The Role of Adjuvant Acid Suppression on the Outcomes of Bleeding Esophageal Varices after Endoscopic Variceal Ligation

PLOS ONE, Dec 2019

The impact of adjuvant acid suppression via proton pump inhibitors or histamine-2 receptor antagonists after endoscopic variceal ligation remains uncertain. We therefore aimed to evaluate the effect of adjuvant acid suppression on the rebleeding and mortality rates in patients who received endoscopic variceal ligation and vasoconstrictor therapy for bleeding esophageal varices. Data from 1997 to 2011 were extracted from the National Health Insurance Research Database in Taiwan. A total of 1576 cirrhotic patients aged > 18 years with a primary diagnosis of acute esophageal variceal bleeding who received endoscopic variceal ligation therapy were screened. After strict exclusion, 637 patients were recruited. The exclusion criteria included patients with gastric variceal bleeding, failure in the control of bleeding, mortality within 12 hours, and history of hepatocellular carcinoma or gastric cancer. Patients were divided into two groups: the vasoconstrictors group (n = 126) and vasoconstrictors plus acid suppression group (n = 511). We observed that the rebleeding and mortality rates were not significantly different between 2 groups during hospitalization and the 15-year follow-up period after discharge. A Charlson score ≥3 (odds ratio: 2.42, 95% confidence interval: 1.55 ~3.79, P = 0.0001), presence of hepatitis C virus (odds ratio: 1.70, 95% confidence interval: 1.15 ~2.52, P = 0.0085), and cirrhosis (odds ratio: 1.69, 95% confidence interval: 1.08 ~2.66, P = 0.0229) were the independent risk factors of mortality after discharge. In conclusion, the results of the current study suggest that adjuvant acid suppression prescription to patients who received endoscopic variceal ligation and vasoconstrictor therapy for bleeding esophageal varices may not change the rebleeding and mortality outcomes compared to that for those who received endoscopic variceal ligation and vasoconstrictor agents without acid suppression.

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The Role of Adjuvant Acid Suppression on the Outcomes of Bleeding Esophageal Varices after Endoscopic Variceal Ligation

