Endoscopic diagnosis and management of esophagogastric variceal hemorrhage: European Society of Gastrointestinal Endoscopy (ESGE) Guideline

Endoscopy, Год журнала: 2022, Номер 54(11), С. 1094 - 1120

Опубликована: Сен. 29, 2022

Main Recommendations 1 ESGE recommends that patients with compensated advanced chronic liver disease (ACLD; due to viruses, alcohol, and/or nonobese [BMI < 30 kg/m2] nonalcoholic steatohepatitis) and clinically significant portal hypertension (hepatic venous pressure gradient [HVPG] > 10 mmHg stiffness by transient elastography 25 kPa) should receive, if no contraindications, nonselective beta blocker (NSBB) therapy (preferably carvedilol) prevent the development of variceal bleeding.Strong recommendation, moderate quality evidence. 2 in those unable receive NSBB a screening upper gastrointestinal (GI) endoscopy demonstrates high risk esophageal varices, endoscopic band ligation (EBL) is prophylactic treatment choice. EBL be repeated every 2–4 weeks until eradication achieved. Thereafter, surveillance EGD performed 3–6 months first year following eradication.Strong 3 recommends, hemodynamically stable acute GI hemorrhage (UGIH) history cardiovascular disease, restrictive red blood cell (RBC) transfusion strategy, hemoglobin threshold ≤ 70 g/L prompting RBC transfusion. A post-transfusion target 70–90 desired.Strong 4 ACLD presenting suspected bleeding stratified according Child–Pugh score MELD score, documentation active/inactive at time endoscopy.Strong 5 vasoactive agents terlipressin, octreotide, or somatostatin initiated presentation continued for duration up days.Strong 6 antibiotic prophylaxis using ceftriaxone g/day 7 days all hemorrhage, accordance local resistance patient allergies.Strong absence intravenous erythromycin 250 mg given 30–120 minutes prior hemorrhage.Strong 8 that, evaluation take place within 12 hours from provided has been resuscitated.Strong 9 (EVH).Strong recurrent successful hemostasis (Child–Pugh C 13 B active EVH despite agents, HVPG 20 mmHg), pre-emptive transjugular intrahepatic portosystemic shunt (TIPS) 72 24 hours) must considered.Strong 11 persistent pharmacological therapy, urgent rescue TIPS considered (where available).Strong cyanoacrylate injection gastric (cardiofundal) (GOV2, IGV1) GOV1-specific recommendations, 14 suggests balloon-occluded retrograde transvenous obliteration (BRTO) when there failure early bleeding.Weak low 15 who have undergone scheduled follow-up EBLs 1- 4-weekly intervals eradicate varices (secondary prophylaxis).Strong 16 use NSBBs (propranolol combination secondary ACLD.Strong

Язык: Английский

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Severity of systemic inflammation is the main predictor of ACLF and bleeding in individuals with acutely decompensated cirrhosis

Journal of Hepatology, Год журнала: 2022, Номер 78(2), С. 301 - 311

Опубликована: Сен. 21, 2022

Язык: Английский

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Liver diseases: epidemiology, causes, trends and predictions

Signal Transduction and Targeted Therapy, Год журнала: 2025, Номер 10(1)

Опубликована: Фев. 4, 2025

Abstract As a highly complex organ with digestive, endocrine, and immune-regulatory functions, the liver is pivotal in maintaining physiological homeostasis through its roles metabolism, detoxification, immune response. Various factors including viruses, alcohol, metabolites, toxins, other pathogenic agents can compromise function, leading to acute or chronic injury that may progress end-stage diseases. While sharing common features, diseases exhibit distinct pathophysiological, clinical, therapeutic profiles. Currently, contribute approximately 2 million deaths globally each year, imposing significant economic social burdens worldwide. However, there no cure for many kinds of diseases, partly due lack thorough understanding development these Therefore, this review provides comprehensive examination epidemiology characteristics covering spectrum from conditions manifestations. We also highlight multifaceted mechanisms underlying initiation progression spanning molecular cellular levels networks. Additionally, offers updates on innovative diagnostic techniques, current treatments, potential targets presently under clinical evaluation. Recent advances pathogenesis hold critical implications translational value novel strategies.

