Gastric cancer(GC)and gastroesophageal junction cancer(GEJC)represent a significant burden globally,with complications such as overt bleeding(OB)further exacerbating patient outcomes.A recent study by Yao et al evalua...Gastric cancer(GC)and gastroesophageal junction cancer(GEJC)represent a significant burden globally,with complications such as overt bleeding(OB)further exacerbating patient outcomes.A recent study by Yao et al evaluated the effectiveness and safety of systematic treatment in GC/GEJC patients presenting with OB.Using propensity score matching,the study balanced the comparison groups to investigate overall survival and treatment-related adverse events.The study's findings emphasize that systematic therapy can be safe and effective and contribute to the ongoing debate about the management of advanced GC/GEJC with OB,highlighting the complexities of treatment decisions in these high-risk patients.展开更多
BACKGROUND Acute variceal bleeding(AVB)represents a life-threatening complication in hepatocellular carcinoma(HCC)patients undergoing systemic therapy,mainly including immune checkpoint inhibitors(ICIs)and antivascula...BACKGROUND Acute variceal bleeding(AVB)represents a life-threatening complication in hepatocellular carcinoma(HCC)patients undergoing systemic therapy,mainly including immune checkpoint inhibitors(ICIs)and antivascular drugs used alone or in combination.The pathogenesis of AVB in this population may involve tumor-related factors,treatment-induced effects,or progression of underlying portal hypertension.Identifying high-risk factors for AVB is crucial for the management of this patient population.AIM To develop and validate a risk prediction model for AVB occurrence in cirrhotic HCC patients receiving ICI-based systemic therapy.METHODS This retrospective study analyzed 286 HCC patients(2021-2022)receiving ICIs(mono-/combination therapy),randomly split into training(n=184)and validation(n=102)cohorts.In the training cohort,bleeding vs nonbleeding groups were compared for general information,etiological data,laboratory indicators,tumor staging,systemic treatment drugs,variceal bleeding history,and endoscopic treatment history.Risk factors for AVB were identified and used to establish a logistic regression model for predicting bleeding,which was further validated in the validation cohort.RESULTS The bleeding group had significantly higher proportions of patients with platelet count≥100×10^(9)/L,alphafetoprotein≥400 ng/mL,tumor diameter≥5 cm,portal vein tumor thrombosis,ascites,bleeding history,prior endoscopic treatment,albumin-bilirubin grade level 2-3,fibrosis-4 index(FIB-4)≥4.57,and prognostic nutritional index<45 compared to the non-bleeding group.Multivariate analysis identified tumor diameter≥5 cm,portal vein thrombosis,bleeding history,and elevated FIB-4 as independent risk factors for bleeding(P<0.05).A predictive model based on these factors showed good discrimination,with area under the receiver operating characteristic curve values of 0.861(training)and 0.816(validation).CONCLUSION A history of pre-ICI bleeding significantly increases recurrent bleeding risk,necessitating close monitoring.The FIB-4 fibrosis model,combined with tumor features,can also serve as a predictive factor for bleeding.展开更多
BACKGROUND Colonic diverticular bleeding is a significant cause of acute overt lower gastrointestinal hemorrhage.Colonoscopy is commonly performed in patients with colonic diverticular bleeding to identify and treat t...BACKGROUND Colonic diverticular bleeding is a significant cause of acute overt lower gastrointestinal hemorrhage.Colonoscopy is commonly performed in patients with colonic diverticular bleeding to identify and treat the source of bleeding,which is crucial for effective management.CASE SUMMARY We present the case of a 70-year-old male with acute painless hematochezia.Colonoscopy showed active bleeding originating from a diverticulum,and the EyeMax direct visualization system was used in the treatment of the colonic diverticular bleeding.No further evidence of bleeding was observed at the end of the procedure.The patient was discharged from hospital on the seventh day.CONCLUSION The EyeMax system proved advantageous in localizing the bleeding diverticulum,thereby facilitating successful hemostatic measures.展开更多
BACKGROUND Gastrointestinal bleeding(GIB)is a critical complication often seen in patients with acute coronary syndrome(ACS),especially those undergoing dual antiplatelet therapy.GIB is associated with increased morta...BACKGROUND Gastrointestinal bleeding(GIB)is a critical complication often seen in patients with acute coronary syndrome(ACS),especially those undergoing dual antiplatelet therapy.GIB is associated with increased mortality and prolonged hospitalization,particularly in ACS patients.Despite advancements in management strategies,the role of gastrointestinal endoscopy(GIE)in this population remains controversial,with concerns about timing,safety,and clinical outcomes.AIM To evaluate the safety and efficacy of GIE in patients with ACS and acute GIB,focusing on outcomes such as mortality,hospital length of stay(LOS),hemorrhage control,rebleeding,and blood transfusion requirements.METHODS Following Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines,a systematic review was conducted using databases including PubMed,Cochrane,and EMBASE,up to December 2024.The protocol was registered with the International Prospective Register of Systematic Reviews(CRD42025630188).Study quality was assessed using the Cochrane Risk of Bias 2.0 tool for randomized controlled trials(RCTs)and the Newcastle-Ottawa Scale for cohort studies.RESULTS Four studies met the inclusion criteria,comprising one RCT and three cohort studies with a total population of 1676130 patients.Most studies indicated that GIE was associated with improved survival in ACS patients with GIB.Three of our studies reported lower mortality rates in patients undergoing GIE compared to those managed without endoscopy,although this varied by study.While GIE demonstrated effectiveness in controlling hemorrhage and reducing rebleeding rates in one study.The rest of the studies did not evaluate these outcomes comprehensively.Hospital LOS outcomes were inconsistent,with two studies suggesting no significant difference,while only one study indicated potential reductions in LOS with GIE.Blood transfusion requirements were reported in one study to be higher in patients undergoing GIE,reflecting its frequent use in severe cases.The safety and effectiveness of GIE varied depending on patient characteristics,timing of the procedure,and type of intervention.CONCLUSION GIE has the potential to improve survival in certain patients with ACS complicated by GIB;however,determining the ideal timing and appropriate candidates necessitates careful individual assessment.While evidence suggests benefits,the limitations of observational studies warrant caution.Collaboration between cardiology and gastroenterology is essential to optimizing outcomes.Future randomized trials should focus on timing,severity,and diverse populations to refine guidelines and improve care for this high-risk group.展开更多
BACKGROUND Colonic diverticular bleeding(CDB)is a leading cause of lower gastrointestinal hemorrhage that has a high risk of recurrence.The endoscopic clipping and endoscopic band ligation(EBL)methods are widely used ...BACKGROUND Colonic diverticular bleeding(CDB)is a leading cause of lower gastrointestinal hemorrhage that has a high risk of recurrence.The endoscopic clipping and endoscopic band ligation(EBL)methods are widely used for hemostasis in patients with CDB.Endoscopic detachable snare ligation(EDSL)has also become an increasingly common treatment option.The data remain inconsistent regarding the comparative efficacy of these endoscopic therapies in achieving initial hemostasis and reduction of early and late rebleeding rates.AIM To study the effectiveness and complications of endoscopic clipping,EBL,and EDSL for CDB.METHODS We conducted a systematic search of PubMed/MEDLINE,Scopus,Web of Science,Embase,Google Scholar,and the Cochrane database for clinical trials to find studies that reported CDB and endoscopic clipping,EBL,or EDSL as treatment methods.The pooled estimates of initial hemostasis,early and late rebleeding,and the need for transarterial embolization or surgery between these groups were calculated.RESULTS We analyzed 28 studies with 5224 patients.Of these,4526 had active CDB and required one of the three endoscopic interventions.The pooled prevalence of early rebleeding was 23.5%,10.7%,and 10.6%in the endoscopic clipping,EBL,and EDSL groups,respectively.Patients who underwent endoscopic clipping had a significantly higher rate of early rebleeding compared to those who received EBL[odds ratio(OR)=3.76(95%CI:2.13-6.63)]and EDSL(OR=3.30,95%CI:1.28-8.53).There was no difference in the initial hemostasis between the three groups.The pooled prevalence of late rebleeding was 27.2%in the clipping,followed by 13.8%in the EBL and 2.7%in the EDSL group.Compared to 2.6%in the EBL group,4.0%of patients who received endoscopic clipping subsequently underwent surgery or transarterial embolization.These results were consistent in the network meta-analysis.Based on the ranking of the indirect comparison of modalities,the snare technique was better at achieving initial hemostasis and had a lower late rebleeding rate.CONCLUSION The findings of this direct and indirect pairwise comparison suggest that EDSL is superior to endoscopic clipping and EBL in achieving initial hemostasis and lowering the rate of late rebleeding in patients with CDB.展开更多
