Advertisement

Digestive Diseases and Sciences

, Volume 51, Issue 2, pp 352–358 | Cite as

Improved Prognosis of Cirrhosis Patients with Esophageal Varices and Thrombocytopenia Treated by Endoscopic Variceal Ligation Plus Partial Splenic Embolization

  • Kenji OhmotoEmail author
  • Naoko Yoshioka
  • Yasuyuki Tomiyama
  • Norikuni Shibata
  • Michihiko Takesue
  • Koji Yoshida
  • Makoto Kuboki
  • Shinichiro Yamamoto
Liver

Abstract

The aim of this study was to assess the efficacy of the combination of endoscopic variceal ligation (EVL) and partial splenic embolization (PSE) compared with EVL alone in cirrhosis patients with thrombocytopenia. In a prospective study, 84 cirrhosis patients with esophageal varices and thrombocytopenia (platelet count < 50,000/mm3) underwent EVL plus PSE (N = 42) or EVL alone (N = 42). Primary end points assessed during the follow-up period included the recurrence of varices, progression to variceal bleeding, and death. Comparison between combined treatment and variceal ligation alone by multivariate analysis showed a hazard ratio of 0.44 for the recurrence of varices (P = 0.02), 0.19 for progression to variceal bleeding (P = 0.01), and 0.31 for death (P = 0.04). These results suggest that the combination of EVL plus PSE can prevent the recurrence of varices, progression to variceal bleeding, and death in cirrhosis patients with esophageal varices and thrombocytopenia.

Key Words

liver cirrhosis portal hypertension esophageal varices thrombocytopenia endoscopic variceal ligation partial splenic embolization 

Preview

Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.

