This document provides clinical practice guidelines for the management of acute variceal bleeding in Malaysia. It was developed by a committee of gastroenterologists, hepatologists, and surgeons based on a review of medical literature. The guidelines include recommendations for screening, primary and secondary prophylaxis, and treatment of acute bleeding for both esophageal and gastric varices. The recommendations are given a grade based on the level of evidence and are meant to assist healthcare professionals in managing variceal bleeding.
This document provides clinical practice guidelines for the management of acute variceal bleeding. It discusses the background of variceal bleeding, including that portal hypertension can lead to the development of gastroesophageal varices. For oesophageal varices, the risk of bleeding is highest within the first year after diagnosis and mortality from the first bleeding episode is high. It also notes gastric varices as a cause of upper gastrointestinal bleeding. The document was developed by a committee following a systematic review of evidence and consideration of local practice. It aims to provide evidence-based recommendations to guide clinicians in the evaluation and management of acute variceal bleeding.
NICE has accredited the process used by surgical specialty associations and Royal College of Surgeons to produce commissioning guidance for gallstone disease. The guidance provides a high value care pathway for gallstone disease management in both primary and secondary care. It outlines best practice referral guidelines from primary to secondary care and recommends treatment pathways including cholecystectomy for symptomatic gallstones and ERCP for common bile duct stones.
This document provides guidelines for the management of menorrhagia (heavy menstrual bleeding). It discusses definitions, assessment, investigation, and treatment options. Assessment involves evaluating blood loss, patterns, pelvic exam, blood counts, and endometrial assessment via ultrasound or biopsy. Treatment includes medical options like NSAIDs, hormones, and intrauterine devices, as well as surgical options like endometrial destruction or hysterectomy. The guidelines were created by an obstetrics and gynecology committee to aid doctors in clinical decision making for menorrhagia patients.
This document provides guidelines on appropriate use of common laboratory tests, including indications, non-indications, and minimum frequencies for re-testing. It covers topics in haematology, clinical chemistry, microbiology, and immunology. The guidelines aim to promote quality healthcare and ensure the highest clinical practice standards while reducing unnecessary testing.
C11 egyptian standards for diabetes mellitus 2009Diabetes for all
The document provides guidelines for diabetes care in Egypt created by a committee of Egyptian diabetes experts. It outlines recommendations for screening, diagnosing, classifying, preventing, and managing both type 1 and type 2 diabetes. The goals are to establish standards for clinical practice, treatment goals, and quality evaluation tools adapted for the Egyptian healthcare system and culture. An initial patient evaluation is recommended to assess family history, medical history, examine for complications, and create a personalized diabetes management plan. Lifestyle interventions including diet, exercise and weight loss are emphasized for prevention and treatment.
C11 egyptian standards for diabetes mellitus 2009Diabetes for all
This document provides an executive summary of the 2009 Egyptian Clinical Practice Recommendations for Diabetes Mellitus. It lists the coordinating and editing committee members who drafted the recommendations as well as other project participants. The recommendations are intended to provide clinicians, patients, and others involved in diabetes care with treatment goals and evaluation tools adapted for the Egyptian context. The recommendations are based on a review of international guidelines as well as primary literature sources, with adaptations made to suit Egypt's culture and resources. Classification, diagnostic criteria, and key points regarding diabetes diagnosis and prediabetes conditions are also summarized.
CPG Management of Chronic Kidney Disease (Second Edition) 2018.pdfssuser9e024e
This document provides guidelines for the management of chronic kidney disease in adults. It was developed by an expert group using a multidisciplinary approach and following international standards. Key recommendations include screening those at high risk for CKD, assessing kidney function using eGFR, treating hypertension and proteinuria, and referring patients for specialist care for advanced CKD or uncontrolled disease. The guidelines aim to support optimal clinical care and slow progression of CKD.
This document provides clinical practice guidelines for the management of acute variceal bleeding. It discusses the background of variceal bleeding, including that portal hypertension can lead to the development of gastroesophageal varices. For oesophageal varices, the risk of bleeding is highest within the first year after diagnosis and mortality from the first bleeding episode is high. It also notes gastric varices as a cause of upper gastrointestinal bleeding. The document was developed by a committee following a systematic review of evidence and consideration of local practice. It aims to provide evidence-based recommendations to guide clinicians in the evaluation and management of acute variceal bleeding.
NICE has accredited the process used by surgical specialty associations and Royal College of Surgeons to produce commissioning guidance for gallstone disease. The guidance provides a high value care pathway for gallstone disease management in both primary and secondary care. It outlines best practice referral guidelines from primary to secondary care and recommends treatment pathways including cholecystectomy for symptomatic gallstones and ERCP for common bile duct stones.
This document provides guidelines for the management of menorrhagia (heavy menstrual bleeding). It discusses definitions, assessment, investigation, and treatment options. Assessment involves evaluating blood loss, patterns, pelvic exam, blood counts, and endometrial assessment via ultrasound or biopsy. Treatment includes medical options like NSAIDs, hormones, and intrauterine devices, as well as surgical options like endometrial destruction or hysterectomy. The guidelines were created by an obstetrics and gynecology committee to aid doctors in clinical decision making for menorrhagia patients.
This document provides guidelines on appropriate use of common laboratory tests, including indications, non-indications, and minimum frequencies for re-testing. It covers topics in haematology, clinical chemistry, microbiology, and immunology. The guidelines aim to promote quality healthcare and ensure the highest clinical practice standards while reducing unnecessary testing.
C11 egyptian standards for diabetes mellitus 2009Diabetes for all
The document provides guidelines for diabetes care in Egypt created by a committee of Egyptian diabetes experts. It outlines recommendations for screening, diagnosing, classifying, preventing, and managing both type 1 and type 2 diabetes. The goals are to establish standards for clinical practice, treatment goals, and quality evaluation tools adapted for the Egyptian healthcare system and culture. An initial patient evaluation is recommended to assess family history, medical history, examine for complications, and create a personalized diabetes management plan. Lifestyle interventions including diet, exercise and weight loss are emphasized for prevention and treatment.
C11 egyptian standards for diabetes mellitus 2009Diabetes for all
This document provides an executive summary of the 2009 Egyptian Clinical Practice Recommendations for Diabetes Mellitus. It lists the coordinating and editing committee members who drafted the recommendations as well as other project participants. The recommendations are intended to provide clinicians, patients, and others involved in diabetes care with treatment goals and evaluation tools adapted for the Egyptian context. The recommendations are based on a review of international guidelines as well as primary literature sources, with adaptations made to suit Egypt's culture and resources. Classification, diagnostic criteria, and key points regarding diabetes diagnosis and prediabetes conditions are also summarized.
CPG Management of Chronic Kidney Disease (Second Edition) 2018.pdfssuser9e024e
This document provides guidelines for the management of chronic kidney disease in adults. It was developed by an expert group using a multidisciplinary approach and following international standards. Key recommendations include screening those at high risk for CKD, assessing kidney function using eGFR, treating hypertension and proteinuria, and referring patients for specialist care for advanced CKD or uncontrolled disease. The guidelines aim to support optimal clinical care and slow progression of CKD.
Clinical Practice Guideline on management of patients with diabetes and chron...Ahmed Albeyaly
This document provides a summary of a clinical practice guideline on managing patients with diabetes and chronic kidney disease (CKD) stage 3b or higher. It outlines the composition of the guideline development group, which included nephrologists, endocrinologists, and epidemiologists from several European countries. The group aimed to provide guidance on evidence-based approaches to improve care for this patient population. The guideline's target audience is healthcare professionals treating adults with both diabetes and reduced kidney function (eGFR <45 mL/min). It focuses on developing standards of care for managing this complex patient group.
The role of ercp in diseases of the biliary tract and pancreasThorsang Chayovan
This document provides guidelines from the American Society for Gastrointestinal Endoscopy (ASGE) on the role of endoscopic retrograde cholangiopancreatography (ERCP) in diseases of the biliary tract and pancreas. It was developed using an evidence-based methodology including a literature review. The guidelines are intended to apply to all physicians performing GI endoscopy. ERCP is described as useful for diagnosing and treating conditions like gallstones, biliary strictures, pancreatic disease, and leaks or injuries to the biliary tract. Outcomes of ERCP for various conditions are discussed along with appropriate patient selection and techniques.
Dr. Niranjan Chavan presented on an obstetrics sepsis bundle approach. Maternal sepsis is a leading cause of maternal mortality worldwide. Early screening and treatment is key to managing sepsis. The sepsis bundle approach involves completing 6 tasks within 1 hour of diagnosis: administering oxygen, collecting cultures, giving antibiotics, fluid resuscitation, measuring lactate levels, and monitoring urine output. Additional treatment may include source control, vasopressors, corticosteroids, DVT prophylaxis, and determining whether delivery is necessary based on maternal and fetal status. With rapid identification and treatment, the sepsis bundle approach can help reduce mortality from this life-threatening condition.
A well-organized endoscopy unit with trained staff is essential for good endoscopic practice and training. The unit should have processes for ongoing competency assessment, skills training, and data management. Endoscopes must be thoroughly decontaminated between uses to prevent infection transmission using either sterilization or high-level disinfection depending on the device. Both diagnostic and therapeutic endoscopy can have risks such as perforation, bleeding, infection, and sedation complications, so appropriate patient selection and safety protocols are important.
Gout Summery Updated 2020 American College Of Rheumatology Guideline Wafa sheikh
- Gout is caused by urate crystal deposition and causes sudden painful inflammation, often in the big toe.
