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Natural history of low risk esophageal varices in cirrhotic patients
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15 NATURAL HJSTORY OF LOW P&K ESOPHAGEAL VARICES CIRRHOTIC PATIENTS G Nicolini, S Angeloni, 0 Rig@, V Rmaldi, AF Attili, M Merli I, Gastroenterology, Uiuversity “La Sapienza”, Rome
I&
Background and aims Early treatment aimed at preventing the development and/or progression of esophageal vatices (EV) and variceal bleeding in cirrhotic patients with low-risk EV has recently been proposed Therefore, it is important to know the natural history of low risk EV and to Identify the factors which predict rapid EV progression Methods We studled 176 cirrhotic patients (96 males and 80 females, mean age 60+12 years) with no EV or grade I EV (deftned as EV protruding less than one third of the esophageal lumen), at first endoscopy None of the patients had past episodes of gastrointestinal bleeding and none was assunung any treatment which could aff’t the portal hemodynamic The origin of cirrhosis was post-viral in 122 cases (106 HCV and I6 HBV), post-alcoholic m 25, cryptogenetx m 17, primary biliary cirrhosis in 9 and metabolic m 3 Casey Upon enrollment 83% of patients were Child Class A and 17% were Child Class B or C None had a diagnosis of hepatocellular carcinoma Patients were followed up as outpatients. medical examination, ultrasonography and biochemistry were performed at 6 months interval, while an endoscopy was performed by the same endoscopist every 12 months The end-points of the study were the appearance or progression of EV and bleeding episodes due to portal hypertension Data were analyzed using the Kaplan M&r plots Factors associated with the progression of EV or bleeding were evaluated by univariate analysis according to the Log rank test Results The mean follow up was 3,6*2,3 years (range 12 - 65 months) 106 patients did not present EV at enrollment (EV 0). In this gmup. the rate of appearance of new arices was 5% at 1 year, 21% at 3 years and 35% at 5 years 70 patients presented grade I EV, at the first endoscopy (EV I) The rate of progression to grade II or III EV was 3% at I year, 22% at 3 years and 44% at 5 years During the follow up bleeding episodes were 4 and 19 (EV 0 vs EV I respectwly, x2= 16.8, p= 0,00004) The cumulative surwval rate was better in patients with no EV at enrollment ( x2= 4,18, p= 0.04) The progression of vances was not influenced by the initial grade of EV (x2= 0.04, p= 0,8). but it was influenced by male sex (x2= 6,1, p= 0,Ol) and by post-alcoholic origm of cirrhoxs (x2=3,49, p= 0,06) Conclusions Our results indicate that a treatment for the preventloo ofEV progression could also be beneficial in patients with low nsk EV
THE RISK OF UPPERGI BLEEIJING IS HIGHER IN ACUTE THAN CHrmNlC NSAm USERS.A CASE-CONTROLsfuLw ON 2251ELDERLY sLlFmc~.
A62
COMBINED ADRENALINE NJECTION AND ARGON PLASM4 COAGULATION IN THE TREATMENT OF PEPTIC ULCER BLEEDING Scamoorrino A.**, Occhigrossi G.**, Marenga G.*, Serafini G.* “Istituto Clinica Chir?treicn d’Ureenza e di Pronto Soccorso Universitl di Roma “La Sapienza” *“U.O. di Gastraenterologia ed Endoscopia Dig&a, Ospedale S.Pertini, Ram& Italy Background the question whether the addition of a thermal method to injection of adrenaline in the endoscopic txatment of patients with ulcer bleeding improve the outcomes is still unclear Our previous study showed that APC alone ,s not sufficiently effective in stopping hemorrhage from
-.
