studies

HEPATOLOGY, VOLUME 62, NUMBER 1 (SUPPL) AASLD ABSTRACTS 581A
The following authors have nothing to disclose: Nicole Loo, Khurram Bari, Salvador
Augustin, Maria Ciarleglio, Yanhong Deng, Mario Strazzabosco
744
Inter-observer variability is high for the assessment of
active bleeding at endoscopy in cirrhotic patients with
variceal bleeding
Simona Tripon 1 , Marika Rudler 1 , Maxime Mallet 1 , Christophe
Bureau 2 , Dominique Thabut 1 ; 1 Hepatology ICU, AP-HP, hôpital
Pitié-Salpêtrière, Paris, France; 2 Service d’Hépato-Gastroentérologie,
Hôpital Purpan, Toulouse, France
Background/Aim: Guidelines stipulate that an early-TIPS
placement must be considered in patients with Child-Pugh B
(CPB) cirrhosis and variceal bleeding (VB) with active bleeding
at initial endoscopy. However, there are no strong data
confirming that active bleeding is predictive of bad survival
in CPB patients. Moreover, it is a subjective criterion, which
inter-observer variability has never been evaluated. The aim
of this study was to assess the inter-observer variability of the
endoscopic finding of active bleeding in patients with cirrhosis
and portal hypertension-related gastrointestinal bleeding
(GIB), using video-recording of endoscopies. Methods: We
prospectively included all consecutive patients with cirrhosis
and upper GIB admitted in Hepatological ICU between October
2014 and May 2015. Endoscopies were performed by
a senior hepatologist in charge of the patient. Patients were
treated according to Baveno V recommendations. Endoscopies
were recorded and analyzed by 4 other senior hepatologists
who were blinded to patients’ diagnosis and outcomes
and to each other findings. Interobserver agreement for endoscopic
findings was determined using an agreement rate and
Kappa statistics. Results: Overall, 224 evaluations were performed
in 56 patients with upper GIB and cirrhosis Patients
characteristics: male gender: 66.1%; age 60 ± 11.9 yrs ;
etiology of cirrhosis: alcohol= 52%, viral=20%, other=28%
; Child-Pugh A/B/C= 12./36/52% ; MELD score 18.8 ± 7
; shock at admission 23%, source of bleeding according to
physician in charge of the patient: oesophageal varices 50 %,
cardial varices 11 %, ulcer 5 %, portal gastropathy 5%, other
29%). Interobserver agreement for assessment of the source
of bleeding was excellent (kappa=0.76, CI95%: 0.54-0.88)
whereas interobserver agreement for the diagnosis of active
bleeding at endoscopy was poor (kappa=0.55, CI95%: 0.35-
0.70). Early-TIPS was indicated in 6 CPB patients because of
active bleeding at endoscopy. Interobserver agreement was
also poor for the diagnosis of active bleeding at endoscopy in
those patients (kappa=0.45, CI95%: 0.24-0.60). Conclusion:
Inter-observer variability in the evaluation of active bleeding at
endoscopy is very high in patients with cirrhosis and variceal
bleeding. This criterion should not be used anymore to indicate
early-TIPS placement.
Disclosures:
Marika Rudler - Speaking and Teaching: Gilead, Mayoly
Christophe Bureau - Grant/Research Support: Gore; Speaking and Teaching:
Gore
The following authors have nothing to disclose: Simona Tripon, Maxime Mallet,
Dominique Thabut
745
Prevention of Recurrent Variceal Hemorrhage: Individual
Patient Data (IPD) Meta-Analyses Of Outcomes With
Current Therapy Based On Severity Of Cirrhosis
Agustin Albillos 1 , Javier M. González 1 , David Arroyo-Manzano 2 ,
Javier Zamora 2 , Irfan Ahmad 3 , Joaquin de la Peña 4 , Juan Carlos
Garcia-Pagan 5 , Gin-Ho Lo 6 , Shiv K. Sarin 7 , Jaime Bosch 5 , Juan
Abraldes 8 , Guadalupe Garcia-Tsao 9 ; 1 Hospital Universitario
Ramon y Cajal, IRYCIS, CIBEREHD, Madrid, Spain; 2 Hospital
Universitario Ramon y Cajal, IRYCIS, CIBERESP, Madrid, Spain;
3 Sheikh Zayed Medical College/Hospital, Rahim Yar Khan, Pakistan;
4 Hospital Universitario Marqués de Valdecilla, Santander,
Spain; 5 Hospital Clinic, IDIBAPS, CIBEREHD, University of Barcelona,
Barcelona, Spain; 6 E-DA Hospital, Kaohsiung, Taiwan;
7 Institute of Liver and Biliary Sciences, New Delhi, India; 8 University
of Alberta, Alberta, AB, Canada; 9 Yale University School of
Medicine, New Haven, CT
Current standard of care to prevent variceal rebleeding, i.e.
endoscopic variceal ligation plus beta-blockers (EVL+BB), is
recommended for all patients. Since risk stratification is essential
in individualizing care, we aimed to investigate whether
outcomes of this therapy would differ depending on cirrhosis
severity. Because data were unavailable from published studies,
we performed meta-analyses using IPD from fully published
RCT that compared EVL+BB vs. each therapy alone (BB or EVL)
and that reported results on all-source rebleeding and mortality
in patients with cirrhosis who had recovered from acute
variceal hemorrhage. We performed two meta-analyses: one
using IPD from 3 trials (389 patients) comparing EVL+BB vs.
BB (+nitrates if tolerated) (Ahmad 2009, Garcia-Pagan 2009,
Lo 2009) and the second using IPD from 4 trials (409 patients)
comparing EVL+BB vs. EVL alone (Ahmad 2009, De la Peña
2005, Kumar 2009 and Lo 2000). We excluded 4 trials: 2
abstracts, 1 with HVPG-guided drug therapy, and 1 not reporting
mortality. Multilevel logistic regression models were fitted to
perform one-step IPD meta-analyses, with rebleeding and mortality
as dependent variables and severity of cirrhosis (Child
A vs. B/C, ascites, bilirubin, albumin) and treatment modality
as independent variables. Interaction terms between treatment
modality and covariates were included in the model to test if
treatment effect varied between subgroups. Results: The first
meta-analysis (BB control group) failed to show superiority of
combination therapy vs. BB alone, with a trend for a significant
benefit in Child A patients. The second meta-analysis
(EVL control group) shows that combination therapy EVL+BB is
superior to EVL alone as it reduces rebleeding in all patients,
with a significant reduction in mortality, particularly in Child
B/C pts. Conclusions: Results suggest that BB alone are equivalent
to combination therapy, however these results should be
taken cautiously given large confidence intervals. In contrast,
results clearly show that EVL alone carries an increased risk of
rebleeding and death, indicating that BB are the cornerstone
of combination therapy in the prevention of recurrent variceal
hemorrhage.