- Diagnosis is usually clinical based on symptoms and elevated uric acid levels. Treatment involves medications to reduce uric acid like allopurinol or febuxostat as well as anti-inflammatory drugs.
- The guidelines recommend a treat-to-target strategy, gradually increasing urate-lowering drugs to reach a target uric acid level of less than 6 mg/dl to prevent gout attacks.
General surgery treatment guidelines Govt of India Dr Jitu Lal Meena
1. The document provides guidelines for the treatment of blunt abdominal trauma and cholecystectomy.
2. For blunt abdominal trauma, the guidelines recommend initial resuscitation and stabilization of patients. For diagnosis, focused abdominal sonography or diagnostic peritoneal lavage are suggested. For treatment, laparotomy is indicated for hemodynamically unstable patients or those with evidence of injury on investigations.
3. For cholecystectomy, the guidelines discuss the indications including symptomatic gallstone disease and complications. The optimal investigations and surgical techniques are provided for both open and laparoscopic approaches. Referral criteria and post-operative care are also outlined.
This document provides 15 pieces of best practice advice for the management of pancreatic necrosis based on a review of the available evidence and expert recommendations. Some key points include:
1) Management of pancreatic necrosis requires a multidisciplinary approach including gastroenterologists, surgeons, radiologists and other specialists.
2) Antibiotics are recommended for confirmed infected necrosis but prophylactic antibiotics are not recommended.
3) Early enteral nutrition via oral, nasogastric or nasojejunal tubes is preferred to total parenteral nutrition to reduce risks of infection and other complications.
4) Drainage and/or debridement of infected or symptomatic necrosis is indicated but should be performed minimally invasively where possible
Discussion of the current medications of chronic hepatitis treatment in the Egyptian market as well as our protocol of management in the Viral Hepatitis Treatment Centers in Egypt. Discussion of the latest recommendations of AASLD/IDSA and EASL are presented
The care of patients with chronic leg ulcerGNEAUPP.
The document provides guidelines for the assessment and treatment of patients with chronic leg ulcers. It discusses the importance of thoroughly assessing the patient, leg, and ulcer characteristics. This includes measuring ankle brachial pressure, ulcer size, edge and base description, and position. It recommends referring patients with certain features such as diabetes, arterial disease, rheumatoid arthritis, suspected malignancy, atypical ulcers, or non-healing ulcers. For treatment, it emphasizes using graduated compression therapy to improve venous insufficiency and heal uncomplicated venous ulcers. Elastic compression is the first choice treatment, and multilayer bandaging is recommended.
This guideline from the Royal College of Obstetricians and Gynaecologists and the British Society for Gynaecological Endoscopy provides recommendations for the management of endometrial hyperplasia. It discusses risk factors, classification, diagnostic methods, and treatment approaches for both hyperplasia without atypia and atypical hyperplasia. Surgical and medical management options are presented, along with recommendations for treatment duration and follow-up.
The National Confidential Enquiry into Peri-operative Deaths (NCEPOD) was established in the UK in 1988 to comprehensively and authoritatively review clinical practice surrounding deaths within 30 days of surgery. NCEPOD aims to maintain and improve standards of care for both adults and children through confidential case reviews, research, and publishing results. The National Early Warning Score (NEWS) is an excellent initiative that helps staff recognize patient deterioration earlier through standardized scoring of physiological parameters, enabling sicker patients to receive timely intensive care.
Revised guidelines for management of antenatal hydronephrosis feb 2013mandar haval
This document revises guidelines from 2000 on the management of antenatally detected hydronephrosis (ANH). It recommends grading ANH based on renal pelvic diameter measured on ultrasound. For unilateral ANH, it recommends at least one follow up ultrasound in the third trimester. For bilateral ANH, it suggests frequent monitoring depending on severity. It also recommends evaluating for other anomalies and referring high-risk cases. Postnatally, it recommends ultrasound and further testing for those with diameters over 10mm or Society of Fetal Urology grade 3-4 to screen for issues like reflux or obstruction. It provides guidance on treatments like antibiotics or surgery depending on the condition. The guidelines aim to distinguish cases needing long
This document provides guidance on managing dyspepsia in adults in primary care. It recommends:
- Urgent specialist referral for patients with alarm symptoms like bleeding or weight loss.
- Considering endoscopy for patients over 55 if symptoms persist after testing and treating H. pylori.
- Providing initial treatment with a PPI or testing/treating H. pylori for uninvestigated dyspepsia. Long-term management involves annual reviews and stepping down treatment when possible.
De-challenge and rechallenge are terms used in pharmacovigilance to describe the occurrence and recurrence of adverse drug reactions (ADRs) in relation to the administration of a particular drug.
De-challenge refers to the cessation or reduction of symptoms or adverse events after discontinuation or reduction of the drug. In other words, de-challenge occurs when the patient's symptoms improve or disappear once the drug is stopped or the dose is reduced. A positive de-challenge suggests that the drug was likely the cause of the adverse event.
Rechallenge, on the other hand, occurs when the patient's symptoms or adverse events recur after the drug is reintroduced. In other words, rechallenge occurs when the patient experiences the same symptoms or adverse events after the drug is given again. A positive rechallenge suggests a strong likelihood that the drug is the cause of the adverse event.
De-challenge and rechallenge are important components of causality assessment, which is the process of determining whether a particular drug or medical intervention is the cause of an adverse event or reaction that has occurred in a patient. De-challenge and rechallenge data can provide valuable information to help assess the likelihood of a causal relationship between the drug and the adverse event.
However, it is important to note that de-challenge and rechallenge data should be interpreted cautiously and in the context of other factors such as temporal relationship, biological plausibility, and alternative explanations. A positive de-challenge or rechallenge does not necessarily indicate a causal relationship between the drug and the adverse event, but rather provides additional evidence to support or refute the likelihood of such a relationship.
A prospective randomized controlled trial assessing the efficacy of omentopex...Ricky Costa
This study aimed to assess whether attaching the omentum (fatty tissue) to the stomach during laparoscopic sleeve gastrectomy (LSG) surgery could help reduce post-operative gastrointestinal (GI) symptoms like nausea and vomiting. The study involved 60 patients undergoing LSG who were randomly assigned to either have LSG alone or LSG with omentopexy. Patients completed surveys assessing GI symptoms at several time points after surgery. The study found that attaching the omentum did not significantly reduce post-operative GI symptoms or food intolerance compared to LSG alone. Patients with omentopexy did require more anti-nausea medication initially but had no difference in other outcomes. The study concludes that
Self-Expandable Metal Stents for the Management of Gastric Outlet Obstruction...JohnJulie1
Gastric outlet obstruction is commonly considered as advanced malignancies of the stomach, duodenum, pancreas, hepatobiliary, and ampullary regions. Surgical bypass and chemotherapy are the common treatment modalities for gastric obstruction. This study was done to determine the outcomes of self-expandable metal stents in patients with gastric outlet obstruction.
Self-Expandable Metal Stents for the Management of Gastric Outlet Obstruction...JapaneseJournalofGas
Gastric outlet obstruction is commonly considered as advanced malignancies of the stomach, duodenum, pancreas, hepatobiliary, and ampullary regions. Surgical bypass and chemotherapy are the common treatment modalities for gastric obstruction. This study was done to determine the outcomes of self-expandable metal stents in patients with gastric outlet obstruction.
7th Middle East Gastroenterology ConferenceCheryl Prior
The 7th Middle East Gastroenterology Conference will provide a forum for all gastroenterologists, internal medicine specialists and haepatologists within the region to exchange ideas, discuss innovative methods and review new developments within the field of gastroenterology.
Topics within this year’s conference programme have been carefully selected to address the gaps in knowledge of gastroenterologists within the region. The program addresses the hottest topics within hepatology, liver surgery, inflammatory bowel disease, endoscopy and gastroenterology. With a particular focus on hepatitis B and C, as well as new medications on the market and innovative surgical techniques.
With an eclectic mix of international and regional speakers and an exciting new programme format, including interactive panel discussions and case presentations, the 7th edition of this conference is not to be missed.
The document provides guidelines from the World Health Organization (WHO) on preventing surgical site infections (SSIs). It discusses 29 recommendations across pre-operative, intra-operative, and post-operative periods. Some key recommendations include using chlorhexidine for skin preparation, mupirocin ointment for nasal carriers of Staphylococcus aureus, appropriate timing of pre-operative antibiotics, and not prolonging antibiotics post-operatively. The guidelines are informed by evidence reviews on topics related to reducing SSI risk and aim to provide guidance based on strength and quality of evidence.
This document provides guidance for obtaining informed consent from women undergoing diagnostic laparoscopy. It discusses the risks and benefits of the procedure, including both serious but rare risks like damage to internal organs, as well as more common but mild risks like bruising or shoulder pain. It recommends discussing any additional procedures that may become necessary during surgery. The goal of diagnostic laparoscopy is to identify the cause of a woman's symptoms, though it may not always provide a clear diagnosis.
As Mumbai's premier kidney transplant and donation center, L H Hiranandani Hospital Powai is not just a medical facility; it's a beacon of hope where cutting-edge science meets compassionate care, transforming lives and redefining the standards of kidney health in India.
