BACKGROUND & AIMS:This randomized controlled trial compared variceal band ligation (VBL), propranolol (PPL), and isosorbide-5-mononitrate (ISMN) in the prevention of first esophageal variceal bleed.METHODS:Over a 6-year period, 172 patients with cirrhosis, grade II or III esophageal varices that had never bled, were recruited; 44 into VBL, 66 into PPL, and 62 into ISMN. Baseline patient characteristics: age, 55 +/- 11 years; Child-Pugh score, 8 +/- 2; 65% alcohol-induced cirrhosis; follow-up period, 19.7 +/- 17.6 months (range, 0.13-72.1 months), were comparable in the 3 groups.RESULTS:On intention-to-treat analysis, variceal bleeding occurred in 7% of patients randomized to VBL, 14% to PPL, and 23% to ISMN. The 2-year actuarial risks for first variceal bleed were 6.2% (95% confidence interval [CI], 0.0%-15.0%) for VBL, 19.4% (95% CI, 0.1%-32.4%) for PPL, and 27.7% (95% CI, 14.2%-41.2%) for ISMN. A significant number of patients reported side effects with drug treatment (45% PPL and 42% ISMN vs. 2% VBL; P = 0.00), resulting in withdrawal from treatment in 30% of PPL and 21% of ISMN patients. There were no statistically significant differences in mortality rates in the 3 groups. In as-treated analysis, there was a statistically significant difference in actuarial risk for bleeding at 2 years between VBL and ISMN (7.5%, 95% CI, 2.5%-10.6% vs. 33.0%, 95% CI, 15%-49%, respectively, log rank test P = 0.03) but not between VBL and PPL.CONCLUSIONS:VBL was equivalent to PPL and superior to ISMN in preventing first variceal bleed. The side-effect profile for pharmacotherapy was considerable.

The Scottish Liver Transplant Unit is now in its sixth year of existence. We present the outcome of the first 165 transplants which have at least 12 months follow up. The overall patient (n=143) survival rates at 1, 3 and 5 years were 86.6%, 79.3% and 74.7% and the graft survival rates were 76.9%, 69.1 % and 64.8%. The one year survival rate for patients with chronic liver disease (n=113) was 89.2% compared with 76.6% for acute liver failure (Breslow= 0.05). The one year survival rate for the first 71 patients receiving their primary graft was 81.7% compared with 91.5% for the subsequent 71 patients (Breslow = 0.09). The majority of deaths (n=29) were due to sepsis (n=7), at operation (n=6) or due to graft vascular insufficiency (n=4). There were two cases ofde novo haematological malignancy. The outcome of the first 165 transplants in Scotland compares very well with other countries throughout the world.

HepatologyVolume 26, Issue 5 p. 1361-1365 Hepatology ElsewhereFree Access TIPSS trials: Design determines outcome R Jalan, R JalanSearch for more papers by this authorN D Finlayson, N D FinlaysonSearch for more papers by this authorP C Hayes, P C HayesSearch for more papers by this author R Jalan, R JalanSearch for more papers by this authorN D Finlayson, N D FinlaysonSearch for more papers by this authorP C Hayes, P C HayesSearch for more papers by this author First published: 30 December 2003 https://doi.org/10.1002/hep.510260541Citations: 6AboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat Citing Literature Volume26, Issue5November 1997Pages 1361-1365 ReferencesRelatedInformation

The aim of this study was to compare transjugular intrahepatic portosystemic stent-shunt (TIPSS) with variceal band ligation (VBL) in the secondary prophylaxis of esophageal variceal hemorrhage in patients with cirrhosis. Fifty-eight patients with cirrhosis who presented with the first episode of esophageal variceal hemorrhage were randomized to TIPSS (31) or VBL (27), 24 hours after control of bleeding. Shunt function was assessed after 1 month and then at 6 monthly intervals thereafter. VBL was performed weekly until variceal eradication, and then at 3 months, 6 months, and yearly thereafter. Mean follow-up in the TIPSS group was 15.7 (+/-10.2) months; in the VBL group, it was 16.8 (+/-10.9) months. Results for rebleeding and mortality were analyzed on an intention-to-treat basis and using the Kaplan-Meier method. The frequency and the severity of variceal rebleeding was significantly lower in the TIPSS group (9.8%), compared with the VBL group (51.9%) (P < .0006). Although mortality rates were not significantly different, 8 of the patients who rebled in the VBL group required TIPSS therapy for uncontrolled bleeding. No significant differences were found in the frequency of other complications such as encephalopathy and sepsis. Patients in the VBL group required significantly greater time in the intensive care unit during the period of this study (<0.03). The total direct cost of treatment incurred was pound sterling 1,373 ($2,200) per patient, the cost being less in the patients treated with TIPSS compared with VBL. The results of this study show that TIPSS is superior to VBL for the secondary prophylaxis of variceal hemorrhage in patients with cirrhosis. (Hepatology 1997 Nov;26(5):1115-22)

