title: Effectiveness of combined pharmacologic and ligation therapy in high-risk patients with acute esophageal variceal bleeding.
abstract: OBJECTIVE
  After an acute variceal bleeding, early decision for aggressive management of patients with worse prognosis may improve outcomes. The effectiveness of currently recommended standard therapy (drugs plus endoscopic ligation) for different risk subgroups and the validity of available risk criteria in clinical practice are unknown.
  
  
  METHODS
  We analyzed data of 301 consecutive cirrhotic patients admitted with esophageal variceal bleeding. All patients received antibiotics, somatostatin, and in 263 early endoscopic therapy. A stratified 6-week mortality assessment according to risk (low-risk: Child-Pugh B without active bleeding or Child-Pugh A; high-risk: Child-Pugh B with active bleeding or Child-Pugh C) was performed. A multivariate analysis was conducted to elaborate a new risk classification rule.
  
  
  RESULTS
  Among the 162 patients receiving emergency ligation, 14% rebled and 16% died. Standard therapy was very effective in all risk strata, even in high-risk patients, specially if eligible for therapeutic trials (child <14, age ≤75 years, creatinine ≤3.0 mg/dl, no hepatocellular carcinoma, or portal thrombosis), showing this stratum a 10% mortality. In patients receiving ligation, Child-Pugh C patients with baseline creatinine <1.0 mg/dl showed similar mortality to Child-Pugh A or B patients (8% vs. 7%, respectively). Only Child-Pugh C patients with creatinine ≥1.0 were at a significant higher risk (Child-Pugh C: 46% mortality if creatinine ≥1.0 vs. 8% if creatinine <1.0, P=0.006).
  
  
  CONCLUSIONS
  The combination of somatostatin, antibiotics, and endoscopic ligation after an acute variceal bleeding in a real-life situation is associated with very low mortality. Child-Pugh C patients with baseline creatinine ≥1.0 mg/dl should be considered high-risk patients in this setting.
authors.affiliation: Liver Unit-Department of Internal Medicine, Universitat Autònoma de Barcelona, Spain. saugustin@vhebron.net
authors.forename: Salvador
authors.initials: S
authors.lastname: Augustin
authors.forename: José
authors.initials: J
authors.lastname: Altamirano
authors.forename: Antonio
authors.initials: A
authors.lastname: González
authors.forename: Joan
authors.initials: J
authors.lastname: Dot
authors.forename: Monder
authors.initials: M
authors.lastname: Abu-Suboh
authors.forename: Josep Ramón
authors.initials: JR
authors.lastname: Armengol
authors.forename: Fernando
authors.initials: F
authors.lastname: Azpiroz
authors.forename: Rafael
authors.initials: R
authors.lastname: Esteban
authors.forename: Jaime
authors.initials: J
authors.lastname: Guardia
authors.forename: Joan
authors.initials: J
authors.lastname: Genescà
mesh_terms: D000208:Acute Disease; D000328:Adult; D000368:Aged; D000900:Anti-Bacterial Agents / Q000627:therapeutic use*; D003131:Combined Modality Therapy / Q000379:methods; D004359:Drug Therapy, Combination; D004932:Esophageal and Gastric Varices / Q000150:complications*; D004945:Esophagoscopy; D005260:Female; D006471:Gastrointestinal Hemorrhage / Q000188:drug therapy* / Q000209:etiology / Q000401:mortality / Q000601:surgery*; D006801:Humans; D008026:Ligation; D016015:Logistic Models; D008297:Male; D008499:Medical Records; D008875:Middle Aged; D015999:Multivariate Analysis; D015203:Reproducibility of Results; D012107:Research Design; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D012720:Severity of Illness Index; D013004:Somatostatin / Q000627:therapeutic use*
chemical_list: D000900:Anti-Bacterial Agents; D013004:Somatostatin