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Clinical Practice Guideline on management of patients with diabetes and chron...Ahmed Albeyaly
This document provides a summary of a clinical practice guideline on managing patients with diabetes and chronic kidney disease (CKD) stage 3b or higher. It outlines the composition of the guideline development group, which included nephrologists, endocrinologists, and epidemiologists from several European countries. The group aimed to provide guidance on evidence-based approaches to improve care for this patient population. The guideline's target audience is healthcare professionals treating adults with both diabetes and reduced kidney function (eGFR <45 mL/min). It focuses on developing standards of care for managing this complex patient group.
The role of ercp in diseases of the biliary tract and pancreasThorsang Chayovan
This document provides guidelines from the American Society for Gastrointestinal Endoscopy (ASGE) on the role of endoscopic retrograde cholangiopancreatography (ERCP) in diseases of the biliary tract and pancreas. It was developed using an evidence-based methodology including a literature review. The guidelines are intended to apply to all physicians performing GI endoscopy. ERCP is described as useful for diagnosing and treating conditions like gallstones, biliary strictures, pancreatic disease, and leaks or injuries to the biliary tract. Outcomes of ERCP for various conditions are discussed along with appropriate patient selection and techniques.
Dr. Niranjan Chavan presented on an obstetrics sepsis bundle approach. Maternal sepsis is a leading cause of maternal mortality worldwide. Early screening and treatment is key to managing sepsis. The sepsis bundle approach involves completing 6 tasks within 1 hour of diagnosis: administering oxygen, collecting cultures, giving antibiotics, fluid resuscitation, measuring lactate levels, and monitoring urine output. Additional treatment may include source control, vasopressors, corticosteroids, DVT prophylaxis, and determining whether delivery is necessary based on maternal and fetal status. With rapid identification and treatment, the sepsis bundle approach can help reduce mortality from this life-threatening condition.
A well-organized endoscopy unit with trained staff is essential for good endoscopic practice and training. The unit should have processes for ongoing competency assessment, skills training, and data management. Endoscopes must be thoroughly decontaminated between uses to prevent infection transmission using either sterilization or high-level disinfection depending on the device. Both diagnostic and therapeutic endoscopy can have risks such as perforation, bleeding, infection, and sedation complications, so appropriate patient selection and safety protocols are important.
Gout Summery Updated 2020 American College Of Rheumatology Guideline Wafa sheikh
- Gout is caused by urate crystal deposition and causes sudden painful inflammation, often in the big toe.
- Diagnosis is usually clinical based on symptoms and elevated uric acid levels. Treatment involves medications to reduce uric acid like allopurinol or febuxostat as well as anti-inflammatory drugs.
- The guidelines recommend a treat-to-target strategy, gradually increasing urate-lowering drugs to reach a target uric acid level of less than 6 mg/dl to prevent gout attacks.
General surgery treatment guidelines Govt of India Dr Jitu Lal Meena
1. The document provides guidelines for the treatment of blunt abdominal trauma and cholecystectomy.
2. For blunt abdominal trauma, the guidelines recommend initial resuscitation and stabilization of patients. For diagnosis, focused abdominal sonography or diagnostic peritoneal lavage are suggested. For treatment, laparotomy is indicated for hemodynamically unstable patients or those with evidence of injury on investigations.
3. For cholecystectomy, the guidelines discuss the indications including symptomatic gallstone disease and complications. The optimal investigations and surgical techniques are provided for both open and laparoscopic approaches. Referral criteria and post-operative care are also outlined.
This document provides 15 pieces of best practice advice for the management of pancreatic necrosis based on a review of the available evidence and expert recommendations. Some key points include:
1) Management of pancreatic necrosis requires a multidisciplinary approach including gastroenterologists, surgeons, radiologists and other specialists.
2) Antibiotics are recommended for confirmed infected necrosis but prophylactic antibiotics are not recommended.
3) Early enteral nutrition via oral, nasogastric or nasojejunal tubes is preferred to total parenteral nutrition to reduce risks of infection and other complications.
4) Drainage and/or debridement of infected or symptomatic necrosis is indicated but should be performed minimally invasively where possible
Discussion of the current medications of chronic hepatitis treatment in the Egyptian market as well as our protocol of management in the Viral Hepatitis Treatment Centers in Egypt. Discussion of the latest recommendations of AASLD/IDSA and EASL are presented
The care of patients with chronic leg ulcerGNEAUPP.
The document provides guidelines for the assessment and treatment of patients with chronic leg ulcers. It discusses the importance of thoroughly assessing the patient, leg, and ulcer characteristics. This includes measuring ankle brachial pressure, ulcer size, edge and base description, and position. It recommends referring patients with certain features such as diabetes, arterial disease, rheumatoid arthritis, suspected malignancy, atypical ulcers, or non-healing ulcers. For treatment, it emphasizes using graduated compression therapy to improve venous insufficiency and heal uncomplicated venous ulcers. Elastic compression is the first choice treatment, and multilayer bandaging is recommended.
This guideline from the Royal College of Obstetricians and Gynaecologists and the British Society for Gynaecological Endoscopy provides recommendations for the management of endometrial hyperplasia. It discusses risk factors, classification, diagnostic methods, and treatment approaches for both hyperplasia without atypia and atypical hyperplasia. Surgical and medical management options are presented, along with recommendations for treatment duration and follow-up.
The National Confidential Enquiry into Peri-operative Deaths (NCEPOD) was established in the UK in 1988 to comprehensively and authoritatively review clinical practice surrounding deaths within 30 days of surgery. NCEPOD aims to maintain and improve standards of care for both adults and children through confidential case reviews, research, and publishing results. The National Early Warning Score (NEWS) is an excellent initiative that helps staff recognize patient deterioration earlier through standardized scoring of physiological parameters, enabling sicker patients to receive timely intensive care.
Revised guidelines for management of antenatal hydronephrosis feb 2013mandar haval
This document revises guidelines from 2000 on the management of antenatally detected hydronephrosis (ANH). It recommends grading ANH based on renal pelvic diameter measured on ultrasound. For unilateral ANH, it recommends at least one follow up ultrasound in the third trimester. For bilateral ANH, it suggests frequent monitoring depending on severity. It also recommends evaluating for other anomalies and referring high-risk cases. Postnatally, it recommends ultrasound and further testing for those with diameters over 10mm or Society of Fetal Urology grade 3-4 to screen for issues like reflux or obstruction. It provides guidance on treatments like antibiotics or surgery depending on the condition. The guidelines aim to distinguish cases needing long
This document provides guidance on managing dyspepsia in adults in primary care. It recommends:
- Urgent specialist referral for patients with alarm symptoms like bleeding or weight loss.
- Considering endoscopy for patients over 55 if symptoms persist after testing and treating H. pylori.
- Providing initial treatment with a PPI or testing/treating H. pylori for uninvestigated dyspepsia. Long-term management involves annual reviews and stepping down treatment when possible.
De-challenge and rechallenge are terms used in pharmacovigilance to describe the occurrence and recurrence of adverse drug reactions (ADRs) in relation to the administration of a particular drug.
De-challenge refers to the cessation or reduction of symptoms or adverse events after discontinuation or reduction of the drug. In other words, de-challenge occurs when the patient's symptoms improve or disappear once the drug is stopped or the dose is reduced. A positive de-challenge suggests that the drug was likely the cause of the adverse event.
Rechallenge, on the other hand, occurs when the patient's symptoms or adverse events recur after the drug is reintroduced. In other words, rechallenge occurs when the patient experiences the same symptoms or adverse events after the drug is given again. A positive rechallenge suggests a strong likelihood that the drug is the cause of the adverse event.
De-challenge and rechallenge are important components of causality assessment, which is the process of determining whether a particular drug or medical intervention is the cause of an adverse event or reaction that has occurred in a patient. De-challenge and rechallenge data can provide valuable information to help assess the likelihood of a causal relationship between the drug and the adverse event.
However, it is important to note that de-challenge and rechallenge data should be interpreted cautiously and in the context of other factors such as temporal relationship, biological plausibility, and alternative explanations. A positive de-challenge or rechallenge does not necessarily indicate a causal relationship between the drug and the adverse event, but rather provides additional evidence to support or refute the likelihood of such a relationship.
A prospective randomized controlled trial assessing the efficacy of omentopex...Ricky Costa
This study aimed to assess whether attaching the omentum (fatty tissue) to the stomach during laparoscopic sleeve gastrectomy (LSG) surgery could help reduce post-operative gastrointestinal (GI) symptoms like nausea and vomiting. The study involved 60 patients undergoing LSG who were randomly assigned to either have LSG alone or LSG with omentopexy. Patients completed surveys assessing GI symptoms at several time points after surgery. The study found that attaching the omentum did not significantly reduce post-operative GI symptoms or food intolerance compared to LSG alone. Patients with omentopexy did require more anti-nausea medication initially but had no difference in other outcomes. The study concludes that
Self-Expandable Metal Stents for the Management of Gastric Outlet Obstruction...JohnJulie1
Gastric outlet obstruction is commonly considered as advanced malignancies of the stomach, duodenum, pancreas, hepatobiliary, and ampullary regions. Surgical bypass and chemotherapy are the common treatment modalities for gastric obstruction. This study was done to determine the outcomes of self-expandable metal stents in patients with gastric outlet obstruction.
Self-Expandable Metal Stents for the Management of Gastric Outlet Obstruction...JapaneseJournalofGas
Gastric outlet obstruction is commonly considered as advanced malignancies of the stomach, duodenum, pancreas, hepatobiliary, and ampullary regions. Surgical bypass and chemotherapy are the common treatment modalities for gastric obstruction. This study was done to determine the outcomes of self-expandable metal stents in patients with gastric outlet obstruction.
