Cirrhosis and bleeding: the need for very early management.
OBJECTIVE
Retrospective studies suggest that the prognosis of patients with cirrhosis and variceal hemorrhage has improved in more recent decades. In a prospective cohort study in which the choice of prophylactic therapy was left to each practitioner, we followed cirrhotic patients with medium/large varices to determine factors predictive of bleeding and death.


METHODS
Three hundred fourteen patients with grades 2 or 3 esophageal varices (Child A and B/C: 218 and 96) were enrolled. One hundred seventy-three patients had no previous history of variceal bleeding. Only 245 patients (100% of patients with prior variceal hemorrhage, 61% of patients without prior hemorrhage) were receiving some form of prophylactic therapy. The median follow-up was 18 months.


RESULTS
There were 76 bleeding events and 14 related deaths (18%); nine of these deaths occurred within 24 h of bleeding onset (two at home, two during hospital transfer, and five in hospital, a mean of 2.5 h after onset; six involved Child C patients). Twenty-five deaths were not due to bleeding but were closely related to cirrhosis. In a Cox model, the presence of tense ascites (relative risk 3.4, 95% confidence interval, CI 2.5-5.9) and a prior history of hemorrhage (relative risk 4.4, 95% CI 2.6-7.5) were independent predictors of variceal hemorrhage. In patients without a prior history of bleeding, bleeding risk was higher with more prolonged prothrombin time and lower when patients were receiving propranolol.


CONCLUSIONS
Despite the advent of effective drugs and endoscopic therapy for variceal bleeding, about a quarter of deaths occur very early after bleeding onset, confirming the need for rapid specific management.
Nidegger
Delphine
D
Institut de Santé Publique Faculté de Médecine de Poitiers, Poitiers, France.
Ragot
Stéphanie
S
Berthelémy
Philippe
P
Masliah
Claude
C
Pilette
Christophe
C
Martin
Thierry
T
Bianchi
Alain
A
Paupard
Thierry
T
Silvain
Christine
C
Beauchant
Michel
M
D000319:Adrenergic beta-Antagonists / Q000627:therapeutic use; D000328:Adult; D000368:Aged; D001201:Ascites / Q000209:etiology; D004311:Double-Blind Method; D004932:Esophageal and Gastric Varices / Q000150:complications*; D006471:Gastrointestinal Hemorrhage / Q000453:epidemiology / Q000401:mortality / Q000517:prevention & control*; D006801:Humans; D015994:Incidence; D008103:Liver Cirrhosis / Q000150:complications* / Q000401:mortality; D008499:Medical Records; D008875:Middle Aged; D011379:Prognosis; D016016:Proportional Hazards Models; D011433:Propranolol / Q000627:therapeutic use; D011517:Prothrombin Time; D012008:Recurrence; D012306:Risk
D000319:Adrenergic beta-Antagonists; D011433:Propranolol