Evidence-based Primary Prevention for One Patient with Cirrhosis and Esophageal Varices_West China Medical Journal

Authors：

 LIJin-hui ¹ ,  ZHANGTao ² , LIXiao-qing ³

1. President's Office, Jian'ge People's Hospital, Jian'ge, Sichuan, 628300, P. R. China;
2. West China Medicine School, Sichuan University, Chengdu, Sichuan 610041, P. R. China;
3. Digestive Endoscopy Center, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, P. R. China;

Corresponding author：

ZHANGTao, Email: 305514271@qq.com

Keywords：

Cirrhosis; Esophageal varices; β-receptor blocker; Ligation; Evidence-based therapy

DOI：

10.7507/1002-0179.20150004

Video：

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Objective To explore an individualized treatment program to prevent the initial bleeding of a patient with cirrhosis and esophageal varices by the methods of evidence-based medicine. Methods One patient with cirrhosis and esophageal varices was admitted into our hospital on November 2, 2013. After evaluating the patient's condition adequately, we proposed the problem according to the PICOS principles. Then, we assessed the clinical evidence from the Cochrane Library (1990-2012), Medline (1950-2012), Embase (1991-2012), VIP (1989-2013), and CBM (1990-2013). The individualized treatment plan was made through doctors' experiences and analysis of those high-quality evidences from the databases. Results Eight studies (randomized controlled trials and 5 meta-analysis) were included. We evaluated a series of associated problems:whether we should take measurement to prevent initial bleeding of esophageal varices; which one (β-blockers or ligation of esophageal varices) was the best method to prevent the initial bleeding based on efficacy, complication and cost-effectiveness. Then, according to the evidences and the patient's view, we gave non-selectiveβ-blocker as the primary prevention. After one-year followed-up, the initial bleeding of the patient did not occur. Conclusion Making the prevention plan for a patient with cirrhosis and esophageal varices can not only find out the individualized program, but also push the patient to make decision for their own health.

Citation： LIJin-hui, ZHANGTao, LIXiao-qing. Evidence-based Primary Prevention for One Patient with Cirrhosis and Esophageal Varices. West China Medical Journal, 2015, 30(1): 18-21. doi: 10.7507/1002-0179.20150004 Copy

1.	Brett BT, Hayes PC, Jalan R. Primary prophylaxis of variceal bleeding in cirrhosis[J]. Eur J Gastroenterol Hepatol, 2001, 13(4):349-358.
2.	Garcia-Tsao G, Sanyal AJ, Grace ND, et al. Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis[J]. Am J Gastroenterol, 2007, 102(9):2086-2102.
3.	中华医学会消化内镜学分会食管胃静脉曲张学组.消化道静脉曲张及出血的内镜诊断和治疗规范试行方案(2009年)[J].中国继续医学教育, 2010, 1(6):21-26.
4.	Ouakaa-Kchaou A, Kharrat J, Mir K, et al. Variceal band ligation in the prevention of variceal bleeding:a multicenter trial[J]. Saudi J Gastroenterol, 2011, 17(2):105-109.
5.	Shah HA, Azam Z, Rauf J, et al. Carvedilol vs. esophageal variceal band ligation in the primary prophylaxis of variceal hemorrhage:a multicentre randomized controlled trial[J]. J Hepatol, 2014, 60(4):757-764.
6.	Imperiale TF, Klein RW, Chalasani N. Cost-effectiveness analysis of variceal ligation vs. beta-blockers for primary prevention of variceal bleeding[J]. Hepatology, 2007, 45(4):870-878.
7.	Imperiale TF, Chalasani N. A meta-analysis of endoscopic variceal ligation for primary prophylaxis of esophageal variceal bleeding[J]. Hepatology, 2001, 33(4):802-807.
8.	D'Amico G, Pagliaro L, Bosch J. Pharmacological treatment of portal hypertension:an evidence-based approach[J]. Semin Liver Dis, 1999, 19(4):475-505.
9.	Gluud LL, Krag A. Banding ligation versus beta-blockers for primary prevention in oesophageal varices in adults[J]. Cochrane Database Syst Rev, 2012, 8:CD004544.
10.	Khuroo MS, Khuroo NS, Farahat KL, et al. Meta-analysis:endoscopic variceal ligation for primary prophylaxis of oesophageal variceal bleeding[J]. Aliment Pharmacol Ther, 2005, 21(4):347-361.
11.	Gluud LL, Klingenberg S, Nikolova D, et al. Banding ligation versus beta-blockers as primary prophylaxis in esophageal varices:systematic review of randomized trials[J]. Am J Gastroenterol, 2007, 102(12):2842-2848.
12.	Li L, Yu C, Li Y. Endoscopic band ligation versus pharmacological therapy for variceal bleeding in cirrhosis:a meta-analysis[J]. Can J Gastroenterol, 2011, 25(3):147-155.
13.	National Clinical Guideline Centre (UK). Acute upper gastrointestinal bleeding:management[M/OL]. London:National Clinical Guideline, Centre, 2012. http://www.ncbi.nlm.nih.gov/books/NBK247794/pdf/TOC.pdf.
14.	Abd Elrazek AE. Criticism of:diagnostic accuracy of abdominal ultrasound in the screening of esophageal varices in patients with cirrhosis[J]. Eur J Gastroenterol Hepatol, 2015, 27(1):106-107.
15.	Hua J, Liu GQ, Bao H, et al. The role of liver stiffness measurement in the evaluation of liver function and esophageal varices in cirrhotic patients[J/OL]. J Dig Dis, 2014, doi:10.1111/1751-1780.
16.	Hammoud GM, Ibdah JA. Utility of endoscopic ultrasound in patients with portal hyertension[J]. World J Gastroenterol, 2014, 20(39):14230-14236.
17.	胡成欢, 黄飞舟, 张瑞, 等.基于气流与激光技术的食道曲张静脉无创测压新系统[J].中国医疗器械杂志, 2014, 38(4):247-250.
18.	Robles-Medranda C, Valle RD, Lukashok HP, et al. Endoscopy clips for treatment of complicated gastric and esopheal varices in patients with cirrhosis[J]. 2014, 46(Suppl 1):E557-E558.
19.	Miyaaki H, Ichikawa T. Endoscopic management of esophagogastric varices in Japan[J]. Ann Transl Med, 2014, 2(5):42.
20.	陆星华, 张泰昌.食管胃静脉曲张内镜下诊断和治疗规范试行方案(2003年)[J].中华消化内镜杂志, 2004(3):5-7.
21.	Kumar S, Asrani SK, Kamath PS. Epidemiology, diagnosis and early patient management of esophagogastric hemorrhage[J]. Gastroenterol Clin North Am, 2014, 43(4):765-782.

