Gastroenterology

Gastroenterology

Volume 117, Issue 3, September 1999, Pages 626-631
Gastroenterology

Liver, Pancreas, and Biliary Tract
Prognostic value of early measurements of portal pressure in acute variceal bleeding,☆☆

https://doi.org/10.1016/S0016-5085(99)70455-5Get rights and content

Abstract

Background & Aims: Variceal bleeding is the most important complication of portal hypertension. However, the relationship between the increase in portal pressure and the outcome of variceal bleeding has not been well defined. Methods: We measured the hepatic venous pressure gradient (HVPG) of 65 cirrhotic patients with acute variceal hemorrhage, early after admission (20.6 ± 15.6 hours). Results: Twenty-three patients had a poor evolution (failure to control bleeding or early variceal rebleeding), and 42 had an uneventful evolution. The only variable associated with outcome was the HVPG, which was higher in patients with a poor evolution (23.7 ± 6.1 vs. 19.2 ± 3.3 mm Hg; P < 0.0004). This was confirmed by multivariate analysis. HVPG was ≥20 mm Hg in 19 of 23 patients with poor evolution vs. 12 of 42 patients with uneventful evolution (P < 0.0001). An initial HVPG of ≥20 mm Hg was associated with a significantly longer intensive care unit stay (7 ± 5 vs. 4 ± 2 days; P < 0.02), longer hospital stay (19 ± 10 vs. 14 ± 6 days; P < 0.02), greater transfusion requirements (9.0 ± 7.7 vs. 4.7 ± 3.2 UU; P < 0.007), and a worse actuarial probability of survival (1-year mortality, 64% vs. 20%; P < 0.002). Conclusions: Early measurement of HVPG in cirrhotic patients during acute variceal bleeding provides useful prognostic information on the evolution of the bleeding episode and long-term survival.

GASTROENTEROLOGY 1999;117:626-631

Section snippets

Patients and methods

Cirrhotic patients who were admitted to our unit because of acute variceal bleeding from February 1996 to August 1997 were asked to participate in this study after an endoscopic diagnosis of variceal bleeding. The study protocol was approved by the ethics committee of the hospital clinic and was in accordance with the Helsinki Declaration of 1975, as revised in 1983. All patients gave written, informed consent for participation in the study.

The variceal bleeding of the cirrhotic patients was

Results

During the study, 99 eligible patients were admitted to the intensive care unit (ICU) of the liver unit because of acute variceal bleeding. Sixty-five patients were included to the study. Reasons for exlusion were lack of consent for 14 patients, inability to schedule the hemodynamic study within 48 hours from admission for 14 patients, and exsanguinating bleeding in 6 patients (4 of whom died and 2 required emergency surgery within the first 24 hours).

Of the 65 included patients, 36 patients

Discussion

This study was aimed at testing the hypothesis that early measurement of portal pressure can provide useful prognostic information in cirrhotic patients admitted because of acute variceal bleeding. The rationale was that previous retrospective studies had suggested such a relationship.9, 10 Also, we made the assumption that variceal bleeding, the main complication of portal hypertension, is likely to be worse in patients with greater portal pressure elevations. Actually, the increase in portal

Acknowledgements

The authors thank Diana Bird for secretarial support; Angeles Baringo, Laura Rocabert, and Rosa Sáez for expert technical assistance; and the Liver Intensive Care Unit nursing staff.

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    Address requests for reprints to: Jaime Bosch, M.D., Liver Unit, Hospital Clinic, Villarroel 170, 08036 Barcelona, Spain. e-mail: [email protected]; fax: (34) 934-515-522.

    ☆☆

    Supported in part by grant FIS 97/1309 from the Fondo de Investigación Sanitaria. Dr. Moitinho was supported by grants FIS 97/5617 and FIS 98/9470 from the Hospital Clinic and from Fondo de Investigación Sanitaria.

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