-
ulcer with large vessel1 and dangerous in non bleeding visible vesselOur hypotesis was the combination adrenalina injection (AI) and thermal therapy together would be superior to thermal therapy alone for permanent haemostsis ulcer in particular for control of arterial bleedmg and nbw Aim to evaluate effkacy and safety of APC in association with Adrenaline injection m treatment of hemorrhage from peptic ulcer. Methods: from October 1998 to February 2000 we encontured 200 patients with
upper
gastrointestinal hemorrhage Fifty-three patients who presented with clmuxlly severe UGI hemorrahage from peptc ulcer received a combination of injection therapy wth adrenaline I 10 000 and Coagulation with Argon Plasma The median age was 67,5+12 2 (range 22-93) There were 34 men and 19 women The bleedmg site was duodenal ulcer in 30 patients, gastric ulcer in I7 patients ,aoastomotic ulcer in 5 esophageal ulcer in I patientStigmata of hemorrhage were actwe bleedmg in 23 patients( 6 spurtmg. I7 oozing), non bleeding visible vessel in 12 patients, fresh adherent clot in I8 patkents Results imtial hemostasis was was a&wed I” 52153 ( 98.1%). Rebleeding war observed in 5152 (9,6%),Surgery 3153 (5,6%) Deaths 4 153 (7,5% Injecion Adrenaline “m priming” providmg initial arrest of hemorrhaze facilited appkation of APC by enablmg more precise local-ization of sac of active bleeding There were sigiticantly lugher rates of mitlal hemostsia with combination injection and APC rispect to APC alone observed in a our previous experwnce APC was easy to use, versatk and resulted m less tissue damage respect to other methods of thermal therapy No major compbcations except epigastric dlscomfwt (6 pts) resulted from this treatment Conclusions we believe that a combination Adrenahna plus APC is a safe and effective method for treating non variceal gastromtestinal bleedlop.
c‘l~lil,~ soM,u~~S’rA,,N RFCRFroH II ,111YP’4 (sst) FXPKESRIIIN “F c<~NSII~I~III‘I>AS FIN I I”,‘. PRrKiNoSII(’ FM,< WS IN PArwN1’Swrr,, INIESII”I‘ NI~IIKOFNI)ITKINli’,1,MO,IRS(~ETS) 7 V D Corleto, S Ciardi. S Angeletti, A Moretti. S Nasoni. ‘A Barao. *A Scarpn, “C.A.?.zoni. “CBordi, G De,,e Fave Dept of Gastroenterology. llniversity La Sapienza, Roma, ‘Dept of Molecular Pathology, Universitv of Verona, “Dept of Pathology, University of Parma Background and Aim: Somatostatin (SS) synthetic analogues have been used either to treat and/or to localise dNETs with somatostatin receptor scintigraphy (SRS) Although SRS is useful to select dNET patients eligible for SS analogue treatment, it does not discriminate among different sst subtypes present on dNBTs. Moreover it is still unclear if tomow poor prognostic factors and/or sst subtype pattern expression can influence the response to SS analoyc treatment. The &lm of this st”dy WBI to determine the expression of sstl.s subtypes and turnour poor prognostic features (size. vascv,er and/or perineum1 invasion. nuclear atypia, capsular penetration. Ki67. P53 over-expression. a-HCG) in turnour specimens taken fi-om patients with primary and/or met&& dNET. Successively all the tumour analyses were related to the efficacy of either medical and/or surgicel twtment a&r almost I year of follow-up Mntcrinl and Methods Surgical or needle biopsy specimens were taken from 22 turnour lesions beloneinv to 16 dNET oatients 14 timctionine (F) and 12 non-functionine (NF)]: Tlmour tissues Lere e&r embeddz ~n’parsffm for histologici analvsis or snao frozen for RNA extraction RT-PCR with seecific primers for ;a,., subtipes was performed on DNAse-I treated &A, including appropriate controls. Results, RT-PCR showed the presence of sst subtypes in all but 2 dNET patients In both (NF). SRS did not visualise the hepatic lesions and the d&se behaved wgressively. One patient died I year at?er the surgery and one is dcahng with diffuse m&stases None of the 22 analysed lesions .howed sstd expression. sstl and sstz were the most exmeswl subtvoes beina oresent in I8 out of 22 dNETs sst1 was present in ,iand sstT in ij out ofii dNETs 3 patients (NF) with multiple l&ions