References

  1. 1.
    The Northern Italian Endoscopic Club for the Study and Treatment of Esophageal Varices: Prediction of the first variceal hemorrhage in patients with cirrhosis of the liver and esophageal varices. N Engl J Med 319:983–989, 1988Google Scholar
  2. 2.
    Burroughs AK, Mezzanotte G, Phillips A, McCormick PA, McIntyre N: Cirrhotics with variceal hemorrhage: the importance of the time interval between admission and the start of analysis for survival and rebleeding rates. Hepatology 9:801–807, 1989PubMedGoogle Scholar
  3. 3.
    Novis BH, Duys P, Barbezat GO, Clain J, Bank S, Terblanche J: Fibreoptic endoscopy and the use of the Sengstaken tube in acute gastrointestinal haemorrhage in patients with portal hypertension and varices. Gut 17:258–263, 1976PubMedGoogle Scholar
  4. 4.
    Graham D, Smith JL: The course of patients after variceal hemorrhage. Gastroenterology 80:800–809, 1981PubMedGoogle Scholar
  5. 5.
    Silverstein FE, Gilbert DA, Tedesco FJ, Buenger NK, Persing H: The national ASGE surveys on upper gastrointestinal bleeding. Clinical prognostic factors. Gastrointest Endosc 27:80–93, 1981Google Scholar
  6. 6.
    D'Amico G, Pagliaro L Bosch J: Pharmacological treatment of portal hypertension: an evidence-based approach. Semin Liver Dis 19:475–505, 1999PubMedGoogle Scholar
  7. 7.
    Sarin SK, Lamba GS, Kumar M, Misra A, Murthy NS: Comparison of endoscopic ligation and propranolol for the primary prevention of variceal bleeding. N Engl J Med 340:988–993, 1999CrossRefPubMedGoogle Scholar
  8. 8.
    Aoki N, Kajiyama T, Beck R, Cone RW, Soma K, Fukui T: Decision analysis of prophylactic treatment for patient with high-risk esophageal varices. Gastrointest Endosc 52:707–714, 2000CrossRefPubMedGoogle Scholar
  9. 9.
    Baroncini D, Milandri GL, Borione D, Piemontese A, Cennamo V, Billi P, Dal Monte PP, D'Imperio N: A prospective randomized trial of sclerotherapy versus ligation in the treatment of bleeding esophageal varices. Endoscopy 29:235–240, 1997PubMedGoogle Scholar
  10. 10.
    Hou MC, Lin HC, Lee FY, Chang FY, Lee SD: Recurrence of esophageal varices following endoscopic treatment and its impact on rebleeding: comparison of sclerotherapy and ligation. J Hepatol 32:202–208, 2000CrossRefPubMedGoogle Scholar
  11. 11.
    Banares R, Albillos A, Rincon D, Alonso S, Gonzalez M, Ritz-del-Arbol L, Salcedo M, Molinero LM: Endoscopic treatment versus endoscopic plus pharmacologic treatment for acute variceal bleeding: a meta-analysis. Hepatology 35:609–615, 2002PubMedGoogle Scholar
  12. 12.
    Hou MC, Chen WC, Lin HC, Lee FY, Chang FY, Lee SD: A new “sandwich” method of combined endoscopic variceal ligation and sclerotherapy versus ligation alone in the treatment of esophageal variceal bleeding: a randomized trial. Gastrointest Endosc 53:572–578, 2001CrossRefPubMedGoogle Scholar
  13. 13.
    Singh P, Pooran N, Indaram A, Bank S: Combined ligation and sclerotherapy versus ligation alone for secondary prophylaxis of esophageal variceal bleeding: a meta- analysis. Am J Gastroenterol 97:623–629, 2002PubMedGoogle Scholar
  14. 14.
    Taniai N, Onda M, Tajiri T, Toba M, Yoshida H: Endoscopic variceal ligation (EVL) combined with partial splenic embolization (PSE). Hepatogastroenterology 46:2849–2853, 1999PubMedGoogle Scholar
  15. 15.
    Taniai N, Onda M, Tajiri T, Yoshida H, Mamada Y: Combined endoscopic and radiologic intervention to treat esophageal varices. Hepatogastroenterology 49:984–988, 2002PubMedGoogle Scholar
  16. 16.
    Beppu K, Inokuchi K, Koyanagi N, Nakayama S, Sakata H, Kitano S, Kobayashi M: Prediction of variceal hemorrhage by esophageal endoscopy. Gastrointest Endosc 27:213–218, 1981PubMedGoogle Scholar
  17. 17.
    Zoli M, Merkel C, Magalotti D, Marchesini G, Gatta A, Pisi E: Evaluation of a new endoscopic index to predict first bleeding from the upper gastrointestinal tract in patients with cirrhosis. Hepatology 24:1047–1052, 1996PubMedGoogle Scholar
  18. 18.
    Lay CS, Tsai YT, Teg CY, Shyu WS, Guo WS, Wu KL, Lo KJ: Endoscopic variceal ligation in prophylaxis of first variceal bleeding in cirrhotic patients with high-risk esophageal v arices. Hepatology 25:1346–1350, 1997CrossRefPubMedGoogle Scholar
  19. 19.
    Merkel C, Zoli M, Siringo S, van Buuren H, Magalotti D, Angeli P, Sacerdoti D, Bolondi L, Gatta A: Prognostic indicators of risk for first variceal bleeding in cirrhosis: a multicenter study in 711 patients to validate and improve the North Italian Endoscopic Club (NIEC) index. Am J Gastroenterol 95:2915–2920, 2000CrossRefPubMedGoogle Scholar
  20. 20.