7th Middle East Gastroenterology ConferenceCheryl Prior
The 7th Middle East Gastroenterology Conference will provide a forum for all gastroenterologists, internal medicine specialists and haepatologists within the region to exchange ideas, discuss innovative methods and review new developments within the field of gastroenterology.
Topics within this year’s conference programme have been carefully selected to address the gaps in knowledge of gastroenterologists within the region. The program addresses the hottest topics within hepatology, liver surgery, inflammatory bowel disease, endoscopy and gastroenterology. With a particular focus on hepatitis B and C, as well as new medications on the market and innovative surgical techniques.
With an eclectic mix of international and regional speakers and an exciting new programme format, including interactive panel discussions and case presentations, the 7th edition of this conference is not to be missed.
The document provides guidelines from the World Health Organization (WHO) on preventing surgical site infections (SSIs). It discusses 29 recommendations across pre-operative, intra-operative, and post-operative periods. Some key recommendations include using chlorhexidine for skin preparation, mupirocin ointment for nasal carriers of Staphylococcus aureus, appropriate timing of pre-operative antibiotics, and not prolonging antibiotics post-operatively. The guidelines are informed by evidence reviews on topics related to reducing SSI risk and aim to provide guidance based on strength and quality of evidence.
This document provides guidance for obtaining informed consent from women undergoing diagnostic laparoscopy. It discusses the risks and benefits of the procedure, including both serious but rare risks like damage to internal organs, as well as more common but mild risks like bruising or shoulder pain. It recommends discussing any additional procedures that may become necessary during surgery. The goal of diagnostic laparoscopy is to identify the cause of a woman's symptoms, though it may not always provide a clear diagnosis.
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Management of Acute Variceal Bleeding 2007.pdf
1. CLINICAL PRACTICE GUIDELINES
MANAGEMENT
OF
ACUTE VARICEAL
BLEEDING
May 2007 MOH/P/PAK/125.07 (GU)
MINISTRY OF HEALTH
MALAYSIA
BERSATU•BERUSAHA•BERBAKTI•
ACADEMY OF MEDICINE
OF MALAYSIA
MALAYSIAN SOCIETY OF
GASTROENTEROLOGY
AND HEPATOLOGY
2. Statement of Intent
This clinical practice guideline is meant to be a guide for clinical
practice, based on the best available evidence at the time of
development. Adherence to these guidelines may not necessarily
ensure the best outcome in every case. Every health care provider
is responsible for the management of his/her unique patient based
on the clinical picture presented by the patient and the management
options available locally.
Review of the Guidelines
This guideline was issued in May 2007 and will be reviewed in 2010
or sooner if new evidence becomes available.
CPG Secretariat
c/o Health Technology Assessment Unit
Medical Development Division
Ministry of Health Malaysia
Level 4, Block E1, Parcel E,
Government Office Complex,
62590 Putrajaya.
Available on the following website : http//www.moh.gov.my
http://www.acadmed.org.my
http://www.msgh.org.my
3. GUIDELINE DEVELOPMENT AND OBJECTIVE
GUIDELINE DEVELOPMENT
The clinical practice guidelines on the management of acute variceal bleeding
was developed by a team of gastroenterologists, a hepatologist and a surgeon.
The information sources and search was carried out using PubMed, Ovid and
other search engines using ‘variceal bleeding’, ‘oesophageal varices’, ‘gastric
varices’, ‘variceal bleeding AND therapy’, ‘variceal bleeding AND prophylaxis’
as keywords and included not only randomised clinical trials or meta-analyses,
but also other relevant articles. The recommendations were formulated based
on a systematic review of current medical literature, taking into consideration
local practice and feedbacks from members of MSGH, general practitioners,
physicians and general surgeons during the Annual Scientific Meeting and the
MSGH Clinical meeting. Where there is lack of evidence, the recommendation
was based on expert opinions, and adapting other international guidelines on
Acute Variceal Bleeding and the Proceedings of the Fourth Baveno International
Consensus Workshop on Portal Hypertension.
The draft guideline was posted on the Ministry of Health Malaysia website for
comment and feedback. This guideline has also been presented to the Technical
Advisory Committee for Clinical Practice Guidelines, and the Health Technology
Assessment and Clinical Practice Guidelines Council, Ministry of Health
Malaysia for review and approval.
OBJECTIVE
The main objective of this guideline is to present evidence-based
recommendations to assist health care professionals in the management of
acute variceal bleeding and not meant as a comprehensive overview of all
aspects of variceal bleeding.
i
4. CLINICAL QUESTIONS
z Could morbidity and mortality associated with acute variceal bleeding be
reduced with proper evaluation?
z How can patients with acute variceal bleeding be managed successfully?
TARGET POPULATION
These guidelines are applicable to patients presenting with acute upper
gastrointestinal bleeding due to oesophageal or gastric varices.
TARGET GROUP/USER
These guidelines are developed for all health care professionals involved in
the evaluation and management of cases with acute variceal bleeding, including
general physicians and general surgeons.
ii
5. GUIDELINE DEVELOPMENT COMMITTEE
CHAIRPERSON :
Professor Rosmawati Mohamed
Consultant Hepatologist and Deputy Dean (Research)
Faculty of Medicine
University Malaya
Kuala Lumpur
PANEL MEMBERS :
Dr. Jason Chin
Consultant Gastroenterologist
Gleneagles Intan Medical Centre
Kuala Lumpur
Dr. Robert Ding
Consultant Gastroenterologist
Island Hospital
Penang
Dr. Ryan Ponnudurai
Consultant Gastroenterologist
Selayang Hospital
Kuala Lumpur
Dr. Sharmila Sachithanandan
Consultant Gastroenterologist
Selayang Hospital
Kuala Lumpur
Mr. Harjit Singh
Consultant Hepatobiliary Surgeon
Selayang Hospital
Kuala Lumpur
Dr. Tan Soon Seng
Consultant Gastroenterologist
Subang Jaya Medical Centre
Selangor
iii
6. EXTERNAL REVIEWERS
Dr. Jayaram Menon
Consultant Gastroenterologist & Head
Department of Medicine
Queen Elizabeth Hospital
Kota Kinabalu
Dr. Tan Soek Siam
Consultant Hepatologist
Selayang Hospital
Kuala Lumpur
Mr. Andrew Gunn
Consultant Surgeon & Head
Department of Surgery
Hospital Sultanah Aminah
Johor Bahru
Mr. Abdul Hamid Mat Saim
Consultant Surgeon
Columbia Asia Medical Centre
Seremban
Dr. Soon Su Yang
Consultant Gastroenterologist
University Malaysia Sarawak
Sarawak
Dr. Lakshumanan Sanker V
Consultant Hepatologist
Selangor Medical Centre
Selangor
iv
7. SUMMARY OF RECOMMENDATIONS
RECOMMENDATIONS GRADE
SCREENING
Screening endoscopy at the time of diagnosis of cirrhosis Grade C
and every 2 years in patients not known to have varices
OESOPHAGEAL VARICES
PRIMARY PROPHYLAXIS (of first variceal bleeding)
Patients with Grade 1 or small varices should not receive Grade C
primary prophylactic therapy but be screened for enlargement
of varices every 1-2 years
Patients with large varices (Grade 3) or medium varices Grade A
(Grade 2) with endoscopic red signs or Child’s C
cirrhosis should be treated
Non-selective beta-blockers or endoscopic variceal ligation Grade A
reduce the risk of index variceal bleeding. Non-selective
beta-blockers is the best available modality for primary
prophylaxis at present (survival benefit and cost-effective)
MANAGEMENT OF ACUTE OESOPHAGEAL VARICEAL BLEEDING
Patients should be referred to and treated in units where Grade C
staff are familiar with the management and the therapeutic
interventions to be performed
Resuscitation Grade C
• Haemodynamic monitoring, large bore IV line or
central venous access
• Blood: group and cross-matched
• Correct coagulopathy
• Consider intubation for airway protection if severe
uncontrollable bleeding, encephalopathic, inability
to maintain O2
saturation adequately and to prevent aspiration
• ICU bed and facilities should be made available
Institute pharmacotherapy Grade A
• IV Terlipressin/Octreotide/Somatostatin for 2-5 days to prevent
early rebleeding
• Terlipressin: 2mg bolus and 1mg every 6 hours for 2-5 days.