BACKGROUND Early transjugular intrahepatic portosystemic shunts(TIPS)is a therapeutic option for acute variceal bleeding(AVB),offering a low risk of rebleeding.However,the long-term outcomes of early TIPS remain uncle...BACKGROUND Early transjugular intrahepatic portosystemic shunts(TIPS)is a therapeutic option for acute variceal bleeding(AVB),offering a low risk of rebleeding.However,the long-term outcomes of early TIPS remain unclear.AIM To evaluate the long-term outcomes for early TIPS compared with standard treatment in patients with cirrhosis and AVB.METHODS We retrospectively analyzed the clinical data of patients with AVB who underwent early TIPS or standard treatment between January 2014 and December 2023.The primary outcome was overall survival(OS).RESULTS A total of 37 patients with AVB underwent early TIPS,while 65 patients received standard treatment.Compared with the standard treatment group,the rates of uncontrolled bleeding or rebleeding in the early TIPS group were significantly lower(10.8%vs 50.8%,P<0.001).Over a median follow-up of 46 months,no statistically significant differences were observed in terms of OS(P=0.507).The presence of comorbidities was identified as an independent predictor of OS(adjusted hazard ratio=3.81;95%confidence interval:1.16-12.46).Notably,new or worsening ascites occurred less frequently in the early TIPS group(13.5%vs 38.5%,P=0.008).There was no significant difference in the rate of overt hepatic encephalopathy between the two groups(45.9%vs 36.9%,P=0.372).CONCLUSION While early TIPS is not associated with a long-term survival benefit compared with standard treatment for AVB,it is associated with reduced risks of rebleeding and ascites.展开更多
BACKGROUND Globally,Liver cirrhosis is the 14th leading cause of death and poses a significant threat to human health.AIM To investigate the effects of a multidisciplinary collaboration model on postoperative recovery...BACKGROUND Globally,Liver cirrhosis is the 14th leading cause of death and poses a significant threat to human health.AIM To investigate the effects of a multidisciplinary collaboration model on postoperative recovery and psychological stress in patients with liver cirrhosis undergoing esophageal variceal bleeding(EVB)surgery within an integrated healthcare system.METHODS Between January 2022 and March 2024,a total of 180 patients with cirrhosis and EVB were admitted and randomly assigned to either a control group(standard care)or an observation group(standard care plus the multidisciplinary collaboration model),with 90 patients in each group.Postoperative recovery indicators(time to symptom improvement,time to start eating,time to bowel sound recovery,time to first flatus,and hospital stay),psychological stress responses[selfrating anxiety scale(SAS);self-rating depression scale(SDS)],subjective wellbeing,and incidence of complications were compared between the two groups.RESULTS Compared to the control group,the observation group showed earlier symptom improvement,earlier return to eating,bowel sound recovery,first flatus,and a shorter hospital stay.Pre-intervention SAS and SDS scores were not significantly different between the groups,but post-intervention scores were significantly lower in the observation group.Similarly,there was no significant difference in the subjective well-being scores before the intervention between the two groups.After the intervention,both groups showed improved scores,with the observation group scoring significantly higher than the control group.CONCLUSION The observation group also had a lower incidence of complications.Therefore,for patients with liver cirrhosis undergoing EVB surgery,a multidisciplinary collaboration model within an integrated healthcare system can promote early postoperative recovery,reduces psychological stress,improves subjective well-being,and reduces complications and rebleeding.展开更多
BACKGROUND Transjugular intrahepatic portosystemic shunt(TIPS)is an effective intervention for managing complications of portal hypertension,particularly acute variceal bleeding(AVB).While effective in reducing portal...BACKGROUND Transjugular intrahepatic portosystemic shunt(TIPS)is an effective intervention for managing complications of portal hypertension,particularly acute variceal bleeding(AVB).While effective in reducing portal pressure and preventing rebleeding,TIPS is associated with a considerable risk of overt hepatic encephalopathy(OHE),a complication that significantly elevates mortality rates.AIM To develop a machine learning(ML)model to predict OHE occurrence post-TIPS in patients with AVB using a 5-year dataset.METHODS This retrospective single-center study included 218 patients with AVB who underwent TIPS.The dataset was divided into training(70%)and testing(30%)sets.Critical features were identified using embedded methods and recursive feature elimination.Three ML algorithms-random forest,extreme gradient boosting,and logistic regression-were validated via 10-fold cross-validation.SHapley Additive exPlanations analysis was employed to interpret the model’s predictions.Survival analysis was conducted using Kaplan-Meier curves and stepwise Cox regression analysis to compare overall survival(OS)between patients with and without OHE.RESULTS The median OS of the study cohort was 47.83±22.95 months.Among the models evaluated,logistic regression demonstrated the highest performance with an area under the curve(AUC)of 0.825.Key predictors identified were Child-Pugh score,age,and portal vein thrombosis.Kaplan-Meier analysis revealed that patients without OHE had a significantly longer OS(P=0.005).The 5-year survival rate was 78.4%,with an OHE incidence of 15.1%.Both actual OHE status and predicted OHE value were significant predictors in each Cox model,with model-predicted OHE achieving an AUC of 88.1 in survival prediction.CONCLUSION The ML model accurately predicts post-TIPS OHE and outperforms traditional models,supporting its use in improving outcomes in patients with AVB.展开更多
Bled air from the high pressure compressor takes up 3%—5% in the air system.However,there are not many studies on the compressor performance after bleeding.By analyzing the low-speed single-stage compressors,six blee...Bled air from the high pressure compressor takes up 3%—5% in the air system.However,there are not many studies on the compressor performance after bleeding.By analyzing the low-speed single-stage compressors,six bleeding structures are presented according to their influence mechanism on the compressor performance,and five kinds of bleeding rate are applied to one of the structures.A numerical simulation is performed to study the influence of bleeding rates and structures on the compressor performance.The results show that for the stators with the large flow separation in the corner,bleeding a small amount of air from the end-wall region can improve the total pressure increase and the stability margin.Moreover there is an optimum value of the bleeding rate in the stator casing.展开更多
BACKGROUND Acute variceal bleeding is one of the deadliest complications of cirrhosis,with a high risk of in-hospital rebleeding and mortality.Some risk scoring systems to predict clinical outcomes in patients with up...BACKGROUND Acute variceal bleeding is one of the deadliest complications of cirrhosis,with a high risk of in-hospital rebleeding and mortality.Some risk scoring systems to predict clinical outcomes in patients with upper gastrointestinal bleeding have been developed.However,for cirrhotic patients with variceal bleeding,data regarding the predictive value of these prognostic scores in predicting in-hospital outcomes are limited and controversial.AIM To validate and compare the overall performance of selected prognostic scoring systems for predicting in-hospital outcomes in cirrhotic patients with variceal bleeding.METHODS From March 2017 to June 2019,cirrhotic patients with acute variceal bleeding were retrospectively enrolled at the Second Affiliated Hospital of Xi’an Jiaotong University.The clinical Rockall score(CRS),AIMS65 score(AIMS65),Glasgow-Blatchford score(GBS),modified GBS(mGBS),Canada-United Kingdom-Australia score(CANUKA),Child-Turcotte-Pugh score(CTP),model for endstage liver disease(MELD)and MELD-Na were calculated.The overall performance of these prognostic scoring systems was evaluated.RESULTS A total of 330 cirrhotic patients with variceal bleeding were enrolled;the rates of in-hospital rebleeding and mortality were 20.3%and 10.6%,respectively.For inhospital rebleeding,the discriminative ability of the CTP and CRS were clinically acceptable,with area under the receiver operating characteristic curves(AUROCs)of 0.717(0.648-0.787)and 0.716(0.638-0.793),respectively.The other tested scoring systems had poor discriminative ability(AUROCs<0.7).For inhospital mortality,the CRS,CTP,AIMS65,MELD-Na and MELD showed excellent discriminative ability(AUROCs>0.8).The AUROCs of the mGBS,CANUKA and GBS were relatively small,but clinically acceptable(AUROCs>0.7).Furthermore,the calibration of all scoring systems was good for either inhospital rebleeding or death.CONCLUSION For cirrhotic patients with variceal bleeding,in-hospital rebleeding and mortality rates remain high.The CTP and CRS can be used clinically to predict in-hospital rebleeding.The performances of the CRS,CTP,AIMS65,MELD-Na and MELD are excellent at predicting in-hospital mortality.展开更多