January The Role of Adjuvant Acid Suppression on the Outcomes of Bleeding Esophageal Varices after Endoscopic Variceal Ligation Cheng-Kun Wu 0 1 2 Chih-Ming Liang 0 1 2 Chien-Ning Hsu 0 2 Tsung-Hsing Hung 0 2 Lan- Ting Yuan 0 2 Seng-Howe Nguang 0 2 Jiunn-Wei Wang 0 2 Kuo-Lun Tseng 0 2 Ming-Kun Ku 0 2 Shih-Cheng Yang 0 1 2 Wei-Chen Tai 0 1 2 Chih-Wei Shih 0 2 Pin-I Hsu 0 2 3 Deng-Chyang Wu 0 2 Seng-Kee Chuah 0 1 2 0 Abbreviations: EV , esophageal variceal; EVL, endoscopic variceal ligation; NHRID , National Health Research Institute database; PPI , proton 1 Division of Hepato-gastroenterology; Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital , Kaohsiung, Taiwan , 2 Department of Pharmacy, Kaohsiung Chang Gung Memorial Hospital , Kaohsiung, Taiwan , 3 School of Pharmacy, Kaohsiung Medical University , Kaohsiung, Taiwan , 4 Division of Hepato-gastroenterology; Department of Internal Medicine, Dalin Tzu Chi General Hospital, Buddhist Tzu Chi Medical Foundation, Chiayi, Taiwan, 5 Divisions of Gastroenterology, Yuan General Hospital , Kaohsiung, Taiwan , 6 Division of Gastroenterology; Pin-Tung Christian Hospital , Pin-Tung, Taiwan , 7 Division of Gastroenterology, Department of Internal Medicine, Kaohsiung Medical University Hospital and Kaohsiung Medical University , Kaohsiung, Taiwan , 8 Division of Gastroenterology; FooYin University Hospital , Pin- Tung, Taiwan , 9 Chang Gung University, College of Medicine, Kaohsiung, Taiwan, 10 Division of Hepatogastroenterology; Department of Internal Medicine, ChiaYi Chang Gung Memorial Hospital , Chiayi , Taiwan 2 Editor: John Green, University Hospital Llandough , UNITED KINGDOM 3 Division of Gastroenterology, Department of Internal Medicine, Kaohsiung Veterans General Hospital, National Yang-Ming University , Kaohsiung , Taiwan The impact of adjuvant acid suppression via proton pump inhibitors or histamine-2 receptor antagonists after endoscopic variceal ligation remains uncertain. We therefore aimed to evaluate the effect of adjuvant acid suppression on the rebleeding and mortality rates in patients who received endoscopic variceal ligation and vasoconstrictor therapy for bleeding esophageal varices. Data from 1997 to 2011 were extracted from the National Health Insurance Research Database in Taiwan. A total of 1576 cirrhotic patients aged > 18 years with a primary diagnosis of acute esophageal variceal bleeding who received endoscopic variceal ligation therapy were screened. After strict exclusion, 637 patients were recruited. The exclusion criteria included patients with gastric variceal bleeding, failure in the control of bleeding, mortality within 12 hours, and history of hepatocellular carcinoma or gastric cancer. Patients were divided into two groups: the vasoconstrictors group (n = 126) and vasoconstrictors plus acid suppression group (n = 511). We observed that the rebleeding and mortality rates were not significantly different between 2 groups during hospitalization and the 15-year follow-up period after discharge. A Charlson score confidence interval: 1.55 ~3.79, P = 0.0001), presence of hepatitis C virus (odds ratio: 1.70, 95% confidence interval: 1.15 ~2.52, P = 0.0085), and cirrhosis (odds ratio: 1.69, 95% confidence interval: 1.08 ~2.66, P = 0.0229) were the independent risk factors of mortality after discharge. In conclusion, the results of the current study suggest that adjuvant acid suppression prescription to patients who received endoscopic variceal ligation and vasoconstrictor therapy for bleeding esophageal varices may not change the rebleeding and mortality - Data Availability Statement: All relevant data is contained within the manuscript and supporting information files. Funding: The authors received no specific funding for this work. Competing Interests: The authors have declared that no competing interests exist. pump inhibitors; H2RA, histamine-2 receptor antagonists; SD, standard deviation; HBV, hepatitis B virus; HCV, hepatitis C virus. outcomes compared to that for those who received endoscopic variceal ligation and vasoconstrictor agents without acid suppression. Introduction Esophageal varices (EV) are one of the most common complications occurring in patients with cirrhosis. About one-third of patients with cirrhosis can experience their first episode of acute EV bleeding during follow-up, with a 70% recurrent bleeding rate and 20~50% mortality rate [1±3]. Fortunately, with recent advances in medicine and endoscopic hemostatic devices, a decrease in mortality rate has been observed over the past two decades [4±9]. Treatment for acute EV bleeding is now standardized, and includes endoscopic variceal ligation (EVL) combined with vasoconstrictor treatment and prophylactic antibiotics [2±4, 10±12]. However, the research regarding the role of an adjuvant proton pump inhibitor (PPI) in EV bleeding after EVL remains limited and unconvincing. Generally, for patients in the acute phase of cirrhosis with sympto (...truncated)


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Cheng-Kun Wu, Chih-Ming Liang, Chien-Ning Hsu, Tsung-Hsing Hung, Lan-Ting Yuan, Seng-Howe Nguang, Jiunn-Wei Wang, Kuo-Lun Tseng, Ming-Kun Ku, Shih-Cheng Yang, Wei-Chen Tai, Chih-Wei Shih, Pin-I Hsu, Deng-Chyang Wu, Seng-Kee Chuah. The Role of Adjuvant Acid Suppression on the Outcomes of Bleeding Esophageal Varices after Endoscopic Variceal Ligation, PLOS ONE, 2017, Volume 12, Issue 1, DOI: 10.1371/journal.pone.0169884