    Jensen DM: Endoscopic screening for varices in cirrhosis: findings, implications, and outcomes. Gastroenterology 122:1620–1630, 2002CrossRefPubMedGoogle Scholar
  21. 21.
    Chalasani N, Imperiale TF, Ismail A, Sood G, Carey M, Wilcox CM, Madichetty H, Kwo PY, Boyer TD: Predictors of large esophageal varices in patients with cirrhosis. Am J Gastroenterol 94:3285–3291, 1999PubMedGoogle Scholar
  22. 22.
    Zaman A, Hapke R, Flora K, Rosen HR, Benner K: Factors predicting the presence of esophageal or gastric varices in patients with advanced liver disease. Am J Gastroenterol 94:3292–3296, 1999PubMedGoogle Scholar
  23. 23.
    Rajvanshi PR, Kowdley KV: Prediction of varices in patients with cirrhosis. A high-stakes numbers game? J Clin Gastroenterol 34:4–5, 2002Google Scholar
  24. 24.
    Madhotra R, Mulcahy HE, Willner I, ReubenA: Prediction of esophageal varices in patients with cirrhosis. J Clin Gastroenterol 34:81–85, 2002PubMedGoogle Scholar
  25. 25.
    Thomopoulos KC, Labropoulou-Karatza C, Mimidis KP, Katsakoulis EC, Iconomou G, Nikolopoulou VN: Non-invasive predictors of the presence of large oesophageal varices in patients with cirrhosis. Dig Liver Dis 35:473–478, 2003CrossRefPubMedGoogle Scholar
  26. 26.
    Giannini E, Botta F, Borro P, Risso D, Romagnoli P, Fasoli A, Mele MR, Testa E, Mansi C, Savarino V, Testa R: Platelet count/spleen diameter ratio: proposal and validation of a non-invasive parameter to predict the presence of oesophageal varices in patients with liver cirrhosis. Gut 52:1200–1205, 2003CrossRefPubMedGoogle Scholar
  27. 27.
    Van Os EC, Kamath PS, Gostout CJ, Heit JA: Gastroenterological procedures among patients with disorders of hemostasis: evaluation and management recommendations. Gastrointest Endosc 50:536–543, 1999Google Scholar
  28. 28.
    Spigos DG, Jonasson O, Mozes M, Capek V: Partial splenic embolization in the treatment of hypersplenism. Am J Roentgenol 132:777–782, 1979Google Scholar
  29. 29.
    Ohmoto K, Iguchi Y, Miyake I, Ohno S, Yamamoto S: Long-term evaluation of partial splenic embolization for liver cirrhosis and hepatocellular carcinoma accompanied by hypersplenism. Hepatol Res 11:73–83, 1998Google Scholar
  30. 30.
    Laine L, Cook D: Endoscopic ligation compared with sclerotherapy for treatment of esophageal variceal bleeding. A meta-analysis. Ann Intern Med 123:280–287, 1995Google Scholar
  31. 31.
    De la Peña J, Rivero M, Sanchez E, Fábrega E, Crespo J, Pons-Romero F: Variceal ligation compared with endoscopic sclerotherapy for variceal hemorrhage: prospective randomized trial. Gastrointerst Endosc 49:417–423, 1999Google Scholar
  32. 32.
    Porter BA, Frey CF, Link DP, Lantz BM, Pimstone NR: Splenic embolization monitored by the video dilution technique. Am J Roentgenol 141:1063–1065, 1983Google Scholar
  33. 33.
    Sato K, Tanaka M, Tanikawa K: The effect of spleen volume on liver regeneration after hepatectomy. A clinical study of liver and spleen volumes by computed tomography. Hepatogastroenterology 42:961–965, 1995Google Scholar
  34. 34.
    Hidaka H, Kokubu S, Saigenji K, Isobe Y, Maeda T: Restoration of thrombopoietin production after partial splenic embolization leads to resolution of thrombocytopenia in liver cirrhosis. Hepatol Res 23:265–273, 2002PubMedGoogle Scholar
  35. 35.
    Tajiri T, Onda M, Yoshida H, Mamada Y, Taniai N, Kumazaki T: Long-term hematological and biochemical effects of partial splenic embolization in hepatic cirrhosis. Hepatogastroenterology 49:1445–1448, 2002PubMedGoogle Scholar
  36. 36.
    Ohira M, Umeyama K, Taniura M, Yamashita T, Morisawa S: An experimental study of a splenic inhibitory factor influencing hepatic regeneration. Surg Gynecol Obstet 164:438–444, 1987PubMedGoogle Scholar
  37. 37.
    Hirai K, Kawazoe Y, Yamashita K, Kumagai M, Tanaka M, Sakai T, Inoue R, Eguchi S, Majima Y, Abe M, Toyonaga A, Tanikawa K: Transcatheter partial splenic arterial embolization in patients with hypersplenism: a clinical evaluation as supporting therapy for hepatocellular carcinoma and liver cirrhosis. Hepatogastroenterology 33:105–108, 1986PubMedGoogle Scholar

Copyright information

© Springer Science + Business Media, Inc. 2006

Authors and Affiliations

  • Kenji Ohmoto
    • 1
    • 2
    Email author
  • Naoko Yoshioka
    • 1
  • Yasuyuki Tomiyama
    • 1
  • Norikuni Shibata
    • 1
  • Michihiko Takesue
    • 1
  • Koji Yoshida
    • 1
  • Makoto Kuboki
    • 1
  • Shinichiro Yamamoto
    • 1
  1. 1.Division of Hepatology, Department of MedicineKawasaki Medical SchoolOkayamaJapan
  2. 2.Division of Hepatology, Department of MedicineKawasaki Medical SchoolOkayamaJapan

Personalised recommendations