AIM: To validate the Rockall scoring system for predicting outcomes of rebleeding, and the need for a surgical procedure and death. METHODS: We used data extracted from the Registry of Upper Gastrointestinal Bleeding ...AIM: To validate the Rockall scoring system for predicting outcomes of rebleeding, and the need for a surgical procedure and death. METHODS: We used data extracted from the Registry of Upper Gastrointestinal Bleeding and Endoscopy including information of 1869 patients with non-variceal upper gastrointestinal bleeding treated in Canadian hospitals. Risk scores were calculated and used to classify patients based on outcomes. For each outcome, we used χ2 goodness-of-fit tests to assess the degree of calibration, and built receiver operating characteristic curves and calculated the area under the curve (AUC) to evaluate the discriminative ability of the scoring system. RESULTS: For rebleeding, the χ2 goodness-of-fit test indicated an acceptable fit for the model [χ2 (8) = 12.83, P = 0.12]. For surgical procedures [χ2 (8) = 5.3, P = 0.73] and death [χ2 (8) = 3.78, P = 0.88], the tests showed solid correspondence between observed proportions and predicted probabilities. The AUC was 0.59 (95% CI: 0.55-0.62) for the outcome of rebleeding and 0.60 (95% CI: 0.54-0.67) for surgical procedures, representing apoor discriminative ability of the scoring system. For the outcome of death, the AUC was 0.73 (95% CI: 0.69-0.78), indicating an acceptable discriminative ability. CONCLUSION: The Rockall scoring system provides an acceptable tool to predict death, but performs poorly for endpoints of rebleeding and surgical procedures.展开更多
BACKGROUND： Transjugular intrahepatic portosystemic shunt（TIPS） and open splenectomy and esophagogastric devascularization（OSED） are widely used to treat patients with portal hypertension and recurrent variceal b...BACKGROUND： Transjugular intrahepatic portosystemic shunt（TIPS） and open splenectomy and esophagogastric devascularization（OSED） are widely used to treat patients with portal hypertension and recurrent variceal bleeding（PHRVB）. This study aimed to compare the effectiveness between TIPS and OSED for the treatment of PHRVB.METHODS： The data were retrospectively retrieved from 479 cirrhotic patients（Child-Pugh A or B class） with PHRVB, who had undergone TIPS（TIPS group） or OSED（OSED group） between January 1, 2010 and October 31, 2014.RESULTS： A total of 196 patients received TIPS, whereas 283 underwent OSED. Within one month after TIPS and OSED, the rebleeding rates were 6.1% and 3.2%, respectively（P=0.122）. Significantly lower incidence of pleural effusion,splenic vein thrombosis, and pulmonary infection, as well as higher hepatic encephalopathy rate, shorter postoperative length of hospital stay, and higher hospital costs were observed in the TIPS group than those in the OSED group. During the follow-up periods（29 months）, significantly higher incidences of rebleeding（15.3% vs 4.6%, P=0.001） and hepatic encephalopathy（17.3% vs 3.9%, P=0.001） were observed in the TIPS group than in the OSED group. The incidence of instent stenosis was 18.9%. The survival rates were 91.3% in the TIPS group and 95.1% in the OSED group. The long-term liver function did not worsen after either TIPS or OSED.CONCLUSION： For the patients with liver function in the Child-Pugh A or B class, TIPS is not superior over OSED in terms of PHRVB treatment and rebleeding prevention.展开更多
Background Frailty is a multidimensional syndrome that reflects the physiological reserve of elderly.It is related to unfavorable outcomes in various cardiovascular conditions.We conducted a systematic review and meta...Background Frailty is a multidimensional syndrome that reflects the physiological reserve of elderly.It is related to unfavorable outcomes in various cardiovascular conditions.We conducted a systematic review and meta-analysis of the association of frailty with all-cause mortality and bleeding after acute myocardial infarction(AMI)in the elderly.Methods We comprehensively searched the databases of MEDLINE and EMBASE from inception to March 2019.The studies that reported mortality and bleeding in AMI patients who were evaluated and classified by frailty status were included.Data from each study were combined using the random-effects,generic inverse variance method of Der Simonian and Laird to calculate hazard ratio(HR),and 95%confidence interval(CI).Results Twenty-one studies from 2011 to 2019 were included in this meta-analysis involving 143,301 subjects(mean age 75.33-year-old,60.0%male).Frailty status was evaluated using different methods such as Fried Frailty Index.Frailty was statistically associated with increased early mortality in nine studies(pooled HR=2.07,95%CI:1.67-2.56,P<0.001,I^2=41.2%)and late mortality in 11 studies(pooled HR=2.30,95%CI:1.70-3.11,P<0.001,I^2=65.8%).Moreover,frailty was also statistically associated with higher bleeding in 7 studies(pooled HR=1.34,95%CI:1.12-1.59,P<0.001,I^2=4.7%).Conclusion Frailty is strongly and independently associated with bleeding,early and late mortality in elderly with AMI.Frailty assessment should be considered as an additional risk factor and used to guide toward personalized treatment strategies.展开更多
AIM To compare the diagnostic accuracy of video capsule endoscopy(VCE) and double-balloon enteroscopy(DBE) in cases of obscure gastrointestinal bleeding(OGIB) of vascular origin.METHODS MEDLINE(via PubMed), LILACS(via...AIM To compare the diagnostic accuracy of video capsule endoscopy(VCE) and double-balloon enteroscopy(DBE) in cases of obscure gastrointestinal bleeding(OGIB) of vascular origin.METHODS MEDLINE(via PubMed), LILACS(via BVS) and Cochrane/CENTRAL virtual databases were searched for studies dated before 2017. We identified prospective and retrospective studies, including observational, cohort, single-blinded and multicenter studies, comparing VCE and DBE for the diagnosis of OGIB, and data of all the vascular sources of bleeding were collected. All patients were subjected to the same gold standard method. Relevant data were then extracted from each included study using a standardized extraction form. We calculated study variables(sensitivity, specificity, prevalence, positive and negative predictive values and accuracy) and performed a meta-analysis using Meta-Disc software.RESULTS In the per-patient analysis, 17 studies(1477 lesions) were included. We identified3150 exams(1722 VCE and 1428 DBE) in 2043 patients and identified 2248 sources of bleeding, 1467 of which were from vascular lesions. Of these lesions, 864(58.5%) were diagnosed by VCE, and 613(41.5%) were diagnosed by DBE. The pretest probability for bleeding of vascular origin was 54.34%. The sensitivity of DBE was 84%(95%CI: 0.82-0.86; heterogeneity: 78.00%), and the specificity was92%(95%CI: 0.89-0.94; heterogeneity: 92.0%). For DBE, the positive likelihood ratio was 11.29(95%CI: 4.83-26.40; heterogeneity: 91.6%), and the negative likelihood ratio was 0.20(95%CI: 0.15-0.27; heterogeneity: 67.3%). Performing DBE after CE increased the diagnostic yield of vascular lesion by 7%, from 83% to90%.CONCLUSION The diagnostic accuracy of detecting small bowel bleeding from a vascular source is increased with the use of an isolated video capsule endoscope compared with isolated DBE. However, concomitant use increases the detection rate of the bleeding source.展开更多
AIM To compare the Glasgow-Blatchford score(GBS), Rockall score(RS) and Baylor bleeding score(BBS) in predicting clinical outcomes and need for interventions in patients with bleeding peptic ulcers. METHODS Between Ja...AIM To compare the Glasgow-Blatchford score(GBS), Rockall score(RS) and Baylor bleeding score(BBS) in predicting clinical outcomes and need for interventions in patients with bleeding peptic ulcers. METHODS Between January 2008 and December 2013, 1012consecutive patients admitted with peptic ulcer bleeding(PUB) were prospectively followed. The pre-endoscopic RS, BBS and GBS, as well as the post-endoscopic diagnostic scores(RS and BBS) were calculated for all patients according to their urgent upper endoscopy findings. Area under the receiver-operating characteristics(AUROC) curves were calculated for the prediction of lethal outcome, rebleeding, needs for blood transfusion and/or surgical intervention, and the optimal cutoff values were evaluated.RESULTS PUB accounted for 41.9% of all upper gastrointestinal tract bleeding, 5.2% patients died and 5.4% patients underwent surgery. By comparing the AUROC curves of the aforementioned pre-endoscopic scores, the RS best predicted lethal outcome(AUROC 0.82 vs 0.67 vs0.63, respectively), but the GBS best predicted need for hospital-based intervention or 30-d mortality(AUROC0.84 vs 0.57 vs 0.64), rebleeding(AUROC 0.75 vs 0.61 vs 0.53), need for blood transfusion(AUROC 0.83 vs0.63 vs 0.58) and surgical intervention(0.82 vs 0.63 vs 0.52) The post-endoscopic RS was also better than the post-endoscopic BBS in predicting lethal outcome(AUROC 0.82 vs 0.69, respectively).CONCLUSION The RS is the best predictor of mortality and the GBS is the best predictor of rebleeding, need for blood transfusion and/or surgical intervention in patients with PUB. There is no one 'perfect score' and we suggest that these two tests be used concomitantly.展开更多
