title: Rebleeding prophylaxis improves outcomes in patients with hepatocellular carcinoma. A multicenter case-control study.
abstract: Outcome of variceal bleeding (VB) in patients with hepatocellular carcinoma (HCC) is unknown. We compared outcomes after VB in patients with and without HCC. All patients with HCC and esophageal VB admitted between 2007 and 2010 were included. Follow-up was prolonged until death, transplantation, or June 2011. For each patient with HCC, a patient without HCC matched by age and Child-Pugh class was selected. A total of 292 patients were included, 146 with HCC (Barcelona Classification of Liver Cancer class 0-3 patients, A [in 25], B [in 29], C [in 45], and D [in 41]) and 146 without HCC. No differences were observed regarding previous use of prophylaxis, clinical presentation, endoscopic findings, and initial endoscopic treatment. Five-day failure was similar (25% in HCC versus 18% in non-HCC; P = 0.257). HCC patients had greater 6-week rebleeding rate (16 versus 7%, respectively; P = 0.025) and 6-week mortality (30% versus 15%; P = 0.003). Fewer patients with HCC received secondary prophylaxis after bleeding (77% versus 89%; P = 0.009), and standard combination therapy was used less frequently (58% versus 70%; P = 0.079). Secondary prophylaxis failure was more frequent (50% versus 31%; P = 0.001) and survival significantly shorter in patients with HCC (median survival: 5 months versus greater than 38 months in patients without HCC; P < 0.001). Lack of prophylaxis increased rebleeding and mortality. On multivariate analysis Child-Pugh score, presence of HCC, portal vein thrombosis, and lack of secondary prophylaxis were predictors of death.
  
  
  CONCLUSIONS
  Patients with HCC and VB have worse prognosis than patients with VB without HCC. Secondary prophylaxis offers survival benefit in HCC patients.
authors.affiliation: Servicio de Aparato Digestivo, Hospital Universitario Gregorio Marañón, IiSGM, CiberEHD, Universidad Complutense, Madrid, Spain.
authors.forename: Cristina
authors.initials: C
authors.lastname: Ripoll
authors.forename: Joan
authors.initials: J
authors.lastname: Genescà
authors.forename: Isis K
authors.initials: IK
authors.lastname: Araujo
authors.forename: Isabel
authors.initials: I
authors.lastname: Graupera
authors.forename: Salvador
authors.initials: S
authors.lastname: Augustin
authors.forename: Marta
authors.initials: M
authors.lastname: Tejedor
authors.forename: Isabel
authors.initials: I
authors.lastname: Cirera
authors.forename: Carles
authors.initials: C
authors.lastname: Aracil
authors.forename: Margarita
authors.initials: M
authors.lastname: Sala
authors.forename: Manuel
authors.initials: M
authors.lastname: Hernandez-Guerra
authors.forename: Elba
authors.initials: E
authors.lastname: Llop
authors.forename: Angels
authors.initials: A
authors.lastname: Escorsell
authors.forename: Maria Vega
authors.initials: MV
authors.lastname: Catalina
authors.forename: Nuria
authors.initials: N
authors.lastname: Cañete
authors.forename: Agustin
authors.initials: A
authors.lastname: Albillos
authors.forename: Càndid
authors.initials: C
authors.lastname: Villanueva
authors.forename: Juan G
authors.initials: JG
authors.lastname: Abraldes
authors.forename: Rafael
authors.initials: R
authors.lastname: Bañares
authors.forename: Jaime
authors.initials: J
authors.lastname: Bosch
mesh_terms: D000368:Aged; D006528:Carcinoma, Hepatocellular / Q000150:complications / Q000628:therapy*; D016022:Case-Control Studies; D004932:Esophageal and Gastric Varices / Q000150:complications* / Q000628:therapy*; D005260:Female; D006471:Gastrointestinal Hemorrhage / Q000401:mortality / Q000517:prevention & control* / Q000628:therapy*; D006801:Humans; D008113:Liver Neoplasms / Q000150:complications / Q000628:therapy*; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D011379:Prognosis; D012189:Retrospective Studies; D013030:Spain / Q000453:epidemiology