Potential precipitating factors of esophageal variceal bleeding: a case-control study.
OBJECTIVE
Valsalva maneuver-associated activities such as straining during defecation, vomiting, and cough are believed to cause abrupt increase in variceal pressure. Whether these actions can precipitate rupture of esophageal varices (EV) is unknown. The association of EV bleeding with these activities and other potential risk factors such as ingestion of alcohol and non-steroidal anti-inflammatory drugs was investigated.


METHODS
Between January 2003 and May 2009, 240 patients with liver cirrhosis and acute EV bleeding (group A) and 240 matched patients with Child-Pugh's class and moderate size EV without bleeding (group B) were included. Each patient was questioned regarding constipation, vomiting, cough, and other potential risk factors in the week prior to index bleeding (group A) or endoscopy (group B) using a standard questionnaire.


RESULTS
Group A had more patients with constipation (n=44 vs. n=16, P<0.001) and higher constipation scores (0.79 ± 1.67 vs. 0.25 ± 0.92, P<0.001) than group B. Group A also had more patients with vomiting (n=60 vs. n=33, P=0.002) and higher vomiting scores (3.0 ± 0.86 vs. 1.85 ± 0.87, P<0.001). No difference in cough existed between the two groups (n=77 group A vs. n=73 group B); however, group A had higher cough scores (5.08 ± 2.70 vs. 3.19 ± 2.23, P<0.001). Group A had more patients with excessive alcohol consumption in the week preceding inclusion in the study (n=58 vs. n=5, P<0.001). On multivariate analysis, constipation score and vomiting score and alcohol consumption were independent determinants of first EV bleeding.


CONCLUSIONS
Constipation, vomiting, severe coughing, and excessive consumption of alcohol may precipitate rupture of EV. A prospective cohort study is required to clarify the causal relationship between potential precipitating factors and EV bleeding.
Liao
Wei-Chih
WC
Faculty of Medicine, School of Medicine, National Yang Ming University, Taipei, Taiwan.
Hou
Ming-Chih
MC
Chang
Chen-Jung
CJ
Lee
Fa-Yauh
FY
Lin
Han-Chieh
HC
Lee
Shou-Dong
SD
D017677:Age Distribution; D000368:Aged; D000428:Alcohol Drinking / Q000453:epidemiology; D000894:Anti-Inflammatory Agents, Non-Steroidal / Q000009:adverse effects / Q000627:therapeutic use; D016022:Case-Control Studies; D003248:Constipation / Q000175:diagnosis / Q000453:epidemiology*; D003371:Cough / Q000453:epidemiology*; D004932:Esophageal and Gastric Varices; D004945:Esophagoscopy / Q000379:methods; D005260:Female; D006471:Gastrointestinal Hemorrhage; D006801:Humans; D008103:Liver Cirrhosis / Q000175:diagnosis / Q000453:epidemiology* / Q000628:therapy; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D015985:Precipitating Factors; D011379:Prognosis; D012016:Reference Values; D018570:Risk Assessment; D012720:Severity of Illness Index; D017678:Sex Distribution; D013624:Taiwan / Q000453:epidemiology; D014839:Vomiting / Q000453:epidemiology*
D000894:Anti-Inflammatory Agents, Non-Steroidal