Background:Studies about treatment of patients with chronic portal vein thrombosis(CPVT)are still limited,especially in different types of CPVT.This study aimed to evaluate the effect of transjugular intrahepatic port...Background:Studies about treatment of patients with chronic portal vein thrombosis(CPVT)are still limited,especially in different types of CPVT.This study aimed to evaluate the effect of transjugular intrahepatic portosystemic shunt(TIPS)in all types of CPVT with variceal bleeding.Methods:Patients with CPVT who received TIPS treatment between January 2011 and June 2019 were divided into four types according to the extent of thrombosis.All patients had a history of variceal bleeding.The characteristics and clinical parameters were collected and recorded.Data on procedure success rate,variation in portal vein pressure,rebleeding,hepatic encephalopathy(HE),stent stenosis,and overall mortality were analyzed.Results:A total of 189 patients were included in this study(39 in type 1,84 in type 2,48 in type 3,18 in type 4).The TIPS procedure success rate was 86.2%.The success rate was significantly different among the four types(89.7%vs.88.1%vs.83.3%vs.77.8%,P=0.001).In the TIPS success group,portal vein pressure was significantly reduced from 27.15±6.59 to 19.74±6.73 mm Hg after the procedure(P<0.001)and the rebleeding rate was significantly lower than that of the fail group(14.7%vs.30.8%,P=0.017).In addition,there were no significant differences in HE rate(30.7%vs.26.9%,P=0.912)or overall mortality(12.9%vs.19.2%,P=0.403)between the TIPS success group and the fail group.In the TIPS success group,we found that the occurrence of HE was significantly different(P=0.020)among the four types,while there were no significant differences in rebleeding rate(P=0.669),stent stenosis rate(P=0.056),or overall mortality(P=0.690).Conclusions:TIPS was safe and effective in decreasing portal vein pressure and rebleeding rate in patients with CPVT.展开更多
Variceal bleeding is a serious complication of cirrhosis and portal hypertension.Despite the improvement in management of acute variceal bleed(AVB),it still carries significant mortality.Portal pressure is the main dr...Variceal bleeding is a serious complication of cirrhosis and portal hypertension.Despite the improvement in management of acute variceal bleed(AVB),it still carries significant mortality.Portal pressure is the main driver of variceal bleeding and also a main predictor of decompensation.Reduction in portal pressure has been the mainstay of management of variceal bleeding.Transjugular intrahepatic porto-systemic stent shunt(TIPSS)is a very effective modality in reducing the portal hypertension and thereby,controlling portal hypertensive bleeding.However,its use in refractory bleeding(rescue/salvage TIPSS)is still associated with high mortality.“Early”use of TIPSS as a“pre-emptive strategy”in patients with AVB at high risk of failure of treatment has shown to be superior to standard treatment in several studies.While patients with Child C cirrhosis(up to 13 points)clearly benefit from early-TIPSS strategy,it’s role in less severe liver disease(Child B)and more severe disease(Child C>13 points)remains less clear.Moreover,standard of care has improved in the last decade leading to improved 1-year survival in high-risk patients with AVB as compared to earlier“early”TIPSS studies.Lastly in the real world,only a minority of patients with AVB fulfil the stringent criteria for early TIPSS.Therefore,there is unmet need to explore role of early TIPSS in management of AVB in well-designed prospective studies. In this review, we have appraised the role of early TIPSS, patient selection anddiscussed future directions in the management of patients with AVB.展开更多
Background： Antithrombotic therapy using new oral anticoagulants （NOACs） in patients with atrial fibril- lation （AF） has been generally shown to have a favorable risk-benefit profile. Since there has been dispute...Background： Antithrombotic therapy using new oral anticoagulants （NOACs） in patients with atrial fibril- lation （AF） has been generally shown to have a favorable risk-benefit profile. Since there has been dispute about the risks of gastrointestinal bleeding （GIB） and intracranial hemorrhage （ICH）, we sought to conduct a systematic review and network meta-analysis using Bayesian inference to analyze the risks of GIB and ICH in AF patients taking NOACs. Methods： We analyzed data from 20 randomized controlled trials of 91 671 AF patients receiving anticoagulants, antiplatelet drugs, or placebo. Bayesian network meta-analysis of two different evidence networks was performed using a binomial likelihood model, based on a network in which different agents （and doses） were treated as separate nodes. Odds ratios （ORs） and 95% confidence intervals （CIs） were modeled using Markov chain Monte Carlo methods Results： Indirect comparisons with the Bayesian model confirmed that aspirin＋clopidogrel significantly increased the risk of GIB in AF patients compared to the placebo （OR 0.33, 95% CI 0.01-0.92）. Warfarin was identified as greatly increasing the risk of ICH compared to edoxaban 30 mg （OR 3.42, 95% CI 1.22-7.24） and dabigatran 110 mg （OR 3.56, 95% CI 1.10-8.45）. We further ranked the NOACs for the lowest risk of GIB （apixaban 5 mg） and ICH （apixaban 5 mg, dabigatran 110 mg, and edoxaban 30 mg）. Conclusions： Bayesian network meta-analysis of treatment of nonvalvular AF patients with anticoagulants suggested that NOACs do not increase risks of GIB and/or ICH, compared to each other.展开更多
We report a case of duodenal varix bleeding as a long term complication of balloon occluded retrograde transvenous obliteration (BRTO), which was successfully treated with a transjugular intrahepatic portosystemic shu...We report a case of duodenal varix bleeding as a long term complication of balloon occluded retrograde transvenous obliteration (BRTO), which was successfully treated with a transjugular intrahepatic portosystemic shunt (TIPS). A 57-year-old man was admitted to the emergency room suffering from melena. He had under-gone BRTO to treat gastric varix bleeding 5 mo before admission. Endoscopy and a computed tomography (CT) scan showed complete obliteration of the gastric varix, but the nodular varices in the second portion of the duodenum expanded after BRTO, and spurting blood was seen. TIPS was performed for treatment of duodenal variceal bleeding, because attempts at endoscopic varix ligation were unsuccessful. The post-operative course was uneventful and the patient was discharged without complications. A follow up CT scan obtained 21 mo after TIPS revealed a patent TIPS tract and complete obliteration of duodenal varices, but multinodular hepatocellular carcinoma had developed. He died of hepatic failure 28 mo after TIPS.展开更多
BACKGROUND Duodenal varices are a lesser-known complication with non-cirrhotic portal hypertension. We report a circuitous route from missed diagnosis of duodenal varices to correction. An extremely rare case of duode...BACKGROUND Duodenal varices are a lesser-known complication with non-cirrhotic portal hypertension. We report a circuitous route from missed diagnosis of duodenal varices to correction. An extremely rare case of duodenal variceal bleeding secondary to idiopathic portal hypertension(IPH) is expounded in this study, which was controlled by transjugular intra-hepatic porto-systemic shunt(TIPS) plus embolization. CASE SUMMARY A 46-year-old woman with anemia for two years was frequently admitted to the local hospital. Upon examination, anemia was attributed to gastrointestinal tract bleeding, which resulted from duodenal variceal bleeding detected by repeated esophagogastroduodenoscopy. At the end of a complete workup, IPH leadingto duodenal varices was diagnosed. Portal venography revealed that the remarked duodenal varices originated from the proximal superior mesenteric vein. TIPS plus embolization with coils and Histoacryl was performed to obliterate the rupture of duodenal varices. The anemia resolved, and the duodenal varices completely vanished by 2 mo after the initial operation. CONCLUSION TIPS plus embolization may be more appropriate to treat the bleeding of large duodenal varices.展开更多
文摘Gastric cancer(GC)and gastroesophageal junction cancer(GEJC)represent a significant burden globally,with complications such as overt bleeding(OB)further exacerbating patient outcomes.A recent study by Yao et al evaluated the effectiveness and safety of systematic treatment in GC/GEJC patients presenting with OB.Using propensity score matching,the study balanced the comparison groups to investigate overall survival and treatment-related adverse events.The study's findings emphasize that systematic therapy can be safe and effective and contribute to the ongoing debate about the management of advanced GC/GEJC with OB,highlighting the complexities of treatment decisions in these high-risk patients.