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Background/Aims: The aim of this study was to analyse prognostic variables predicting mortality, shunt insufficiency, variceal rebleeding and encephalopathy following transjugular intrahepatic portosystemic stent-shunt for variceal haemorrhage.Methods: Sixty-eight patients with cirrhosis who successfully underwent transjugular intrahepatic portosystemic stent-shunt for variceal haemorrhage were studied. Mean age was 54.8 years (s.e. 1.5); 41 were males and 27 were females. Mean Child score was 8.3 (s.e. 0.3). Cirrhosis was alcohol related in 47. The patients have been followed up for a mean of 10.8 (s.e. 1.1) months. The univariate association between 30 prognostic variables and post-treatment encephalopathy was tested by the Chi-squared or Wilcoxon rank-sum tests and multiple logistic regression was used to test the significance of factors adjusted for one another. Cox's proportional hazard regression was used to test the univariate and multivariate significance of the other three outcomes.Results: Transjugular intrahepatic portosystemic stent-shunt was performed successfully in 89.5% of patients. Twenty-two patients have died and eight have been transplanted. Fourteen patients died within 30 days of transjugular intrahepatic portosystemic stent-shunt and death was predicted independently by hyponatraemia (p<0.001) and by severe liver disease (Child C, p<0.001). Eight patients died during follow up and survival in the long term was predicted independently by the presence of encephalopathy (p<0.001) prior to transjugular intrahepatic portosystemic stent-shunt (p<0.001). Shunt insufficiency was predicted by an initial portal pressure gradient of greater than 18 mmHg (p<0.01). None of the variables analysed predicted variceal rebleeding. Encephalopathy following transjugular intrahepatic portosystemic stent-shunt was only predicted independently by its presence prior to transjugular intrahepatic portosystemic stent-shunt (p<0.001).Conclusions: The results of this study suggest that patients with severe liver disease and hyponatraemia are liable to die early, and the presence of encephalopathy prior to transjugular intrahepatic portosystemic stent-shunt independently determines long-term survival. Patients in these groups should be considered high risk and worked up for orthotopic liver transplantation early. Shunt function in patients with an initial portal pressure gradient of >18 mmHg requires close supervision. Encephalopathic patients should have smaller shunts and prophylactic measures to prevent worsening encephalopathy.

OBJECTIVE:To describe a patient with pulmonary and portal hypertension and to review the pathogenesis and management of this condition.PATIENT:A 22-year-old woman with portal hypertension and liver cirrhosis who later developed pulmonary hypertension.INTERVENTIONS:The patient received antibiotic therapy and underwent a splenectomy and proximal splenorenal shunt for portal hypertension. She later received hydralazine, digoxin and warfarin for pulmonary hypertension.MAIN OUTCOME MEASURES:After undergoing a splenorenal shunt the patient made a good recovery. However, she later developed pulmonary hypertension and died after undergoing a hysterectomy and a bilateral salpingo-oophorectomy.CONCLUSIONS:The concomitant development of portal and pulmonary hypertension in the same patient has a poor prognosis. The treatment available for patients with these conditions is unsatisfactory and most patients eventually die as a result of cardiovascular disease. Cardiopulmonary and liver transplantation should be considered in suitable patients.

BACKGROUND:Variceal bleeding is a common, life-threatening complication of primary biliary cirrhosis (PBC) that remains difficult to predict.OBJECTIVE:The aim of this study was to identify whether certain biochemical and hematological parameters may be used as predictors of variceal bleeding in patients with PBC.METHODS:Cox proportional hazard regression analysis was used to test whether various prognostic factors were significantly associated with the time of first bleeding in 63 patients with proven PBC, of whom 11 had subsequent bleeding.RESULTS:Both the first available platelet count and the bilirubin level were of significant value in predicting variceal bleeding, but only the platelet count was an independent predictor of bleeding. In the group of patients who subsequently bled, there was a progressive drop in the platelet count over the follow-up period, with a proportional increase in the risk of bleeding; a platelet count below 200 x 10(9)/L was strongly associated with variceal bleeding (p < 0.001). None of the patients with platelet count above 200 x 10(9)/L bled over a total of 136 patient-years follow-up. In the group who did not bleed, no change in platelet count was identified during follow up.CONCLUSION:We conclude that the platelet count can be used as a predictor of variceal bleeding in PBC.

The clinical history and examination is essential in the evaluation of patients with liver disease. This chapter details important points in the clinical history and examination allowing the physician to identify likely causes of liver damage and their investigation. The evaluation should allow the physician to differentiate acute and chronic liver diseases, and in the latter case separate those with obstructive or chronic parenchymal liver disease. It should also allow identification of important complications such as encephalopathy, ascites and portal hypertension. Identification of these main features or complications of liver disease by the clinical evaluation leads to a logical plan of investigation and prompt diagnosis and management of the liver disease.