• Somatostatin: 250mcg bolus followed by 250mcg/hour infusion
for 5 days
• Octreotide: 50mcg bolus followed by 50mcg/hour for 5 days
v
8. Antibiotic prophylaxis in patients with cirrhosis Grade A
• Antibiotic treatment should be continued for 7 days
• Norfloxacin 400mg bd
OR Ciprofloxacin 500mg bd
OR IV 200mg bd
OR Third generation cephalosporins (e.g. Ceftriaxone 1g daily)
Upper GI Endoscopy
• As soon as possible Grade C
• If endoscopy is unavailable and there is presence of active Grade C
bleeding, consider balloon tamponade and referral to tertiary centre
Control of Bleeding
• Endoscopic variceal ligation (EVL) is recommended; Grade A
endoscopic sclerotherapy can be used if EVL is technically difficult
Persistent Active Bleeding
• Consider repeating endoscopy, TIPS or surgical intervention Grade B
• Balloon tamponade may be considered Grade C
SECONDARY PROPHYLAXIS
Non-selective beta-blockers, EVL or both should be used. Grade A
However, beta-blockers and EVL are the treatment of first choice
TIPS or shunt surgery if non-compliant or refractory to Grade B
pharmacological and/or endoscopic therapy
GASTRIC VARICES
Gastro-oesophageal varices Type 1
• Treat as for oesophageal varices Grade B
Gastro-oesophageal varices Type 2 and isolated gastric varices
• For acute bleeding: injection with cyanoacrylate Grade A
If persistent active bleeding
• TIPS or surgical intervention Grade B
• Balloon tamponade should be considered Grade C
Secondary prophylaxis
• Beta-blockers, injection with cyanoacrylate or TIPS Grade B
vi
9. TABLE OF CONTENTS
GUIDELINE DEVELOPMENT AND OBJECTIVE i
GUIDELINE DEVELOPMENT COMMITTEE iii
SUMMARY OF RECOMMENDATIONS v
1. INTRODUCTION 1
2. BACKGROUND 1
2.1 Oesophageal Varices 1
2.2 Gastric Varices 3
3. PRIMARY PROPHYLAXIS 4
3.1 Oesophageal Varices 4
3.1.1 Pharmacological Therapy for Oesophageal Varices 4
3.1.2 Endoscopic Therapy for Oesophageal Varices 5
3.2 Gastric Varices 6
4. SCREENING ENDOSCOPY 6
5. MANAGEMENT OF ACUTE VARICEAL BLEEDING 7
5.1 General Management 7
5.2 Antibiotics in Acute Variceal Bleeding 7
5.3 Pharmacological Therapy for Acute Variceal Bleeding 8
6. MANAGEMENT OF OESOPHAGEAL VARICEAL BLEEDING 9
6.1 Endoscopic Therapy 9
6.2 Balloon Tamponade 10
6.3 Transjugular Intrahepatic Portosystemic Shunts (TIPS) 10
6.4 Surgical Therapy 10
6.5 Secondary Prophylaxis 11
6.5.1 Pharmacological Therapy 11
6.5.2 Endoscopic Therapy 11
6.5.3 Combination of Pharmacological and Endoscopic Therapy 12
6.5.4 Transjugular Intrahepatic Portosystemic Shunts (TIPS) 13
6.5.5 Surgical Therapy 13
7. MANAGEMENT OF ACUTE GASTRIC VARICEAL BLEEDING 14
7.1 Gastro-Oesophageal Varices (GOV) Type 1 14
7.2 Gastro-Oesophageal Varices (GOV) Type 2 and
Isolated Gastric Varices (IGV) 14
7.2.1 Endoscopic Therapy 14
7.2.2 Balloon Tamponade 14
7.2.3 Transjugular Intrahepatic Portosystemic Shunts (TIPS) 14
7.2.4 Secondary Prophylaxis 15
8. CONCLUSION 15
ALGORITHMS 16
REFERENCE 18
ACKNOWLEDGEMENT 25
DISCLOSURE STATEMENT 25
SOURCES OF FUNDING 25
vii
10. 1. INTRODUCTION
Gastroesophageal variceal bleeding accounts for 10-30% of upper
gastrointestinal haemorrhage and is a major cause of death in patients with
cirrhosis.1
The prevalence of oesophageal varices in patients with cirrhosis
varies from 24-81%.2-5
At the time of diagnosis of cirrhosis, oesophageal varices
are present in about 60% of decompensated and 30% of compensated patients.6
Variceal bleeding accounts for 6.4% of upper gastrointestinal bleeding in
Malaysia.7
Fifteen percent (105/699) of emergency endoscopy for upper
gastrointestinal bleeding performed in Selayang Hospital are due to acute
variceal bleeding (unpublished data). The aetiology of cirrhosis in Malaysia is
mainly due to hepatitis B or alcohol.8
The majority of patients who presented
with variceal bleeding are Chinese followed by Indians.
2. BACKGROUND
2.1 Oesophageal Varices
Portal hypertension leads to the development of portosystemic collaterals
including gastroesophageal varices. The hepatic venous pressure gradient
(HVPG), defined as the difference between the wedged/occluded hepatic
venous pressure and the free hepatic venous pressure, is the most commonly
used parameter to measure portal pressure. The HVPG threshold for the
development of varices is 10mmHg (normal HVPG < 5mmHg). However, not
all patients with hepatic venous pressure gradient above this level have
oesophageal varices.9
Although the measurement of HVPG is reliable and is a
useful adjunct, the procedure is invasive and thus is not widely used in clinical
practice.
It is estimated that the annual risk of developing ‘de novo’ varices after initial
diagnosis of cirrhosis is about 5-8% per year.10,11
The appearance of
oesophageal varices has some correlation with the severity of liver disease
and portosystemic shunting as well as continued alcohol abuse.12-14
In alcoholic
liver disease, continued abstinence from alcohol may result in a decreasing
size or even disappearance of varices. Abstainers have a significantly higher
survival rate and a decrease probability of bleeding.
1
11. Table 1 : Size classifications of oesophageal varices
Japanese US VA Trial Paquet
Absent Absent Absent Absent
Grade 1: small, straight varices not
disappearing with insufflation Small < 5 mm I
Grade 2: medium varices occupying
less than one third of the lumen Medium 5-9 mm II
Grade 3: large varices occupying
more than one third of the lumen Large > 9 mm III
Giant IV
To date, there is no consensus on the definition of small varices. Amongst the
various classifications of oesophageal varices shown in Table 1,15-18
the grading
developed in Japanese studies is preferred (Level of evidence III). Varices
increase in size from small to large at an annual rate of 10-15%.11
Despite the
high occurrence of varices in cirrhotic patients, only 30% of patients with varices
will experience variceal haemorrhage.4,5
The risk of bleeding appears to be
greatest within the first year after diagnosis. Mortality of the first bleeding episode
is high and ranges between 30% and 50% within 6 weeks;19
mortality from
uncontrolled bleeding in the first instance is between 5-8%.20
The risk factors
for the first episode of variceal bleeding in cirrhotic patients include the severity
of the liver dysfunction, the size of the varices (large greater than small), and
the presence of endoscopic red wale signs.4,17,21
Another important risk factor
to consider is the hepatic venous pressure gradient (HVPG). It is now well
accepted that variceal bleeding will not occur if the HVPG is below 12mmHg.22
Once this 12mmHg HVPG threshold is crossed, bleeding is expected to occur
at some point.
Patients who survived the first bleed from oesophageal varices are at a
significant risk of recurrent haemorrhage: 70% of patients will experience
recurrent haemorrhage and about a third of further bleeding episodes are
fatal.4,23
Up to fifty percent of recurrent haemorrhage occurs within the first 6
weeks after the index bleed.20
The risk of re-bleeding is highest during the first
2
12. five days, decreases slowly over the first 6 weeks, and becomes virtually equal
to that before the index bleed after the sixth week.19
Risk factors predictive of
re-bleeding include the degree of hepatic decompensation, age greater than
60, severity of initial bleed, renal insufficiency, level of portal pressure, size of
varices, active bleeding at the time of initial endoscopy and the presence of
hepatoma.20,23
Recommendation for classification of oesophageal varices
The Japanese classification is the preferred grading scale for the staging
of oesophageal varices. (Grade C)
2.2 Gastric Varices
Gastric varices account for approximately 20-30% of cases of variceal bleeding.
The prevalence of gastric varices in patients with portal hypertension varies
from 6-78% and approximately 25% of gastric varices bleed during lifetime.24
Primary gastric varices are varices detected at the time of the first endoscopy,
whereas, secondary gastric varices are those which occur within two years of
eradication of oesophageal varices. Gastric varices occur five times more often
in patients with oesophageal varices that have previously bled than in those
that have never bled. Although gastric variceal haemorrhage occurs less
frequently than oesophageal variceal haemorrhage, the severity of bleeding
and mortality, especially with fundal varices, is greater.25
The preferred classification of gastric varices is based on location, size and
endoscopic features of the varices:24,26
gastro-oesophageal varices (GOV) and
isolated gastric varices (IGV). GOV extend beyond the gastro-oesophageal
junction (OGJ) and are always associated with oesophageal varices. They are
further subdivided into Type 1 (GOV I): these varices are a continuation of
oesophageal varices and extend for 2-5 cm below the OGJ along the lesser
curvature of the stomach. Type 2 (GOV II): these varices extend below the
OGJ towards the fundus of the stomach. Gastric varices in the absence of
oesophageal varices are termed isolated gastric varices (IGV). Depending on
the location, they are subdivided into Type 1 (IGV I): these are located in the
fundus of the stomach and fall short of the cardia by a few centimetres. Type 2
(IGV II): these include isolated ectopic varices and can present anywhere in
the stomach.
3
13. 3. PRIMARY PROPHYLAXIS
3.1 Oesophageal Varices
Primary prophylaxis of variceal bleeding is therapy given to patients with known
varices to prevent the first episode of variceal haemorrhage. Given the high
risk of initial haemorrhage and the high rate of mortality from the first bleeding
episode, strategies for prevention of the first bleed are therefore important.
3.1.1 Pharmacological Therapy for Oesophageal Varices
Non-selective ß-adrenergic antagonists such as propranolol and nadolol are
widely used in the prevention of the initial bleeding episode. Non-selective
rather than selective beta-blockers are more appropriate as blocking ß1
activity
causes splanchnic vasoconstriction (by means of reflex á-adrenergic receptors)
and by eliminating ß2
-receptor mediated splanchnic arterial vasodilation,
splanchnic blood flow is reduced.