基金Supported by Tianjin Key Medical Discipline(Specialty)Construction Project,No.TJYXZDXK-034AHebei Province 2025 Traditional Chinese Medicine Scientific Research Project Plan,No.T2025008.
文摘BACKGROUND Acute variceal bleeding(AVB)represents a life-threatening complication in hepatocellular carcinoma(HCC)patients undergoing systemic therapy,mainly including immune checkpoint inhibitors(ICIs)and antivascular drugs used alone or in combination.The pathogenesis of AVB in this population may involve tumor-related factors,treatment-induced effects,or progression of underlying portal hypertension.Identifying high-risk factors for AVB is crucial for the management of this patient population.AIM To develop and validate a risk prediction model for AVB occurrence in cirrhotic HCC patients receiving ICI-based systemic therapy.METHODS This retrospective study analyzed 286 HCC patients(2021-2022)receiving ICIs(mono-/combination therapy),randomly split into training(n=184)and validation(n=102)cohorts.In the training cohort,bleeding vs nonbleeding groups were compared for general information,etiological data,laboratory indicators,tumor staging,systemic treatment drugs,variceal bleeding history,and endoscopic treatment history.Risk factors for AVB were identified and used to establish a logistic regression model for predicting bleeding,which was further validated in the validation cohort.RESULTS The bleeding group had significantly higher proportions of patients with platelet count≥100×10^(9)/L,alphafetoprotein≥400 ng/mL,tumor diameter≥5 cm,portal vein tumor thrombosis,ascites,bleeding history,prior endoscopic treatment,albumin-bilirubin grade level 2-3,fibrosis-4 index(FIB-4)≥4.57,and prognostic nutritional index<45 compared to the non-bleeding group.Multivariate analysis identified tumor diameter≥5 cm,portal vein thrombosis,bleeding history,and elevated FIB-4 as independent risk factors for bleeding(P<0.05).A predictive model based on these factors showed good discrimination,with area under the receiver operating characteristic curve values of 0.861(training)and 0.816(validation).CONCLUSION A history of pre-ICI bleeding significantly increases recurrent bleeding risk,necessitating close monitoring.The FIB-4 fibrosis model,combined with tumor features,can also serve as a predictive factor for bleeding.
文摘BACKGROUND Colonic diverticular bleeding is a significant cause of acute overt lower gastrointestinal hemorrhage.Colonoscopy is commonly performed in patients with colonic diverticular bleeding to identify and treat the source of bleeding,which is crucial for effective management.CASE SUMMARY We present the case of a 70-year-old male with acute painless hematochezia.Colonoscopy showed active bleeding originating from a diverticulum,and the EyeMax direct visualization system was used in the treatment of the colonic diverticular bleeding.No further evidence of bleeding was observed at the end of the procedure.The patient was discharged from hospital on the seventh day.CONCLUSION The EyeMax system proved advantageous in localizing the bleeding diverticulum,thereby facilitating successful hemostatic measures.
文摘BACKGROUND Gastrointestinal bleeding(GIB)is a critical complication often seen in patients with acute coronary syndrome(ACS),especially those undergoing dual antiplatelet therapy.GIB is associated with increased mortality and prolonged hospitalization,particularly in ACS patients.Despite advancements in management strategies,the role of gastrointestinal endoscopy(GIE)in this population remains controversial,with concerns about timing,safety,and clinical outcomes.AIM To evaluate the safety and efficacy of GIE in patients with ACS and acute GIB,focusing on outcomes such as mortality,hospital length of stay(LOS),hemorrhage control,rebleeding,and blood transfusion requirements.METHODS Following Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines,a systematic review was conducted using databases including PubMed,Cochrane,and EMBASE,up to December 2024.The protocol was registered with the International Prospective Register of Systematic Reviews(CRD42025630188).Study quality was assessed using the Cochrane Risk of Bias 2.0 tool for randomized controlled trials(RCTs)and the Newcastle-Ottawa Scale for cohort studies.RESULTS Four studies met the inclusion criteria,comprising one RCT and three cohort studies with a total population of 1676130 patients.Most studies indicated that GIE was associated with improved survival in ACS patients with GIB.Three of our studies reported lower mortality rates in patients undergoing GIE compared to those managed without endoscopy,although this varied by study.While GIE demonstrated effectiveness in controlling hemorrhage and reducing rebleeding rates in one study.The rest of the studies did not evaluate these outcomes comprehensively.Hospital LOS outcomes were inconsistent,with two studies suggesting no significant difference,while only one study indicated potential reductions in LOS with GIE.Blood transfusion requirements were reported in one study to be higher in patients undergoing GIE,reflecting its frequent use in severe cases.The safety and effectiveness of GIE varied depending on patient characteristics,timing of the procedure,and type of intervention.CONCLUSION GIE has the potential to improve survival in certain patients with ACS complicated by GIB;however,determining the ideal timing and appropriate candidates necessitates careful individual assessment.While evidence suggests benefits,the limitations of observational studies warrant caution.Collaboration between cardiology and gastroenterology is essential to optimizing outcomes.Future randomized trials should focus on timing,severity,and diverse populations to refine guidelines and improve care for this high-risk group.