Язык: Английский

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Guidance-Based Appropriateness of Hemostasis Testing in the Acute Setting

Hämostaseologie, Год журнала: 2025, Номер 45(01), С. 024 - 048

Опубликована: Фев. 1, 2025

Abstract In this review, we aim to highlight the extent of inappropriate hemostasis testing and provide practical guidance on how prevent it. We will focus acute setting, including but not limited emergency department intensive care unit. To end, first discuss significance inappropriateness, in general context laboratory medicine. This includes acknowledging importance phenomenon attempting define Next, describe harmful consequences testing. Finally, use setting. The second section describes interventions―in particular, implementation for testing—can efficiently reduce inappropriateness. third section, summarize available recommendations rational (platelet count, activated partial thromboplastin time, prothrombin time/international normalized ratio, fibrinogen, thrombin D-dimer, anti-Xa assay, antithrombin, ADAMTS13 activity, antiheparin-PF4 antibodies, viscoelastometric tests, coagulation factors, platelet function testing), as supported by guidelines, recommendations, and/or expert opinions. Overall, review is intended be a toolkit effort promote appropriate Hopefully, new Vitro Diagnostic Medical Device Regulation (EU) 2017/746 (IVDR) should help improving availability evidence regarding clinical performance assays.

Язык: Английский

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Global hemostatic profiling in patients with decompensated cirrhosis and bacterial infections

JHEP Reports, Год журнала: 2022, Номер 4(7), С. 100493 - 100493

Опубликована: Апрель 20, 2022

Bacterial infections in cirrhosis are associated with increased bleeding risk. To assess the factors responsible for tendency patients bacterial infections, we conducted a prospective study comparing all 3 aspects of hemostasis (platelets, coagulation, and fibrinolysis) hospitalized decompensated vs. without infections.Primary assessment included whole blood platelet aggregation von Willebrand factor (VWF). Coagulation procoagulant (fibrinogen, II, V, VII, VIII, IX, X, XI, XII, XIII), natural anticoagulants (protein C, protein S, antithrombin) thrombomodulin-modified thrombin generation test. Fibrinolysis fibrinolytic (plasminogen, t-PA, PAI-1, α2-AP, TAFIa/ai) plasmin-antiplasmin complex (PAP).Eighty were (40 40 infections). Severity count comparable between groups. At baseline, had significantly lower aggregation, significant differences VWF. Regarding reduced VII reduction anticoagulants. However, was Finally, although mixed potentially hypo-fibrinolytic (lower plasminogen) hyper-fibrinolytic (higher t-PA) changes present level PAP detected both Upon resolution infection (n = 29/40), further deteriorated whereas coagulation fibrinolysis returned to levels observed infections.In cirrhosis, decrease anticoagulants, which may unbalance increase risk thrombosis.Bacterial common issue (i.e. due severe complications advanced chronic liver disease). Patients who acquire be at following invasive procedures (that is procedure body penetrated or entered, instance by needle tube). As high decompensation death, there an urgent need understand such tendency. Herein, investigated alterations physiological process clot formation stability) infections. We found that development these (particularly platelets clotting cascade) thrombotic complications.

Язык: Английский

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Haemostasis in cirrhosis: Understanding destabilising factors during acute decompensation

Journal of Hepatology, Год журнала: 2023, Номер 78(5), С. 1037 - 1047

Опубликована: Янв. 25, 2023

Hospitalised patients with decompensated cirrhosis are in a rebalanced haemostatic state due to parallel decline both pro- and anti-haemostatic pathways. However, this is highly susceptible perturbations may easily tilt towards hypocoagulability bleeding. Acute kidney injury, bacterial infections sepsis, progression from acute decompensation acute-on-chronic liver failure associated additional alterations of specific pathways higher risk Unfortunately, there no single laboratory method that can accurately stratify an individual patient's bleeding guide pre-procedural prophylaxis. A better understanding during illness would lead more rational individualised management hospitalised cirrhosis. This review will outline the latest findings on driven by infections/sepsis, these difficult-to-treat provide evidence supporting tailored risk.