Beta-blockers have been shown by 3 meta-analyses to statistically reduce the
relative risk of bleeding by approximately 45% with a trend towards reducing
mortality.27-29
The average number of patients that are needed to treat to prevent
one bleeding episode is 11. The benefit of beta-blockers has been proven in
patients with moderate or large varices (>5mm), either with good or poor liver
function.11
Although beta-blocker prophylaxis reduced the rate of variceal
bleeding in patients with small oesophageal varices,30
there is insufficient
evidence to support treatment of patients with small varices. Beta-blockers
have also been shown to prevent bleeding from portal hypertensive
gastropathy.31
A cost-effectiveness analysis in the USA supports the use of propranolol as
cost-effective in the primary prophylaxis of variceal bleeding.32
Beta-blocker
therapy should be maintained for life as bleeding may occur after stopping
treatment.33
However, the side-effect profile for beta-blocker therapy is
considerable: 15-25% of cirrhotic patients are intolerant or have
contraindications to beta-blockers that preclude its use.34
Other pharmacological alternatives which have been evaluated include nitrates.
Although nitrates have been shown to reduce portal pressure, it can potentially
worsen the vasodilative haemodynamics typically found in cirrhotic patients.
Nitrates were ineffective to prevent variceal bleeding in patients with
contraindications or intolerance to beta-blockers and should not be used as
4
14. monotherapy to prevent the index variceal bleed.34
Furthermore, a comparative
study between isosorbide mononitrate (ISMN) with propranolol for the prevention
of variceal bleeding showed a higher long-term mortality in patients over 50
years of age receiving ISMN.35
It has been suggested that the higher mortality
observed when nitrates was compared to beta-blockers were probably due to
a beneficial effect of beta-blockers rather than a real detrimental effect of nitrates.36
Recommendations for pharmacological therapy for oesophageal
varices
Non-selective beta-blockers is the best available modality for primary
prophylaxis at present. (Grade A)
3.1.2 Endoscopic Therapy for Oesophageal Varices
Endoscopic treatment modalities available include variceal ligation and injection
sclerotherapy. Endoscopic sclerotherapy is based on the concept that bleeding
from varices is halted by thrombosis of the bleeding varix by intravariceal or
paravariceal injection of a sclerosant. The most commonly used sclerosants
are sodium tetradecyl sulphate (thrombovar) and ethanolamine oleate.
There is little, if any, role for endoscopic sclerotherapy in the prevention of the
index variceal bleed. A meta-analysis of 20 randomised trials comparing
prophylactic endoscopic sclerotherapy with no treatment showed significant
heterogeneity between the trials to draw firm conclusions.37
The risk of side-
effects of sclerotherapy probably outweighs the potential benefits and two
studies suggest superiority of propranolol over sclerotherapy.38, 39
Endoscopic variceal ligation (EVL) is achieved by suction and ligating the varix
in a banding device attached to the tip of the endoscope, similar to the technique
used for ligation of internal haemorrhoids. Multiband ligators are now available.
An initial meta-analysis of 4 randomised clinical trials40-43
comparing endoscopic
ligation and beta-blockers suggested that ligation is superior to beta-blockers
in the prevention of variceal bleeding but the risk for mortality was similar in
both groups.44
A further meta-analysis of 5 trials failed to show significant
differences between endoscopic ligation and beta-blockers either for bleeding
or survival.36
In a more recent study, although a significantly higher failure rate
of variceal bleeding and mortality was noted in patients on beta-blockers
compared to those receiving prophylactic EVL, the bleeding rate in the EVL
group is unusually low with a relatively short period of follow-up.45
The
5
15. comparison between EVL and beta-blockers versus EVL monotherapy for
primary prophylaxis showed no difference between the two groups.46, 47
Non-selective beta-blockers is the best available modality for primary
prophylaxis at present (Level of evidence I). Prophylactic ligation may be
indicated for patients who are intolerant or have contraindications to beta-
blockers.
3.2 Gastric Varices
The risk of first bleeding from gastric varices is no greater than that from
oesophageal varices. Data on prevention of the first bleeding in patients with
gastric varices is sparse. It is conceivable that beta-blocker therapy is equally
effective in this situation. The efficacy of cyanoacrylate in these patients remains
controversial.48
4. SCREENING ENDOSCOPY
Current guidelines for the primary prophylaxis of oesophageal varices
recommend universal screening endoscopy in patients with cirrhosis to identify
those who could benefit from therapy. TheAmerican College of Gastroenterology
and the American Association for the Study of Liver Disease advocate screening
endoscopy every other year in patients with cirrhosis not known to have varices.
Patients with small varices on initial endoscopy should be screened for
enlargement of varices every 1-2 years.26
A recent analysis by Spiegel et al.49
suggests that empiric beta-blocker therapy may be a more cost-effective
approach in patients with compensated cirrhosis, whereas Arguedas et al.50
found that this strategy was cost-effective only in patients with decompensated
cirrhosis. Until there are more studies comparing screening-directed versus
empiric beta-blocker prophylaxis, the recent data should not immediately affect
our current practice.
Recommendations for screening endoscopy
Screening endoscopy at the time of diagnosis of cirrhosis and every 2
years in patients not known to have varices. (Grade C)
6
16. 5. MANAGEMENT OF ACUTE VARICEAL BLEEDING
The report of the Baveno IV Consensus Workshop on portal hypertension states
the time frame for the acute variceal bleeding episode as 5 days and failure to
control bleeding as the need to change specific therapy.51
5.1 General Management
Acute variceal bleeding is a medical emergency that should be managed under
intensive care facilities by a team of experienced medical staff including
endoscopists, hepatologists, surgeons and nurses. Therapy is aimed at correcting
hypovolumic shock and at achieving haemostasis at the bleeding site. This would
be instituted by aggressive resuscitation to restore haemodynamic stability. Two
large bore intravenous lines should be in place. Blood volume restitution,
preferably packed red blood cells, should be transfused cautiously and
conservatively to keep the haemoglobin ideally around 8g/dL or haemocrit of
24%.52
Overtransfusion should be avoided as this can increase portal pressures
and exacerbate further bleeding. If the patient is haemodynamically unstable,
elective intubation for airway protection should be considered. Pharmacotherapy
to reduce portal pressure should be instituted and emergency endoscopy
performed to establish the diagnosis and location of the bleeding site.
5.2 Antibiotics in Acute Variceal Bleeding
Bacterial infections are seen in about 20% of cirrhotics presenting with upper
gastrointestinal bleeding within 48 hours.53,54
The incidence of sepsis increases to
almost 66% at two weeks.50-57
Development of bacterial infection is associated
with high mortality and variceal re-bleeding.54,55
Antibiotic prophylaxis has been
shown to reduce the rate of infection, spontaneous bacterial peritonitis and re-
bleeding.56-60
In addition, antibiotic prophylaxis was clearly proven in a meta-analysis
to significantly increase the survival rate.61
Short-term antibiotic prophylaxis for 7
days should be considered the standard of care in cirrhotic patients with upper
gastrointestinal bleeding, irrespective of the type of haemorrhage (variceal or non-
variceal) or the presence or absence of ascites (Level of evidence I). As to the
choice of antibiotic, either third generation cephalosporins given intravenously or
oral quinolones (norfloxacin/ciprofloxacin) are generally recommended.
Recommendations for antibiotics in acute variceal bleeding
Short-term antibiotic prophylaxis for 7 days should be considered the
standard of care in cirrhotic patients with upper gastrointestinal bleeding,
irrespective of the type of haemorrhage (variceal or non-variceal) or the
presence or absence of ascites. (Grade A)
7
17. 5.3 Pharmacological Therapy for Acute Variceal Bleeding
Pharmacologic treatment is aimed at arresting haemorrhage by decreasing
pressure and blood flow within the oesophageal varices, thus, allowing
haemostasis at the bleeding points. Vasoactive drugs have been shown to
control acute variceal bleeding in about 80% of patients.62-68
Vasoactive therapy
can be used empirically when variceal bleeding seems likely on clinical grounds.
The current recommendation (Level of evidence I) is to start a vasoactive
drug as early as possible from the time of admission or even upon the patient’s
transfer to the hospital.62,63
The agents available are vasopressin (either alone
or in combination with nitroglycerine) or its analogues and somatostatin or its
analogues. The selection of the vasoactive drug is highly dependent on
availability and the treating clinician’s familiarity with each.
Vasopressin was the first vasoactive agent used in the treatment of acute
variceal bleeding. It does, however, have significant systemic side-effects which
include myocardial and mesenteric ischaemia and infarction.69
The addition of
nitroglycerine to vasopressin enhances its efficacy and reduces the
cardiovascular side-effects.70, 71
Terlipressin, a synthetic vasopressin analogue with fewer side-effects and a longer
half-life than vasopressin, is effective in controlling acute variceal bleeding.72,73
Terlipressin is administered as IV injections of 2mg bolus and 1mg every four to
six hours for 2-5 days. A meta-analysis demonstrated that terlipressin was
associated with a 34% relative risk reduction in mortality compared to placebo.72
Somatostatin and its synthetic analogues, octreotide and vapreotide, control acute
variceal bleeding in up to 80% of patients and are generally considered to be
equivalent to terlipressin but superior to vasopressin for the control of acute
variceal haemorrhage.73
Somatostatin is given as an IV 250mcg bolus followed
by 250mcg/hour infusion. Octreotide is administered as a bolus injection of 50mcg
followed by an infusion at a rate of 50mcg/hour. Somatostatin or octreotide therapy
should be maintained for 5 days to prevent early re-bleeding.
