Khawaja Imran, Babar Muhammad, Awan Shakeel Ahmad, Shaikh Asif J, Abbasi Adnan A
Internal Medicine, Ayub Teaching Hospital, Abbottabad, PAK.
Medicine, University Hospitals Birmingham NHS Foundation Trust, Birmingham, GBR.
Cureus. 2023 Jan 18;15(1):e33932. doi: 10.7759/cureus.33932. eCollection 2023 Jan.
Background Endoscopic variceal ligation (EVL) is a surgical intervention that can work well to curb variceal bleeding in people with liver cirrhosis. However, it could make ulcer bleeding worse and be fatal in some cases. The widespread use of proton pump inhibitors (PPI) in cirrhotic individuals with variceal bleeding is empirical rather than based on scientific data. According to many studies, PPIs reduce the size of post-EVL ulcers. This study aimed to see if PPI use could reduce rebleeding after endoscopy therapy in cirrhotic patients with variceal bleeding. Methodology A retrospective cross-sectional study was conducted at a tertiary care hospital from August 2019 to September 2021. Cirrhotic patients with bleeding gastroesophageal varices(GEVs) who had undergone EVL at the same hospital were enrolled in the study. Medical records were organized, and the sample was divided into two groups based on whether or not PPI was given. Both PPI and non-PPI patients had their endoscopic findings, initial hemostasis outcomes, rebleeding rates, bleeding-related mortality rates, and treatment-related comorbidities compared. Results A total of 46 patients were selected for the study and divided into two groups (PPI group n=28 and non-PPI group n=18). The majority of the patients were males. The PPI group had a mean age of 58.6 ±7.8 years, whereas the non-PPI group had a mean age of 53.6 ±4.4 years. Hepatitis B virus (HBV) infection was the most prevalent cause of cirrhosis in both groups. After endoscopic treatment, three patients (16%) in the non-PPI group suffered a variceal hemorrhage. Bleeding-related fatalities and the time it took for the bleeding to stop varied significantly between the two groups. History of variceal bleeding (relative risk (RR)=1.45; 95% confidence interval (CI), 1.60-7.67; p=0.02), presence of gastric varices (RR=2.23; 95% CI, 2.56-9.832; p=0.035), and not administering PPIs (RR =7.542; 95% CI, 3.98-29.13; p=0.008) were linked with rebleeding. The presence of red concurrent esophageal varices (RR=6.37; 95% CI, 0.562-15.342; p=0.002) and failure to provide PPIs (RR=2.3; 95% CI, 1.621-25.64; p=0.04) were linked with post-EVL bleeding in a multivariate analysis. Conclusions Proton pump inhibitors reduce the occurrence of early bleeding and adverse events after EVL in cirrhotic patients. Not prescribing PPIs and the presence of GEVs were substantially related to a higher risk of bleeding during preventative EVL. Not initiating PPI medication immediately was the sole predictor of bleeding complications in patients who had undergone EVL without gastric varix treatment. To lower the risk of post-EVL ulcer bleeding, we recommend PPI use in patients undergoing EVL.
内镜下静脉曲张结扎术（EVL）是一种手术干预措施，对控制肝硬化患者的静脉曲张出血效果良好。然而，它可能会使溃疡出血恶化，在某些情况下甚至会致命。质子泵抑制剂（PPI）在伴有静脉曲张出血的肝硬化患者中广泛使用是基于经验而非科学数据。多项研究表明，PPI可减小EVL术后溃疡的大小。本研究旨在探讨使用PPI是否能降低静脉曲张出血的肝硬化患者内镜治疗后的再出血率。
于2019年8月至2021年9月在一家三级医院进行了一项回顾性横断面研究。纳入在同一家医院接受过EVL的出血性胃食管静脉曲张（GEV）肝硬化患者。整理病历，并根据是否给予PPI将样本分为两组。比较PPI组和非PPI组患者的内镜检查结果、初始止血效果、再出血率、出血相关死亡率以及治疗相关合并症。
共46例患者入选本研究并分为两组（PPI组n = 28，非PPI组n = 18）。大多数患者为男性。PPI组的平均年龄为58.6±7.8岁，而非PPI组的平均年龄为53.6±4.4岁。两组中，乙型肝炎病毒（HBV）感染是肝硬化最常见的病因。内镜治疗后，非PPI组有3例患者（16%）发生静脉曲张出血。两组间出血相关死亡率及出血停止时间差异有统计学意义。静脉曲张出血史（相对危险度（RR）= 1.45；95%置信区间（CI），1.60 - 7.67；p = 0.02）、胃静脉曲张的存在（RR = 2.23；95% CI，2.56 - 9.832；p = 0.035）以及未使用PPI（RR = 7.542；95% CI，3.98 - 29.13；p = 0.008）与再出血有关。多因素分析显示，红色并发食管静脉曲张的存在（RR = 6.37；95% CI，0.562 - 15.342；p = 0.002）和未使用PPI（RR = 2.3；95% CI，1.621 - 25.64；p = 0.04）与EVL术后出血有关。
质子泵抑制剂可降低肝硬化患者EVL术后早期出血及不良事件的发生率。未开具PPI处方以及存在GEV与预防性EVL期间出血风险较高密切相关。未立即开始使用PPI药物是未接受胃静脉曲张治疗的EVL患者出血并发症的唯一预测因素。为降低EVL术后溃疡出血的风险，我们建议对接受EVL的患者使用PPI。