Язык: Английский

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Management of splanchnic vein thrombosis

JHEP Reports, Год журнала: 2023, Номер 5(4), С. 100667 - 100667

Опубликована: Янв. 3, 2023

The expression splanchnic vein thrombosis encompasses Budd-Chiari syndrome and portal thrombosis. These disorders have common characteristics: they are both rare diseases which can cause hypertension its complications. in the absence of underlying liver disease share many risk factors, among myeloproliferative neoplasms represent most common; a rapid comprehensive work-up for factors is needed these patients. Long-term anticoagulation indicated Portal also develop patients with cirrhosis those porto-sinusoidal vascular disease. presence nature impacts management Indications growing, while transjugular intrahepatic portosystemic shunt now second-line option. Due to rarity diseases, studies yielding high-grade evidence scarce. However, collaborative provided new insight into This article focuses on causes, diagnosis, syndrome, without disease, or non-malignant

Язык: Английский

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Procedural-Related Bleeding in Hospitalized Patients With Liver Disease (PROC-BLeeD): An International, Prospective, Multicenter Observational Study

Gastroenterology, Год журнала: 2023, Номер 165(3), С. 717 - 732

Опубликована: Июнь 2, 2023

Hospitalized patients with cirrhosis frequently undergo multiple procedures. The risk of procedural-related bleeding remains unclear, and management is not standardized. We conducted an international, prospective, multicenter study hospitalized undergoing nonsurgical procedures to establish the incidence identify factors.

Язык: Английский

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Bleeding and Thrombotic Complications in Patients With Cirrhosis: A State-of-the-Art Appraisal

Clinical Gastroenterology and Hepatology, Год журнала: 2023, Номер 21(8), С. 2110 - 2123

Опубликована: Апрель 28, 2023

Much has evolved over the past 25 years regarding our understanding of coagulopathy liver disease. Paradoxically, this form is relatively hypercoagulability despite common clinical impression a hemorrhagic tendency. The latter largely driven by portal-mesenteric venous pressure (ie, portal hypertension) and little to do with hemostatic pathways. It cannot be emphasized enough that INR does not offer meaningful measure in situation may lead interventions such as fresh frozen plasma can actually worsen hence pressure-driven bleeding. With regard procedure-related bleeding, we point out substantial differences definition high-risk procedures propose new operational dependent on applicability local measures, although requires further investigation. occurrence thrombosis these patients careful consideration pathways overall risk benefit intervention. decision anticoagulation therapy needs only global assessment including history non-portal hypertensive-related but also fall which result head trauma prone encephalopathy. This probably best estimated frailty yet adequately investigated. In background concerns, several superimposed complex conditions infections renal dysfunction should taken into account. Inherited forms thrombophilia setting cirrhosis perhaps outweigh inherent disease warrant consideration.

Язык: Английский

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The evolving knowledge on primary hemostasis in patients with cirrhosis: A comprehensive review

Hepatology, Год журнала: 2023, Номер 79(2), С. 460 - 481

Опубликована: Фев. 24, 2023

Patients with cirrhosis develop complex alterations in primary hemostasis that include both hypocoagulable and hypercoagulable features. This includes thrombocytopenia, multiple of platelet function, increased plasma levels von Willebrand factor. Contrary to the historical view dysfunction might be responsible for an bleeding tendency, current theory posits a rebalanced patients cirrhosis. Severe thrombocytopenia is not indicative risk undergoing invasive procedures does dictate per se need pre-procedural prophylaxis. A more comprehensive individualized assessment should combine hemostatic impairment, severity decompensation systemic inflammation, presence additional factors may impair such as acute kidney injury bacterial infections. Although there are multiple, function cirrhosis, their net effect yet fully understood. More investigations evaluating association between bleeding/thrombosis improve stratification decompensated Besides hemostasis, factor Ag ADP-induced, whole-blood aggregation normalized by count (VITRO score PLT ratio) promising biomarkers predict hepatic survival compensated patients. Further into vivo interplay platelets, circulating blood elements, endothelial cells help advance our understanding cirrhotic coagulopathy. Here, we review changes platelets potential clinical implications.

Язык: Английский

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