In acute variceal bleeding, terlipressin may have an added advantage as it can
potentially reverse hepatorenal syndrome.74
In addition, terlipressin has been
shown to have a more sustained haemodynamic effect compared to treatment
with octreotide.75
Recommendations for pharmacological therapy for acute variceal
haemorrhage
A vasoactive drug should be started as early as possible from the time of
admission or even upon the patient’s transfer to the hospital. (Grade A)
8
18. 6. MANAGEMENT OF OESOPHAGEAL VARICEAL BLEEDING
6.1 Endoscopic Therapy
Endoscopic sclerotherapy stops bleeding in 80-90% of patients with acute
variceal haemorrhage.76-78
There was no difference between vasoactive drugs
and endoscopic sclerotherapy in failure to control bleeding, early re-bleeding
and mortality.79-81
However, adverse events such as oesophageal ulceration
and stricture were significantly more severe with sclerotherapy. Control of
bleeding may also be achieved by injection of tissue adhesives e.g. histoacryl/
cyanoacrylate glue. Re-bleeding rates are similar to sclerosants but there is
also a higher risk of complications and damage to the endoscopic instrument.
This should only be performed by experienced endoscopists when haemostasis
has not been achieved.
Endoscopic variceal ligation (EVL) is more effective than sclerotherapy in
controlling acute oesophageal variceal bleeding but without a survival
advantage.82-85
EVL is favoured in most settings because it leads to fewer
complications and a survival advantage was demonstrated in one study.85
Technically, banding may be difficult at times because of limited visualisation
from bleeding and sclerotherapy is used as it is easier to perform in this setting.
The use of endoscopic therapy alone in the treatment of acute oesophageal
variceal bleeding has been challenged as pharmacological therapy is as
effective as sclerotherapy, but with significantly less side-effects.86
However, a
meta-analysis on the efficacy of therapeutic regimens in acute variceal bleeding
showed that ligation was significantly more successful than pharmacological
therapy in the control of ongoing variceal bleeding.82
Therefore, EVL is
recommended for patients with acute variceal bleeding (Level of evidence I).
An important newer approach has been the combination of a vasoactive agent
and endoscopic therapy. The addition of vasoactive drugs for a period of five
days has been shown to facilitate endoscopy, improve control of bleeding, reduce
5-day re-bleeding rate and transfusion requirements,87-90
but with no effect on
mortality.91
Combination therapy was beneficial both in low-risk and high-risk
patients,92
even if administered just after the endoscopic procedure.11,93,94
Recommendations for endoscopic therapy for acute oesophageal
variceal haemorrhage
Endoscopic variceal ligation (EVL) is recommended for patients with acute
variceal bleeding. (Grade A)
9
19. 6.2 Balloon Tamponade
Although generally considered effective for stopping bleeding,95
balloon
tamponade is known to have a high re-bleeding rate when the balloon is
decompressed and is associated with serious complications such as ulceration,
perforation and aspiration pneumonia. In addition, sclerotherapy achieved a
higher rate of initial haemostasis compared to balloon tamponade.96,97
Thus,
this should only be considered if facilities for endoscopy are not available prior
to transfer to a tertiary centre or as a temporary ‘bridge’ for a maximum of 24
hours until definitive treatment can be instituted. This should be used in
conjunction with pharmacological therapy. The balloon should be kept in the
refrigerator, taken out only at the time of the procedure and inserted by a
personnel who is familiar with the procedure.
6.3 Transjugular Intrahepatic Portosystemic Shunts (TIPS)
Transjugular intrahepatic portosystemic shunts (TIPS) is effective in the
treatment of acute variceal bleeding with a success rate of over 90% in arresting
haemorrhage.98,99
The main limiting factors to the use of TIPS are the high
morbidity and mortality:100,101
the 30-day mortality approaches 100% in patients
with advanced liver disease, ongoing sepsis and multi-organ failure.102
Therefore, the most widely accepted indication for TIPS is as a rescue therapy
for uncontrolled variceal bleeding after combined pharmacological and
endoscopic therapy (Level of evidence II). Further studies are required to
define the role of early TIPS placement in patients with haemodynamically
defined (using HVPG measurement) high-risk patients.103
Recommendations for Transjugular Intrahepatic Portosystemic
Shunts (TIPS)
TIPS is indicated as a rescue therapy for uncontrolled variceal bleeding
after combined pharmacological and endoscopic therapy. (Grade B)
6.4 Surgical Therapy
Surgical options include oesophageal transection with or without
devascularisation, portosystemic shunts and liver transplantation. Regardless
of the choice of the surgical technique, morbidity and mortality are high: the
30-day mortality associated with emergency surgical procedures is nearly 80%.98
Similar to TIPS, the role of surgical therapy in the management of acute variceal
bleed has been relegated to salvage haemostatic therapy (Level of evidence
II). Liver transplantation is probably only appropriate for liver transplant
candidates who bleed while on the waiting list.
10
20. Recommendations for surgical therapy
The role of surgical therapy in the management of acute variceal bleed
has been relegated to salvage haemostatic therapy. (Grade B)
6.5 Secondary Prophylaxis
Secondary prophylaxis is the prevention of recurrent bleeding after a first
episode variceal bleed. Secondary prophylaxis should be started from the sixth
day of the index variceal bleed.51
6.5.1 Pharmacological Therapy
Secondary prophylactic therapy with pharmacological therapy is based on the
assumption that a sustained reduction in portal pressure reduces the incidence
of variceal re-bleeding. Beta-blockers are still the mainstay of
pharmacotherapy.104-106
A meta-analysis of 12 randomised controlled trials
comparing non-selective beta-blockers to either no treatment or placebo showed
a statistically significant reduction in the risk of recurrent bleeding and survival
advantage.107
The incidence of recurrent variceal bleeding was 42.7% in the
placebo group and 32% in the beta-blocker group, a reduction in the risk of
bleeding by one third, and mortality from 27% to 20%.11,108
The number of
patients needed to treat in order to prevent one re-bleeding episode is 5, and
the number needed to treat in order to prevent a death is 14. Intolerance to
propranolol leads to discontinuation of treatment in 30% of patients. Although
the addition of isosorbide mononitrate to beta-blockers for secondary
prophylaxis appears to be superior to beta-blocker monotherapy in the
prevention of variceal re-bleeding, survival benefit was not demonstrated.108
Therefore, non-selective beta-blockers should be used for secondary
prophylaxis (Level of evidence I).
Recommendations for secondary prophylaxis – pharmacological
therapy
Non-selective beta-blockers should be used for secondary prophylaxis.
(Grade A)
6.5.2 Endoscopic Therapy
For the prevention of variceal re-bleeding, endoscopic sclerotherapy is
performed every 10-14 days until the varices are obliterated, which typically
requires 5 or 6 sessions. Sclerotherapy proved more effective than placebo in
terms of prevention of variceal re-bleeding and mortality.109
However, endoscopic
11
21. variceal band ligation has superseded sclerotherapy in the prevention of
recurrent oesophageal variceal haemorrhage (Level of evidence I) because
the risk of re-bleeding is lower than sclerotherapy (approximately 25% vs. 30%
respectively at one year), causes fewer complications, requires fewer sessions
to eradicate the varices and has a survival benefit.83,110-113
Similar to
sclerotherapy, EVL is performed every 10 to 14 days until the varices are
eradicated, which usually takes 3 or 4 sessions. The addition of sclerotherapy
to ligation has not been shown to be advantageous:114,115
a higher incidence of
oesophageal stricture was noted in the group who had both sclerotherapy and
ligation.116
A more recent meta-analysis confirmed earlier reports that the
combination of EVL and sclerotherapy is not superior to EVL alone in the risk
of oesophageal variceal re-bleeding, death or time to variceal obliteration.117
Comparison of beta-blockers and isosorbide mononitrate with endoscopic
variceal band ligation revealed either no significant difference in the variceal
re-bleeding episodes or in survival,118,119
or significantly less variceal re-bleeding
but a higher death rate in the EVL group.120
In one study, a higher variceal re-
bleeding rate was noted in the EVL group as compared with pharmacological
therapy (49% vs. 33% respectively).121
However, pharmacological therapy was
found to be effective largely in patients with Child-Pugh A cirrhosis. Noteworthy,
the risk of recurrent bleeding and of death was significantly lower in patients
who had a haemodynamic response to therapy (defined as a reduction in the
HVPG by more than 20% of the baseline value or to less than 12mmHg).
Currently, there is not enough evidence to support the use of the targeted
reduction of HVPG in routine clinical practice.122
Recommendations for secondary prophylaxis – endoscopic therapy
Endoscopic variceal band ligation has superseded sclerotherapy in the
prevention of recurrent oesophageal variceal haemorrhage. (Grade A)
6.5.3 Combination of Pharmacological and Endoscopic Therapy
The combination of endoscopic therapy and pharmacologic therapy for secondary
prophylaxis is attractive and may improve the results of either form of therapy
alone. Studies comparing the use of sclerotherapy and beta-blockers showed a
lower incidence of variceal re-bleeding than beta-blocker monotherapy but with
no improvement in survival.123,124
The combination of ligation plus ß-adrenergic
blockers and sucralfate (EVL to reduce variceal size, nadolol to lower portal
pressure and sucralfate to heal oesophageal ulcers) was compared with EVL
alone.125
Triple therapy proved more effective in terms of prevention of variceal
re-bleeding; however, no significant difference in death rate was identified.