did lnot show the same sst subtype expression pattern A very long lasting inhibition of tumoral disease was obtained in a patient with carcinoid syndrome that expressed only sstl subtype Over all somatostatin receptors. mcluding sst2 subtype. were expressed in 80% of both F and NF somatostatin rmalozzues treated patients Despite the presence of tomour poor prognostic f&tors, at follow-up all pat&s showed a stabilisation of the residual turnour disease during SS analogues treatment Conclusion These data so&test that the presence of sst subtypes on digestive Ineuroendocrinetomours tmsitively affect the clinical outcome and coo thus be considered as positivebrognosiic factors
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15 NATURAL HJSTORY OF LOW P&K ESOPHAGEAL VARICES CIRRHOTIC PATIENTS G Nicolini, S Angeloni, 0 Rig@, V Rmaldi, AF Attili, M Merli I, Gastroenterology, Uiuversity “La Sapienza”, Rome
I&
Background and aims Early treatment aimed at preventing the development and/or progression of esophageal vatices (EV) and variceal bleeding in cirrhotic patients with low-risk EV has recently been proposed Therefore, it is important to know the natural history of low risk EV and to Identify the factors which predict rapid EV progression Methods We studled 176 cirrhotic patients (96 males and 80 females, mean age 60+12 years) with no EV or grade I EV (deftned as EV protruding less than one third of the esophageal lumen), at first endoscopy None of the patients had past episodes of gastrointestinal bleeding and none was assunung any treatment which could aff’t the portal hemodynamic The origin of cirrhosis was post-viral in 122 cases (106 HCV and I6 HBV), post-alcoholic m 25, cryptogenetx m 17, primary biliary cirrhosis in 9 and metabolic m 3 Casey Upon enrollment 83% of patients were Child Class A and 17% were Child Class B or C None had a diagnosis of hepatocellular carcinoma Patients were followed up as outpatients. medical examination, ultrasonography and biochemistry were performed at 6 months interval, while an endoscopy was performed by the same endoscopist every 12 months The end-points of the study were the appearance or progression of EV and bleeding episodes due to portal hypertension Data were analyzed using the Kaplan M&r plots Factors associated with the progression of EV or bleeding were evaluated by univariate analysis according to the Log rank test Results The mean follow up was 3,6*2,3 years (range 12 - 65 months) 106 patients did not present EV at enrollment (EV 0). In this gmup. the rate of appearance of new arices was 5% at 1 year, 21% at 3 years and 35% at 5 years 70 patients presented grade I EV, at the first endoscopy (EV I) The rate of progression to grade II or III EV was 3% at I year, 22% at 3 years and 44% at 5 years During the follow up bleeding episodes were 4 and 19 (EV 0 vs EV I respectwly, x2= 16.8, p= 0,00004) The cumulative surwval rate was better in patients with no EV at enrollment ( x2= 4,18, p= 0.04) The progression of vances was not influenced by the initial grade of EV (x2= 0.04, p= 0,8). but it was influenced by male sex (x2= 6,1, p= 0,Ol) and by post-alcoholic origm of cirrhoxs (x2=3,49, p= 0,06) Conclusions Our results indicate that a treatment for the preventloo ofEV progression could also be beneficial in patients with low nsk EV
THE RISK OF UPPERGI BLEEIJING IS HIGHER IN ACUTE THAN CHrmNlC NSAm USERS.A CASE-CONTROLsfuLw ON 2251ELDERLY sLlFmc~.
A62
COMBINED ADRENALINE NJECTION AND ARGON PLASM4 COAGULATION IN THE TREATMENT OF PEPTIC ULCER BLEEDING Scamoorrino A.**, Occhigrossi G.**, Marenga G.*, Serafini G.* “Istituto Clinica Chir?treicn d’Ureenza e di Pronto Soccorso Universitl di Roma “La Sapienza” *“U.O. di Gastraenterologia ed Endoscopia Dig&a, Ospedale S.Pertini, Ram& Italy Background the question whether the addition of a thermal method to injection of adrenaline in the endoscopic txatment of patients with ulcer bleeding improve the outcomes is still unclear Our previous study showed that APC alone ,s not sufficiently effective in stopping hemorrhage from
-.
