Factors predictive of relapse in variceal upper gastrointestinal bleeding. A prospective study in patients with liver cirrhosis

Rebleeding occurs in 50-80% of these patients, and in more than half of them, during the first 6 weeks (De Franchis et al 2010; Paunescu et al 2004). Each episode of variceal gastrointestinal bleeding is associated with a 20-35% mortality rate (Cerquiera et al 2009). Variceal rebleeding is a new haemorrhagic episode that occurs later than 5 days from the first one, an interval that defines the acute bleeding episode. There is a higher risk of rebleeding between 5 days and 6 weeks (De Franchis et al 2015). After this period, the risk of rebleeding is the same as in other patients with cirrhosis and without variceal bleeding (Sharma et al 2011). Failure to control bleeding is defined as an impossibility to manage the bleeding, including death, or rebleeding in the interval from the onset of bleeding and day 5 (Herrera 2014; De Franchis et al 2010; De Franchis et al 2015). Rebleeding can be associated with failure to control bleeding, presence of ascites, hepatic encephalopathy, spontaneous bacterial peritonitis, marked changes in coagulation factors, low platelet counts, extensive esophageal varices, gastric varicose veins as the source of bleeding, or active bleeding during endoscopy (Biecker 2013). The low survival rate among patients with variceal bleeding and liver cirrhosis is primarily due to the decompensation of liver disease presence of ascites and hepatic encephalopathy (Kim et al 2014; Garcia-Tsao et al 2007). Other risk factors for mortality in variceal bleeding are: rebleeding, hepatocarcinoma, Introduction Upper gastrointestinal bleeding (UGIB) is one of the most frequent and severe gastroenterological emergencies, with an annual incidence of 50-150 in 100,000 people (Vreeburg et al 1999). Upper gastrointestinal bleeding is characterized by hematemesis (i.e. vomiting of red blood or coffee ground emesis), or melena (black, shiny, tarry and smelly faeces), or both at the same time. Another sign that is less common is hematochezia (the passage of fresh blood through the anus), and can occur if the intestinal transit is accelerated or bleeding is severe (Cappel et al 2008). Severe complications of UGIB may occur. The most important are rebleeding and death. Over the past 10 years, the reported mortality rate has remained between 3% and 14% (Sostres et al 2011). In our previous study (Groza et al 2017) we found a 10-20% six-week mortality rate. Rebleeding is considered to be one of the risk factors for mortality. It occurs between 10% and 30% of the cases considered at first to be successfully treated (Matei et al 2013, Chandra et al 2011, Ahmed et al 2003). Upper gastrointestinal bleeding may occur from either variceal or non-variceal sources. Variceal bleeding is present in 60-65% of patients with liver cirrhosis, and 30% of them bleed in the first year after diagnosis (Garcia-Tsao et al 2007). The incidence of esophageal varices varies from 30% to 70% in patients with liver cirrhosis. Gastric varices are present in 5-33% of patients with portal hypertension (McKay et al 2007; Popovici et al 2013). Abstract. Aim: The aim of the study was to identify the main predictive factors of relapse in variceal upper gastrointestinal bleeding (UGIB) in cirrhotic patients.Methods: The study was performed on 184 cirrhotic patients who presented for variceal UGIB to the emergency department of a tertiary hospital during a period of 26 months. Clinical, laboratory and endoscopic data were recorded.Results: The rate of failure to control bleeding was 17.9%, of these, 48.5% died in the first 5 days (p<0.001). Two factors proved to be independently associated with failure to control bleeding: the grade of esophageal varices (OR=4.35, 95%CI: 1.23-15.34)(p=0.022) and hypoalbuminemia (OR=2.56, 95%CI:1.086.09)(p=0.033). Failure to control bleeding was more frequent in patients with an albumin level <2.9g/dL.The rebleeding rate at 6 weeks was 16.7%. Two factors were independently associated with rebleeding: failure to control bleeding (OR=6.63, 95%CI: 2.16-20.37)(p=0.001) and the INR level (OR=3.87, 95%CI: 1.58-9.45)(p=0.003). The risk of rebleeding increased above an INR cut-off of 1.94 (p=0.011).Conclusion: Several factors have been identified to correlate with failure to control bleeding and rebleeding in patients with cirrhosis and variceal hemorrhage.