Combination therapy involving endoscopic variceal ligation and beta-adrenergic
blockers is probably the preferred treatment but warrants additional trials.51
12
22. 6.5.4 Transjugular Intrahepatic Portosystemic Shunts (TIPS)
TIPS is more effective than endoscopic therapy for the prevention of variceal re-
bleeding with 8-18% recurrent variceal bleeding rate at one year:126-129
shunt
dysfunction either due to occlusion or stenosis is almost always the cause. However,
TIPS is associated with the occurrence of hepatic encephalopathy in at least 25%
of patients after the procedure,130,131
lacks survival benefit over endoscopic
therapy,132-134
is more costly than pharmacological therapy135
and therefore, should
not be used as a first-choice treatment for secondary prophylaxis.
6.5.5 Surgical Therapy
Prevention of recurrent variceal bleeding with surgery may be more effective
than pharmacological or endoscopic therapy in patients with preserved synthetic
function provided that it is performed by an experienced surgeon.136-139
Portal
blood flow-preserving procedures such as selective shunts or devascularisation
procedures appears to be better than decompressive surgical shunts with re-
bleeding rate of 6% vs. 14.3% and postoperative encephalopathy of 6% vs.
21% respectively.140,141
In addition, selective shunts do not exclude the patients
for future liver transplantation.
In comparison with TIPS, surgical shunts are significantly more invasive but
placement of TIPS resulted in higher re-bleeding rate142
and cost143
than surgical
shunt due to subsequent occlusion and re-bleeding with no significant effect
on mortality. TIPS is most suited for patients with Child’s B or C cirrhosis,
particularly those who are candidates for liver transplantation while surgical
shunts should be limited to patients with Child’s A cirrhosis.144
Secondary prophylaxis with TIPS or surgical shunt is preferred for patients
who are non-compliant with pharmacological or endoscopic therapy (Level of
evidence II).
Recommendations for secondary prophylaxis – surgical therapy
Secondary prophylaxis with TIPS or surgical shunt is preferred for patients
who are non-compliant with pharmacological or endoscopic therapy.
(Grade B)
13
23. 7. MANAGEMENT OF ACUTE GASTRIC VARICEAL BLEEDING
The treatment goals for acute gastric variceal bleeding are the same as for
oesophageal varices: to control acute bleeding and prevent re-bleeding.
Indications for treatment are: active bleeding from varices, stigmata of recent
bleeding episode on gastric varices, history of a previous bleeding episode
and presence of gastric varices as the only source of bleeding.
7.1 Gastro-Oesophageal Varices (GOV) Type 1
Treat as for oesophageal varices (Level of evidence II).
Recommendations for GOV type 1
Treat as for oesophageal varices. (Grade B)
7.2 Gastro-OesophagealVarices(GOV)Type2andIsolatedGastricVarices(IGV)
7.2.1 Endoscopic Therapy
Injection of cyanoacrylate glue has been shown to achieve haemostasis in 90%
of acutely bleeding gastric varices145-147
and has been shown to be better than
alcohol and band ligation.148,149
It is important to ensure the intravariceal position
of the needle. Histoacryl is mixed with lipiodol in a ratio of 0.5:0.8ml. Histoacryl
should be injected in a slow and controlled fashion and should not exceed 2ml
as there is a risk of thrombotic complications including pulmonary embolism.
These procedures should only be performed by experienced endoscopists.
For acute GOV Type 2 and IGV: injection with cyanoacrylate (Level of evidence I).
Recommendations for GOV type 2 and IGV
For acute bleeding: injection with cyanoacrylate. (Grade A)
7.2.2 Balloon Tamponade
Immediate control of bleeding from all types of gastric varices except IGV II
can be obtained by using the Sengstaken-Blakemore tube with the gastric
balloon held under traction.
7.2.3 Transjugular Intrahepatic Portosystemic Shunts (TIPS)
This is the treatment modality when bleeding GOV is not responsive to
endoscopic and pharmacological treatment.
14
24. 7.2.4 Secondary Prophylaxis
Data on long-term outcome after GOV obliteration are scanty. In general,
recurrence after obliteration is much lower in patients with gastric varices than
in patients with oesophageal varices except for patients with fundal varices.150
Cyanoacrylate glue was shown to be more effective than alcohol sclerotherapy
for the control of variceal re-bleeding (100% vs. 44% respectively).149
TIPS and
surgical intervention are the other therapeutic options for gastric variceal re-
bleeding. TIPS has been shown to be effective in patients with gastric varices
in terms of re-bleeding and survival.151,152
8. CONCLUSION
The current first choice treatment in patients with oesophageal varices who have
not bled is prophylactic non-selective beta-blocker therapy. Therapy with beta-
blockers is cheap, easy to administer, and significantly reduces the risk of index
variceal haemorrhage. Only patients with Grade 3 (large varices), Grade 2
(moderate varices) with endoscopic red wale signs or Child’s C cirrhosis should
be offered this therapy. Typically, the initial dose of propranolol is 20mg twice
daily with the dose titrated to achieve a 25% decrement in resting pulse rate or a
pulse rate of 55-60 bpm. Endoscopic variceal band ligation may be an alternative
for patients who cannot tolerate, or have contraindications to beta-blockers.
The best approach for patients with acute variceal bleeding is the combination
of vasoactive drugs and endoscopic therapy. Terlipressin is administered as
2mg IV bolus and 1mg every six hours for 2-5 days. Somatostatin is given as
an IV 250mcg bolus followed by 250mcg/hour infusion and octreotide is
administered as a bolus injection of 50mcg followed by an infusion at a rate of
50mcg/hour. Somatostatin or octreotide therapy should be maintained for 5
days to prevent early re-bleeding.
Regarding endoscopic therapy, EVL is preferred but sclerotherapy may be used
depending on the endoscopist’s experience and the particular circumstances
found during endoscopy.
The first-line treatment for prevention of recurrent variceal haemorrhage is beta-
blockers, endoscopic variceal ligation or the combination of beta-blockers and
endoscopic variceal ligation. TIPS or surgical shunt appears to be more
appropriate for patients who are non-compliant or refractory to pharmacological
and endoscopic therapy.
15
25. ALGORITHM: PRIMARY PROPHYLAXIS OF VARICEAL BLEED
Large varices (Grade 3)
or moderate varices
(Grade 2) with
endoscopic red wale
signs or Child’s C
cirrhosis
Beta-blocker therapy
(Propranolol 20mg bd
titrated to achieve a
25% decrement in
resting pulse rate or
a pulse rate of
55-60 bpm)
EVL if beta-blocker
contraindicated or
intolerant
If Child’s C cirrhosis consider
liver transplant evaluation
À
À
À
À
À
À
À
À
À
À
16
26. ALGORITHM: MANAGEMENT OF ACUTE VARICEAL BLEEDING
Suspected acute variceal bleeding (AVB)
Endoscopy service
unavailable
Balloon tamponade
if active bleeding
Transfer to
endoscopy centre
Terlipressin / Octreotide / Somatostatin for 2-5 days
Antibiotic Prophylaxis for 7 days in patients with cirrhosis
Resuscitation, IV access, GXM
Urgent Endoscopy
Oesophageal varices Gastric varices
EVL preferred;
sclerotherapy if EVL
difficult
Injection with
cyanoacrylate
Persistent active
bleeding
Persistent active
bleeding
TIPS or surgical
intervention
Beta-blockers, EVL
or both
Repeat endoscopic
therapy
TIPS or surgical
shunt
†
†
† †
†
† † †
† †
†
† †
†
NO YES
† †
17
Ò
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34. ACKNOWLEDGEMENT
The committee for this guideline would like to express their gratitude and
appreciation to the following for their contribution:
¾ Panel of reviewers who reviewed the draft
¾ Technical Advisory Committee for Clinical Practice Guidelines for their
valuable input and feedback
DISCLOSURE STATEMENT
The panel members have no potential conflict of interest to disclose.
SOURCES OF FUNDING
The development of this CPG was supported financially in its entirety by the
Malaysian Society of Gastroenterology and Hepatology without any involvement
of the pharmaceutical industry.
25
35. LEVELS OF EVIDENCE SCALE
Level
I
II - 1
II - 2
II - 3
III
Evidence obtained from at least one properly randomised
controlled trial
Evidence obtained from well-designed controlled trials without
randomization
Evidence obtained from well-designed cohort or case-control
analytic studies, preferably from more than one center or
research group
Evidence obtained from multiple time series with or without the
intervention.
Opinions of respected authorities, based on clinical experience;
descriptive studies and case reports; or reports of expert
committees
(U.S. / Canadian Preventive Services Task Force)
Evidence from large, randomised clinical trials or meta-analyses
High quality study of non-randomised cohorts who did not receive
therapy or high quality case series
Opinions from experts based on arguments from physiology
bench research or first principles
GRADES OF RECOMMENDATIONS
Grade A
Grade B
Grade C
Similar to the clinical practice guidelines on acute non-variceal upper gastrointestinal
bleeding, the grading of the quality of evidence and the strength of each
recommendation are as follows
LEVELS OF EVIDENCE SCALE & GRADES OF RECOMMENDATIONS