Abstract
Background/aims
Despite secondary-prophylaxis with β-blockers and endoscopic-variceal-ligation rebleeding
is frequent, particularly within the first-6-weeks. Early-rebleeding may have greater
impact on death-risk than late rebleeding, which may affect therapy. We assessed whether
the influence of rebleeding on long-term survival of patients on secondary-prophylaxis
is greater in patients with early-rebleeding.
Methods
369 patients with cirrhosis were consecutively included once recovered from first
variceal-bleeding. The impact of rebleeding on survival was investigated according
to whether it occurred within 6-weeks (early-rebleeding) or later (late-rebleeding).
Results
During 46-months of follow-up (IQR: 14-61), 45 patients (12%) had early-rebleeding,
74(20%) had late-rebleeding and 250(68%) had not rebleeding. Mortality risk was higher
in early-rebleeding group vs. late-rebleeding (HR = 0.476, 95%CI = 0.318–0.712, p < 0.001) and was similar in late-rebleeding group vs. no-rebleeding (HR = 0.902,
95%CI = 0.749–1.086, p = 0.271). Adjusting for baseline risk-factors, early-rebleeding was independently
associated with mortality-risk (HR = 1.58, 95%CI = 1.02–2.45; p = 0.04). Child-Pugh&MELD scores improved at 3rd-4th-week only in patients without
early-rebleeding (p < 0.05). Presence of ascites or encephalopathy, MELD-score>12 and HVPG>20 mmHg identified
patients at risk of early-rebleeding.
Conclusions
Patients with early-rebleeding have higher risk of death than patients without rebleeding
and even than those rebleeding later. Our results suggest that patients at risk of
early rebleeding might benefit from preemptive therapies such as early-TIPS.
Keywords
Abbreviations:
AKI (acute kidney injury), ACLF (acute on chronic liver failure), CART (classification-and-regression-tree analysis), CI (confidence interval), EVL (endoscopic variceal ligation), HCC (Hepatocellular carcinoma), HR (hazard ratio), HVPG (hepatic venous pressure gradient), IQR (interquartile range), ISMN (Isosorbide Mononitrate), MELD (Model for End-Stage Liver Disease), NSBBs (non selective β-blockers), NPV (negative predictive value), OLT (orthotopic liver transplantation), PHT (portal hypertension), PPV (positive predictive value), RCT (randomized controlled trial), SBP (systolic blood pressure), TIPS (transjugular intrahepatic portosystemic shunt)To read this article in full you will need to make a payment
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Article info
Publication history
Published online: July 08, 2020
Accepted:
June 1,
2020
Received:
November 22,
2019
Identification
Copyright
© 2020 Editrice Gastroenterologica Italiana S.r.l. Published by Elsevier Ltd. All rights reserved.