文摘BACKGROUND Colonic diverticular bleeding(CDB)is a leading cause of lower gastrointestinal hemorrhage that has a high risk of recurrence.The endoscopic clipping and endoscopic band ligation(EBL)methods are widely used for hemostasis in patients with CDB.Endoscopic detachable snare ligation(EDSL)has also become an increasingly common treatment option.The data remain inconsistent regarding the comparative efficacy of these endoscopic therapies in achieving initial hemostasis and reduction of early and late rebleeding rates.AIM To study the effectiveness and complications of endoscopic clipping,EBL,and EDSL for CDB.METHODS We conducted a systematic search of PubMed/MEDLINE,Scopus,Web of Science,Embase,Google Scholar,and the Cochrane database for clinical trials to find studies that reported CDB and endoscopic clipping,EBL,or EDSL as treatment methods.The pooled estimates of initial hemostasis,early and late rebleeding,and the need for transarterial embolization or surgery between these groups were calculated.RESULTS We analyzed 28 studies with 5224 patients.Of these,4526 had active CDB and required one of the three endoscopic interventions.The pooled prevalence of early rebleeding was 23.5%,10.7%,and 10.6%in the endoscopic clipping,EBL,and EDSL groups,respectively.Patients who underwent endoscopic clipping had a significantly higher rate of early rebleeding compared to those who received EBL[odds ratio(OR)=3.76(95%CI:2.13-6.63)]and EDSL(OR=3.30,95%CI:1.28-8.53).There was no difference in the initial hemostasis between the three groups.The pooled prevalence of late rebleeding was 27.2%in the clipping,followed by 13.8%in the EBL and 2.7%in the EDSL group.Compared to 2.6%in the EBL group,4.0%of patients who received endoscopic clipping subsequently underwent surgery or transarterial embolization.These results were consistent in the network meta-analysis.Based on the ranking of the indirect comparison of modalities,the snare technique was better at achieving initial hemostasis and had a lower late rebleeding rate.CONCLUSION The findings of this direct and indirect pairwise comparison suggest that EDSL is superior to endoscopic clipping and EBL in achieving initial hemostasis and lowering the rate of late rebleeding in patients with CDB.
基金Supported by the Natural Science Foundation of the Science and Technology Commission of Shanghai Municipality,No.23ZR1458300the Key Discipline Project of Shanghai Municipal Health System,No.2024ZDXK0004the Doctoral Innovation Talent Base Project for Diagnosis and Treatment of Chronic Liver Diseases,No.RCJD2021B02.
文摘BACKGROUND Early transjugular intrahepatic portosystemic shunts(TIPS)is a therapeutic option for acute variceal bleeding(AVB),offering a low risk of rebleeding.However,the long-term outcomes of early TIPS remain unclear.AIM To evaluate the long-term outcomes for early TIPS compared with standard treatment in patients with cirrhosis and AVB.METHODS We retrospectively analyzed the clinical data of patients with AVB who underwent early TIPS or standard treatment between January 2014 and December 2023.The primary outcome was overall survival(OS).RESULTS A total of 37 patients with AVB underwent early TIPS,while 65 patients received standard treatment.Compared with the standard treatment group,the rates of uncontrolled bleeding or rebleeding in the early TIPS group were significantly lower(10.8%vs 50.8%,P<0.001).Over a median follow-up of 46 months,no statistically significant differences were observed in terms of OS(P=0.507).The presence of comorbidities was identified as an independent predictor of OS(adjusted hazard ratio=3.81;95%confidence interval:1.16-12.46).Notably,new or worsening ascites occurred less frequently in the early TIPS group(13.5%vs 38.5%,P=0.008).There was no significant difference in the rate of overt hepatic encephalopathy between the two groups(45.9%vs 36.9%,P=0.372).CONCLUSION While early TIPS is not associated with a long-term survival benefit compared with standard treatment for AVB,it is associated with reduced risks of rebleeding and ascites.
文摘BACKGROUND Globally,Liver cirrhosis is the 14th leading cause of death and poses a significant threat to human health.AIM To investigate the effects of a multidisciplinary collaboration model on postoperative recovery and psychological stress in patients with liver cirrhosis undergoing esophageal variceal bleeding(EVB)surgery within an integrated healthcare system.METHODS Between January 2022 and March 2024,a total of 180 patients with cirrhosis and EVB were admitted and randomly assigned to either a control group(standard care)or an observation group(standard care plus the multidisciplinary collaboration model),with 90 patients in each group.Postoperative recovery indicators(time to symptom improvement,time to start eating,time to bowel sound recovery,time to first flatus,and hospital stay),psychological stress responses[selfrating anxiety scale(SAS);self-rating depression scale(SDS)],subjective wellbeing,and incidence of complications were compared between the two groups.RESULTS Compared to the control group,the observation group showed earlier symptom improvement,earlier return to eating,bowel sound recovery,first flatus,and a shorter hospital stay.Pre-intervention SAS and SDS scores were not significantly different between the groups,but post-intervention scores were significantly lower in the observation group.Similarly,there was no significant difference in the subjective well-being scores before the intervention between the two groups.After the intervention,both groups showed improved scores,with the observation group scoring significantly higher than the control group.CONCLUSION The observation group also had a lower incidence of complications.Therefore,for patients with liver cirrhosis undergoing EVB surgery,a multidisciplinary collaboration model within an integrated healthcare system can promote early postoperative recovery,reduces psychological stress,improves subjective well-being,and reduces complications and rebleeding.
基金Natural Science Foundation of Guangdong Province,No.2024A1515013069.
文摘BACKGROUND Transjugular intrahepatic portosystemic shunt(TIPS)is an effective intervention for managing complications of portal hypertension,particularly acute variceal bleeding(AVB).While effective in reducing portal pressure and preventing rebleeding,TIPS is associated with a considerable risk of overt hepatic encephalopathy(OHE),a complication that significantly elevates mortality rates.AIM To develop a machine learning(ML)model to predict OHE occurrence post-TIPS in patients with AVB using a 5-year dataset.METHODS This retrospective single-center study included 218 patients with AVB who underwent TIPS.The dataset was divided into training(70%)and testing(30%)sets.Critical features were identified using embedded methods and recursive feature elimination.Three ML algorithms-random forest,extreme gradient boosting,and logistic regression-were validated via 10-fold cross-validation.SHapley Additive exPlanations analysis was employed to interpret the model’s predictions.Survival analysis was conducted using Kaplan-Meier curves and stepwise Cox regression analysis to compare overall survival(OS)between patients with and without OHE.RESULTS The median OS of the study cohort was 47.83±22.95 months.Among the models evaluated,logistic regression demonstrated the highest performance with an area under the curve(AUC)of 0.825.Key predictors identified were Child-Pugh score,age,and portal vein thrombosis.Kaplan-Meier analysis revealed that patients without OHE had a significantly longer OS(P=0.005).The 5-year survival rate was 78.4%,with an OHE incidence of 15.1%.Both actual OHE status and predicted OHE value were significant predictors in each Cox model,with model-predicted OHE achieving an AUC of 88.1 in survival prediction.CONCLUSION The ML model accurately predicts post-TIPS OHE and outperforms traditional models,supporting its use in improving outcomes in patients with AVB.
基金Supported by the National Natural Science Foundation of China(60934001)~~
文摘Bled air from the high pressure compressor takes up 3%—5% in the air system.However,there are not many studies on the compressor performance after bleeding.By analyzing the low-speed single-stage compressors,six bleeding structures are presented according to their influence mechanism on the compressor performance,and five kinds of bleeding rate are applied to one of the structures.A numerical simulation is performed to study the influence of bleeding rates and structures on the compressor performance.The results show that for the stators with the large flow separation in the corner,bleeding a small amount of air from the end-wall region can improve the total pressure increase and the stability margin.Moreover there is an optimum value of the bleeding rate in the stator casing.
文摘BACKGROUND Acute variceal bleeding is one of the deadliest complications of cirrhosis,with a high risk of in-hospital rebleeding and mortality.Some risk scoring systems to predict clinical outcomes in patients with upper gastrointestinal bleeding have been developed.However,for cirrhotic patients with variceal bleeding,data regarding the predictive value of these prognostic scores in predicting in-hospital outcomes are limited and controversial.AIM To validate and compare the overall performance of selected prognostic scoring systems for predicting in-hospital outcomes in cirrhotic patients with variceal bleeding.METHODS From March 2017 to June 2019,cirrhotic patients with acute variceal bleeding were retrospectively enrolled at the Second Affiliated Hospital of Xi’an Jiaotong University.The clinical Rockall score(CRS),AIMS65 score(AIMS65),Glasgow-Blatchford score(GBS),modified GBS(mGBS),Canada-United Kingdom-Australia score(CANUKA),Child-Turcotte-Pugh score(CTP),model for endstage liver disease(MELD)and MELD-Na were calculated.The overall performance of these prognostic scoring systems was evaluated.RESULTS A total of 330 cirrhotic patients with variceal bleeding were enrolled;the rates of in-hospital rebleeding and mortality were 20.3%and 10.6%,respectively.For inhospital rebleeding,the discriminative ability of the CTP and CRS were clinically acceptable,with area under the receiver operating characteristic curves(AUROCs)of 0.717(0.648-0.787)and 0.716(0.638-0.793),respectively.The other tested scoring systems had poor discriminative ability(AUROCs<0.7).For inhospital mortality,the CRS,CTP,AIMS65,MELD-Na and MELD showed excellent discriminative ability(AUROCs>0.8).The AUROCs of the mGBS,CANUKA and GBS were relatively small,but clinically acceptable(AUROCs>0.7).Furthermore,the calibration of all scoring systems was good for either inhospital rebleeding or death.CONCLUSION For cirrhotic patients with variceal bleeding,in-hospital rebleeding and mortality rates remain high.The CTP and CRS can be used clinically to predict in-hospital rebleeding.The performances of the CRS,CTP,AIMS65,MELD-Na and MELD are excellent at predicting in-hospital mortality.
