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Determinants of mortality in patients with cirrhosis and uncontrolled variceal bleeding

      Highlights

      • Failure to control variceal bleeding in cirrhosis is associated with high mortality and frequently causes ACLF.
      • ACLF is the most important determinant of 42-day and 1-year mortality in cirrhotic patients with failure to control variceal bleeding.
      • Transjugular intrahepatic shunt insertion improves 42-day and 1-year survival in patients with ACLF secondary to failure to control variceal bleeding.

      Background & Aims

      Failure to control oesophago-gastric variceal bleeding (OGVB) and acute-on-chronic liver failure (ACLF) are both important prognostic factors in cirrhosis. The aims of this study were to determine whether ACLF and its severity define the risk of death in OGVB and whether insertion of rescue transjugular intrahepatic shunt (TIPS) improves survival in patients with failure to control OGVB and ACLF.

      Methods

      Data on 174 consecutive eligible patients, with failure to control OGVB between 2005 and 2015, were collected from a prospectively maintained intensive care unit registry. Rescue TIPS was defined as technically successful TIPS within 72 hours of presentation with failure to control OGVB. Cox-proportional hazards regression analyses were applied to explore the impact of ACLF and TIPS on survival in patients with failure to control OGVB.

      Results

      Patients with ACLF (n = 119) were significantly older, had organ failures and higher white cell count than patients with acute decompensation (AD, n = 55). Mortality at 42-days and 1-year was significantly higher in patients with ACLF (47.9% and 61.3%) than in those with AD (9.1% and 12.7%, p <0.001), whereas there was no difference in the number of endoscopies and transfusion requirements between these groups. TIPS was inserted in 78 patients (AD 21 [38.2%]; ACLF 57 [47.8%]; p = 0.41). In ACLF, rescue TIPS insertion was an independent favourable prognostic factor for 42-day mortality. In contrast, rescue TIPS did not impact on the outcome of patients with AD.

      Conclusions

      This study shows that in patients with failure to control OGVB, the presence and severity of ACLF determines the risk of 42-day and 1-year mortality. Rescue TIPS is associated with improved survival in patients with ACLF.

      Lay summary

      Variceal bleeding that is not controlled by initial endoscopy is associated with high risk of death. The results of this study showed that in the occurrence of failure of the liver and other organs defines the risk of death. In these patients, insertion of a shunt inside the liver to drain the portal vein improves survival.

      Graphical abstract

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      Linked Article

      • Failure to control variceal bleeding: Definition matters
        Journal of HepatologyVol. 74Issue 6
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          Acute variceal bleeding (AVB) is recognized as a leading cause of mortality in patients with cirrhosis.1 Importantly, an episode of AVB comprises not only the risk of bleeding and re-bleeding but also the risk of triggering other complications, among which acute-on-chronic liver failure (ACLF) stands out.2–5 The term ACLF defines an abrupt worsening of hepatic and extrahepatic organ failure in patients with underlying liver disease. On the other side, transjugular intrahepatic portosystemic shunt (TIPS) is a highly effective tool to treat patients with portal hypertension and variceal bleeding, thus markedly reducing the risk of rebleeding, further liver decompensation and death.
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      • Reply to: “Failure to control variceal bleeding: Definition matters”
        Journal of HepatologyVol. 74Issue 6
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          We thank Baiges et al.1 for their keen interest and observations regarding our study.2 We completely agree that the definition of ‘failure to control bleeding’ is difficult to apply in individual clinical cases and in general its interpretation is dependent upon many factors including how sick the patients is, whether they have ongoing bleeding during an endoscopy session and the severity of bleeding. In our study,2 we defined ‘failure to control bleeding’ strictly as failure to achieve haemostasis despite 2 endoscopies or need for adjuncts such as Sengstaken-Blakemore tube (SBT) or a stent within 5 days of the first bleed in combination with vasoactive drugs.
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