179 adult patients selected by computerized randomization, newly evaluated for cirrhosis at the Cleveland Clinic from 2003 to 2006. These patients were followed for 23 months; doctors assessed actual compliance rates of gastroenterologists with current practice guidelines, which recommend screening and intervention for high-risk esophageal varices. Subsequent bleeding rates were also determined.

The study authors reported that 94 percent of the patients had a screening endoscopy (EGD), with 80 percent having one within six months of the initial visit. Varices were present in half of the patients. In addition, 68 percent of all patients screened and 91 percent with large varices received a practice guideline-recommended treatment. Seven percent had an episode of EVH; 82 percent of patients without bleeding had their screening EGD within six months versus 50 percent of those with bleeding. The likelihood of bleeding at two years, as predicted by the North Italian Endoscopy Club model, was 13 percent versus 27 percent.

"Our study suggests that the significant reduction in observed bleeding rates may be related to adherence to practice guideline-recommended care. Patients who did not bleed were more likely to have received their screening EGD within the six-month window as compared to those who bled, demonstrating the effectiveness of early variceal screening," added Dr. Moodley.

The risk of developing gastroesophageal varices in patients with cirrhosis is between 50 percent and 66 percent, and 30 percent to 40 percent of patients with varices suffer a variceal hemorrhage. If untreated, variceal hemorrhage portends a 70 percent risk of death within one year.