基金Supported by the Canadian Association of Gastroenterology and an unrestricted grant from Altana Pharma Canada (formerly Byk Canada Inc.)
文摘AIM: To validate the Rockall scoring system for predicting outcomes of rebleeding, and the need for a surgical procedure and death. METHODS: We used data extracted from the Registry of Upper Gastrointestinal Bleeding and Endoscopy including information of 1869 patients with non-variceal upper gastrointestinal bleeding treated in Canadian hospitals. Risk scores were calculated and used to classify patients based on outcomes. For each outcome, we used χ2 goodness-of-fit tests to assess the degree of calibration, and built receiver operating characteristic curves and calculated the area under the curve (AUC) to evaluate the discriminative ability of the scoring system. RESULTS: For rebleeding, the χ2 goodness-of-fit test indicated an acceptable fit for the model [χ2 (8) = 12.83, P = 0.12]. For surgical procedures [χ2 (8) = 5.3, P = 0.73] and death [χ2 (8) = 3.78, P = 0.88], the tests showed solid correspondence between observed proportions and predicted probabilities. The AUC was 0.59 (95% CI: 0.55-0.62) for the outcome of rebleeding and 0.60 (95% CI: 0.54-0.67) for surgical procedures, representing apoor discriminative ability of the scoring system. For the outcome of death, the AUC was 0.73 (95% CI: 0.69-0.78), indicating an acceptable discriminative ability. CONCLUSION: The Rockall scoring system provides an acceptable tool to predict death, but performs poorly for endpoints of rebleeding and surgical procedures.
文摘BACKGROUND： Transjugular intrahepatic portosystemic shunt（TIPS） and open splenectomy and esophagogastric devascularization（OSED） are widely used to treat patients with portal hypertension and recurrent variceal bleeding（PHRVB）. This study aimed to compare the effectiveness between TIPS and OSED for the treatment of PHRVB.METHODS： The data were retrospectively retrieved from 479 cirrhotic patients（Child-Pugh A or B class） with PHRVB, who had undergone TIPS（TIPS group） or OSED（OSED group） between January 1, 2010 and October 31, 2014.RESULTS： A total of 196 patients received TIPS, whereas 283 underwent OSED. Within one month after TIPS and OSED, the rebleeding rates were 6.1% and 3.2%, respectively（P=0.122）. Significantly lower incidence of pleural effusion,splenic vein thrombosis, and pulmonary infection, as well as higher hepatic encephalopathy rate, shorter postoperative length of hospital stay, and higher hospital costs were observed in the TIPS group than those in the OSED group. During the follow-up periods（29 months）, significantly higher incidences of rebleeding（15.3% vs 4.6%, P=0.001） and hepatic encephalopathy（17.3% vs 3.9%, P=0.001） were observed in the TIPS group than in the OSED group. The incidence of instent stenosis was 18.9%. The survival rates were 91.3% in the TIPS group and 95.1% in the OSED group. The long-term liver function did not worsen after either TIPS or OSED.CONCLUSION： For the patients with liver function in the Child-Pugh A or B class, TIPS is not superior over OSED in terms of PHRVB treatment and rebleeding prevention.
文摘Background Frailty is a multidimensional syndrome that reflects the physiological reserve of elderly.It is related to unfavorable outcomes in various cardiovascular conditions.We conducted a systematic review and meta-analysis of the association of frailty with all-cause mortality and bleeding after acute myocardial infarction(AMI)in the elderly.Methods We comprehensively searched the databases of MEDLINE and EMBASE from inception to March 2019.The studies that reported mortality and bleeding in AMI patients who were evaluated and classified by frailty status were included.Data from each study were combined using the random-effects,generic inverse variance method of Der Simonian and Laird to calculate hazard ratio(HR),and 95%confidence interval(CI).Results Twenty-one studies from 2011 to 2019 were included in this meta-analysis involving 143,301 subjects(mean age 75.33-year-old,60.0%male).Frailty status was evaluated using different methods such as Fried Frailty Index.Frailty was statistically associated with increased early mortality in nine studies(pooled HR=2.07,95%CI:1.67-2.56,P<0.001,I^2=41.2%)and late mortality in 11 studies(pooled HR=2.30,95%CI:1.70-3.11,P<0.001,I^2=65.8%).Moreover,frailty was also statistically associated with higher bleeding in 7 studies(pooled HR=1.34,95%CI:1.12-1.59,P<0.001,I^2=4.7%).Conclusion Frailty is strongly and independently associated with bleeding,early and late mortality in elderly with AMI.Frailty assessment should be considered as an additional risk factor and used to guide toward personalized treatment strategies.
文摘AIM To compare the diagnostic accuracy of video capsule endoscopy(VCE) and double-balloon enteroscopy(DBE) in cases of obscure gastrointestinal bleeding(OGIB) of vascular origin.METHODS MEDLINE(via PubMed), LILACS(via BVS) and Cochrane/CENTRAL virtual databases were searched for studies dated before 2017. We identified prospective and retrospective studies, including observational, cohort, single-blinded and multicenter studies, comparing VCE and DBE for the diagnosis of OGIB, and data of all the vascular sources of bleeding were collected. All patients were subjected to the same gold standard method. Relevant data were then extracted from each included study using a standardized extraction form. We calculated study variables(sensitivity, specificity, prevalence, positive and negative predictive values and accuracy) and performed a meta-analysis using Meta-Disc software.RESULTS In the per-patient analysis, 17 studies(1477 lesions) were included. We identified3150 exams(1722 VCE and 1428 DBE) in 2043 patients and identified 2248 sources of bleeding, 1467 of which were from vascular lesions. Of these lesions, 864(58.5%) were diagnosed by VCE, and 613(41.5%) were diagnosed by DBE. The pretest probability for bleeding of vascular origin was 54.34%. The sensitivity of DBE was 84%(95%CI: 0.82-0.86; heterogeneity: 78.00%), and the specificity was92%(95%CI: 0.89-0.94; heterogeneity: 92.0%). For DBE, the positive likelihood ratio was 11.29(95%CI: 4.83-26.40; heterogeneity: 91.6%), and the negative likelihood ratio was 0.20(95%CI: 0.15-0.27; heterogeneity: 67.3%). Performing DBE after CE increased the diagnostic yield of vascular lesion by 7%, from 83% to90%.CONCLUSION The diagnostic accuracy of detecting small bowel bleeding from a vascular source is increased with the use of an isolated video capsule endoscope compared with isolated DBE. However, concomitant use increases the detection rate of the bleeding source.