-
ulcer with large vessel1 and dangerous in non bleeding visible vesselOur hypotesis was the combination adrenalina injection (AI) and thermal therapy together would be superior to thermal therapy alone for permanent haemostsis ulcer in particular for control of arterial bleedmg and nbw Aim to evaluate effkacy and safety of APC in association with Adrenaline injection m treatment of hemorrhage from peptic ulcer. Methods: from October 1998 to February 2000 we encontured 200 patients with
upper
gastrointestinal hemorrhage Fifty-three patients who presented with clmuxlly severe UGI hemorrahage from peptc ulcer received a combination of injection therapy wth adrenaline I 10 000 and Coagulation with Argon Plasma The median age was 67,5+12 2 (range 22-93) There were 34 men and 19 women The bleedmg site was duodenal ulcer in 30 patients, gastric ulcer in I7 patients ,aoastomotic ulcer in 5 esophageal ulcer in I patientStigmata of hemorrhage were actwe bleedmg in 23 patients( 6 spurtmg. I7 oozing), non bleeding visible vessel in 12 patients, fresh adherent clot in I8 patkents Results imtial hemostasis was was a&wed I” 52153 ( 98.1%). Rebleeding war observed in 5152 (9,6%),Surgery 3153 (5,6%) Deaths 4 153 (7,5% Injecion Adrenaline “m priming” providmg initial arrest of hemorrhaze facilited appkation of APC by enablmg more precise local-ization of sac of active bleeding There were sigiticantly lugher rates of mitlal hemostsia with combination injection and APC rispect to APC alone observed in a our previous experwnce APC was easy to use, versatk and resulted m less tissue damage respect to other methods of thermal therapy No major compbcations except epigastric dlscomfwt (6 pts) resulted from this treatment Conclusions we believe that a combination Adrenahna plus APC is a safe and effective method for treating non variceal gastromtestinal bleedlop.
c‘l~lil,~ soM,u~~S’rA,,N RFCRFroH II ,111YP’4 (sst) FXPKESRIIIN “F c<~NSII~I~III‘I>AS FIN I I”,‘. PRrKiNoSII(’ FM,< WS IN PArwN1’Swrr,, INIESII”I‘ NI~IIKOFNI)ITKINli’,1,MO,IRS(~ETS) 7 V D Corleto, S Ciardi. S Angeletti, A Moretti. S Nasoni. ‘A Barao. *A Scarpn, “C.A.?.zoni. “CBordi, G De,,e Fave Dept of Gastroenterology. llniversity La Sapienza, Roma, ‘Dept of Molecular Pathology, Universitv of Verona, “Dept of Pathology, University of Parma Background and Aim: Somatostatin (SS) synthetic analogues have been used either to treat and/or to localise dNETs with somatostatin receptor scintigraphy (SRS) Although SRS is useful to select dNET patients eligible for SS analogue treatment, it does not discriminate among different sst subtypes present on dNBTs. Moreover it is still unclear if tomow poor prognostic factors and/or sst subtype pattern expression can influence the response to SS analoyc treatment. The &lm of this st”dy WBI to determine the expression of sstl.s subtypes and turnour poor prognostic features (size. vascv,er and/or perineum1 invasion. nuclear atypia, capsular penetration. Ki67. P53 over-expression. a-HCG) in turnour specimens taken fi-om patients with primary and/or met&& dNET. Successively all the tumour analyses were related to the efficacy of either medical and/or surgicel twtment a&r almost I year of follow-up Mntcrinl and Methods Surgical or needle biopsy specimens were taken from 22 turnour lesions beloneinv to 16 dNET oatients 14 timctionine (F) and 12 non-functionine (NF)]: Tlmour tissues Lere e&r embeddz ~n’parsffm for histologici analvsis or snao frozen for RNA extraction RT-PCR with seecific primers for ;a,., subtipes was performed on DNAse-I treated &A, including appropriate controls. Results, RT-PCR showed the presence of sst subtypes in all but 2 dNET patients In both (NF). SRS did not visualise the hepatic lesions and the d&se behaved wgressively. One patient died I year at?er the surgery and one is dcahng with diffuse m&stases None of the 22 analysed lesions .howed sstd expression. sstl and sstz were the most exmeswl subtvoes beina oresent in I8 out of 22 dNETs sst1 was present in ,iand sstT in ij out ofii dNETs 3 patients (NF) with multiple l&ions did lnot show the same sst subtype expression pattern A very long lasting inhibition of tumoral disease was obtained in a patient with carcinoid syndrome that expressed only sstl subtype Over all somatostatin receptors. mcluding sst2 subtype. were expressed in 80% of both F and NF somatostatin rmalozzues treated patients Despite the presence of tomour poor prognostic f&tors, at follow-up all pat&s showed a stabilisation of the residual turnour disease during SS analogues treatment Conclusion These data so&test that the presence of sst subtypes on digestive Ineuroendocrinetomours tmsitively affect the clinical outcome and coo thus be considered as positivebrognosiic factors
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