1. Brett BT, Hayes PC, Jalan R. Primary prophylaxis of variceal bleeding in cirrhosis[J]. Eur J Gastroenterol Hepatol, 2001, 13(4):349-358.
2. Garcia-Tsao G, Sanyal AJ, Grace ND, et al. Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis[J]. Am J Gastroenterol, 2007, 102(9):2086-2102.
3. 中华医学会消化内镜学分会食管胃静脉曲张学组.消化道静脉曲张及出血的内镜诊断和治疗规范试行方案(2009年)[J].中国继续医学教育, 2010, 1(6):21-26.
4. Ouakaa-Kchaou A, Kharrat J, Mir K, et al. Variceal band ligation in the prevention of variceal bleeding:a multicenter trial[J]. Saudi J Gastroenterol, 2011, 17(2):105-109.
5. Shah HA, Azam Z, Rauf J, et al. Carvedilol vs. esophageal variceal band ligation in the primary prophylaxis of variceal hemorrhage:a multicentre randomized controlled trial[J]. J Hepatol, 2014, 60(4):757-764.
6. Imperiale TF, Klein RW, Chalasani N. Cost-effectiveness analysis of variceal ligation vs. beta-blockers for primary prevention of variceal bleeding[J]. Hepatology, 2007, 45(4):870-878.
7. Imperiale TF, Chalasani N. A meta-analysis of endoscopic variceal ligation for primary prophylaxis of esophageal variceal bleeding[J]. Hepatology, 2001, 33(4):802-807.
8. D'Amico G, Pagliaro L, Bosch J. Pharmacological treatment of portal hypertension:an evidence-based approach[J]. Semin Liver Dis, 1999, 19(4):475-505.
9. Gluud LL, Krag A. Banding ligation versus beta-blockers for primary prevention in oesophageal varices in adults[J]. Cochrane Database Syst Rev, 2012, 8:CD004544.
10. Khuroo MS, Khuroo NS, Farahat KL, et al. Meta-analysis:endoscopic variceal ligation for primary prophylaxis of oesophageal variceal bleeding[J]. Aliment Pharmacol Ther, 2005, 21(4):347-361.
11. Gluud LL, Klingenberg S, Nikolova D, et al. Banding ligation versus beta-blockers as primary prophylaxis in esophageal varices:systematic review of randomized trials[J]. Am J Gastroenterol, 2007, 102(12):2842-2848.
12. Li L, Yu C, Li Y. Endoscopic band ligation versus pharmacological therapy for variceal bleeding in cirrhosis:a meta-analysis[J]. Can J Gastroenterol, 2011, 25(3):147-155.
13. National Clinical Guideline Centre (UK). Acute upper gastrointestinal bleeding:management[M/OL]. London:National Clinical Guideline, Centre, 2012. http://www.ncbi.nlm.nih.gov/books/NBK247794/pdf/TOC.pdf.
14. Abd Elrazek AE. Criticism of:diagnostic accuracy of abdominal ultrasound in the screening of esophageal varices in patients with cirrhosis[J]. Eur J Gastroenterol Hepatol, 2015, 27(1):106-107.
15. Hua J, Liu GQ, Bao H, et al. The role of liver stiffness measurement in the evaluation of liver function and esophageal varices in cirrhotic patients[J/OL]. J Dig Dis, 2014, doi:10.1111/1751-1780.
16. Hammoud GM, Ibdah JA. Utility of endoscopic ultrasound in patients with portal hyertension[J]. World J Gastroenterol, 2014, 20(39):14230-14236.
17. 胡成欢, 黄飞舟, 张瑞, 等.基于气流与激光技术的食道曲张静脉无创测压新系统[J].中国医疗器械杂志, 2014, 38(4):247-250.
18. Robles-Medranda C, Valle RD, Lukashok HP, et al. Endoscopy clips for treatment of complicated gastric and esopheal varices in patients with cirrhosis[J]. 2014, 46(Suppl 1):E557-E558.
19. Miyaaki H, Ichikawa T. Endoscopic management of esophagogastric varices in Japan[J]. Ann Transl Med, 2014, 2(5):42.
20. 陆星华, 张泰昌.食管胃静脉曲张内镜下诊断和治疗规范试行方案(2003年)[J].中华消化内镜杂志, 2004(3):5-7.
21. Kumar S, Asrani SK, Kamath PS. Epidemiology, diagnosis and early patient management of esophagogastric hemorrhage[J]. Gastroenterol Clin North Am, 2014, 43(4):765-782.

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West China Medical Journal

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