文摘AIM To compare the Glasgow-Blatchford score(GBS), Rockall score(RS) and Baylor bleeding score(BBS) in predicting clinical outcomes and need for interventions in patients with bleeding peptic ulcers. METHODS Between January 2008 and December 2013, 1012consecutive patients admitted with peptic ulcer bleeding(PUB) were prospectively followed. The pre-endoscopic RS, BBS and GBS, as well as the post-endoscopic diagnostic scores(RS and BBS) were calculated for all patients according to their urgent upper endoscopy findings. Area under the receiver-operating characteristics(AUROC) curves were calculated for the prediction of lethal outcome, rebleeding, needs for blood transfusion and/or surgical intervention, and the optimal cutoff values were evaluated.RESULTS PUB accounted for 41.9% of all upper gastrointestinal tract bleeding, 5.2% patients died and 5.4% patients underwent surgery. By comparing the AUROC curves of the aforementioned pre-endoscopic scores, the RS best predicted lethal outcome(AUROC 0.82 vs 0.67 vs0.63, respectively), but the GBS best predicted need for hospital-based intervention or 30-d mortality(AUROC0.84 vs 0.57 vs 0.64), rebleeding(AUROC 0.75 vs 0.61 vs 0.53), need for blood transfusion(AUROC 0.83 vs0.63 vs 0.58) and surgical intervention(0.82 vs 0.63 vs 0.52) The post-endoscopic RS was also better than the post-endoscopic BBS in predicting lethal outcome(AUROC 0.82 vs 0.69, respectively).CONCLUSION The RS is the best predictor of mortality and the GBS is the best predictor of rebleeding, need for blood transfusion and/or surgical intervention in patients with PUB. There is no one 'perfect score' and we suggest that these two tests be used concomitantly.
基金supported by grants from Shandong Province Key Research and Development projects(2017GSF218026 and 2016GSF201001)Health and Family Planning Commission of Shandong Province(2017WS199)。
文摘Background:Studies about treatment of patients with chronic portal vein thrombosis(CPVT)are still limited,especially in different types of CPVT.This study aimed to evaluate the effect of transjugular intrahepatic portosystemic shunt(TIPS)in all types of CPVT with variceal bleeding.Methods:Patients with CPVT who received TIPS treatment between January 2011 and June 2019 were divided into four types according to the extent of thrombosis.All patients had a history of variceal bleeding.The characteristics and clinical parameters were collected and recorded.Data on procedure success rate,variation in portal vein pressure,rebleeding,hepatic encephalopathy(HE),stent stenosis,and overall mortality were analyzed.Results:A total of 189 patients were included in this study(39 in type 1,84 in type 2,48 in type 3,18 in type 4).The TIPS procedure success rate was 86.2%.The success rate was significantly different among the four types(89.7%vs.88.1%vs.83.3%vs.77.8%,P=0.001).In the TIPS success group,portal vein pressure was significantly reduced from 27.15±6.59 to 19.74±6.73 mm Hg after the procedure(P<0.001)and the rebleeding rate was significantly lower than that of the fail group(14.7%vs.30.8%,P=0.017).In addition,there were no significant differences in HE rate(30.7%vs.26.9%,P=0.912)or overall mortality(12.9%vs.19.2%,P=0.403)between the TIPS success group and the fail group.In the TIPS success group,we found that the occurrence of HE was significantly different(P=0.020)among the four types,while there were no significant differences in rebleeding rate(P=0.669),stent stenosis rate(P=0.056),or overall mortality(P=0.690).Conclusions:TIPS was safe and effective in decreasing portal vein pressure and rebleeding rate in patients with CPVT.
文摘Variceal bleeding is a serious complication of cirrhosis and portal hypertension.Despite the improvement in management of acute variceal bleed(AVB),it still carries significant mortality.Portal pressure is the main driver of variceal bleeding and also a main predictor of decompensation.Reduction in portal pressure has been the mainstay of management of variceal bleeding.Transjugular intrahepatic porto-systemic stent shunt(TIPSS)is a very effective modality in reducing the portal hypertension and thereby,controlling portal hypertensive bleeding.However,its use in refractory bleeding(rescue/salvage TIPSS)is still associated with high mortality.“Early”use of TIPSS as a“pre-emptive strategy”in patients with AVB at high risk of failure of treatment has shown to be superior to standard treatment in several studies.While patients with Child C cirrhosis(up to 13 points)clearly benefit from early-TIPSS strategy,it’s role in less severe liver disease(Child B)and more severe disease(Child C>13 points)remains less clear.Moreover,standard of care has improved in the last decade leading to improved 1-year survival in high-risk patients with AVB as compared to earlier“early”TIPSS studies.Lastly in the real world,only a minority of patients with AVB fulfil the stringent criteria for early TIPSS.Therefore,there is unmet need to explore role of early TIPSS in management of AVB in well-designed prospective studies. In this review, we have appraised the role of early TIPSS, patient selection anddiscussed future directions in the management of patients with AVB.
基金Project supported by the National Natural Science Foundation of China(No.30800999)
文摘Background： Antithrombotic therapy using new oral anticoagulants （NOACs） in patients with atrial fibril- lation （AF） has been generally shown to have a favorable risk-benefit profile. Since there has been dispute about the risks of gastrointestinal bleeding （GIB） and intracranial hemorrhage （ICH）, we sought to conduct a systematic review and network meta-analysis using Bayesian inference to analyze the risks of GIB and ICH in AF patients taking NOACs. Methods： We analyzed data from 20 randomized controlled trials of 91 671 AF patients receiving anticoagulants, antiplatelet drugs, or placebo. Bayesian network meta-analysis of two different evidence networks was performed using a binomial likelihood model, based on a network in which different agents （and doses） were treated as separate nodes. Odds ratios （ORs） and 95% confidence intervals （CIs） were modeled using Markov chain Monte Carlo methods Results： Indirect comparisons with the Bayesian model confirmed that aspirin＋clopidogrel significantly increased the risk of GIB in AF patients compared to the placebo （OR 0.33, 95% CI 0.01-0.92）. Warfarin was identified as greatly increasing the risk of ICH compared to edoxaban 30 mg （OR 3.42, 95% CI 1.22-7.24） and dabigatran 110 mg （OR 3.56, 95% CI 1.10-8.45）. We further ranked the NOACs for the lowest risk of GIB （apixaban 5 mg） and ICH （apixaban 5 mg, dabigatran 110 mg, and edoxaban 30 mg）. Conclusions： Bayesian network meta-analysis of treatment of nonvalvular AF patients with anticoagulants suggested that NOACs do not increase risks of GIB and/or ICH, compared to each other.
文摘We report a case of duodenal varix bleeding as a long term complication of balloon occluded retrograde transvenous obliteration (BRTO), which was successfully treated with a transjugular intrahepatic portosystemic shunt (TIPS). A 57-year-old man was admitted to the emergency room suffering from melena. He had under-gone BRTO to treat gastric varix bleeding 5 mo before admission. Endoscopy and a computed tomography (CT) scan showed complete obliteration of the gastric varix, but the nodular varices in the second portion of the duodenum expanded after BRTO, and spurting blood was seen. TIPS was performed for treatment of duodenal variceal bleeding, because attempts at endoscopic varix ligation were unsuccessful. The post-operative course was uneventful and the patient was discharged without complications. A follow up CT scan obtained 21 mo after TIPS revealed a patent TIPS tract and complete obliteration of duodenal varices, but multinodular hepatocellular carcinoma had developed. He died of hepatic failure 28 mo after TIPS.
基金Supported by National Natural Science Foundation of China under Grant No.81503437
文摘BACKGROUND Duodenal varices are a lesser-known complication with non-cirrhotic portal hypertension. We report a circuitous route from missed diagnosis of duodenal varices to correction. An extremely rare case of duodenal variceal bleeding secondary to idiopathic portal hypertension(IPH) is expounded in this study, which was controlled by transjugular intra-hepatic porto-systemic shunt(TIPS) plus embolization. CASE SUMMARY A 46-year-old woman with anemia for two years was frequently admitted to the local hospital. Upon examination, anemia was attributed to gastrointestinal tract bleeding, which resulted from duodenal variceal bleeding detected by repeated esophagogastroduodenoscopy. At the end of a complete workup, IPH leadingto duodenal varices was diagnosed. Portal venography revealed that the remarked duodenal varices originated from the proximal superior mesenteric vein. TIPS plus embolization with coils and Histoacryl was performed to obliterate the rupture of duodenal varices. The anemia resolved, and the duodenal varices completely vanished by 2 mo after the initial operation. CONCLUSION TIPS plus embolization may be more appropriate to treat the bleeding of large duodenal varices.
