Esophageal Variceal Bleeding as the First Manifestation of COVID-19 Infection: A Case Report

Liver cirrhosis is a defined liver disease with a wide range of clinical manifestations. Variceal bleeding is the main source of gastrointestinal hemorrhage among cirrhotic patients induced by several factors, such as alcohol consumption or infections. This is a report of a cirrhotic patient presenting with esophageal variceal bleeding in the context of COVID-19 infection. We report the case of a 53-year-old patient with liver cirrhosis and multifocal hepatocellular carcinoma presenting with upper gastrointestinal bleeding as the first manifestation of COVID-19 infection. Upon admission, the patient had no symptoms suggestive of a respiratory tract infection or any contact with positive SARS-CoV-2 individual and upper gastrointestinal endoscopy revealed variceal hemorrhage. After a few hours the patient manifested with fever, cough and dyspnea and a SARS-CoV-2 polymerase chain reaction test obtained was positive. The patient was initially treated with endoscopic band ligation and transferred in the COVID-19 infection clinic, where after a few days of hospitalization he passed away. The devastating pandemic of coronavirus disease 2019 had altered the pathophysiology and clinical presentation of several chronic diseases. This case report suggests that coronavirus disease as a potential triggering factor of variceal bleeding.

Comparing the Effectiveness of Carvedilol and Propranolol to Prevent Reoccurrence of Esophageal Variceal Bleeding in Patients with Liver Cirrhosis.

Objective: To compare the efficacy of carvedilol and propranolol to prevent reoccurrence of esophageal variceal bleeding in patients with liver cirrhosis. Study Design: Place and Duration: Department of Gastroenterology and Hepatology, Ayub Teaching Hospital, Abbottabad, Pakistan for six months duration from 15th November 2020 to 15th May 2021. Methods: Total one hundred and forty patients of ages between 18-65 years were presented in this study. Patients detailed demographics age, sex, body mass index and Child-Turcotte-Pugh (CTP) class were recorded after taking written informed consent. Patients were equally (n=70) divided into two groups. Group A had 70 patients and received carvedilol while group B had 70 patients and received propranolol for 6 months. Reoccurrence ofesophageal variceal bleeding in cirrhotic patients among both groups were observed at 2nd, 4th and 6th months and patients pulse rate, arterial pressure and portal vein flow were recorded at these time points. Complete data was analyzed by SPSS 26.0 version. Results: Mean age of the patients in group A was 40.38 ± 5.87 years with mean BMI 28.09 ± 7.33 kg/m2 and in group B mean age was 39.43 ± 12.69 years with mean BMI 27.53 ± 8.84 kg/m2. In group A 45 (64.3%) patients were males and 25 (35.7%) were female patients while in group B 50 (71.43%) were male patients and 20 (28.7%) patients were females. We found that there was no statistically significant difference observed among both groups regarding these demographic variables. Reoccurrence of bleeding observed in group A was significantly lower (among 20 (28.6%) cases) as compared to group B (among 36 (51.43%) cases). Pulse rate, mean arterial pressure and portal vein flow was found lower in the carvedilol group as compared to propanol group with p value < 0.05 upon follow up at2,4 and 6 months. Conclusion: We found in this study that the drug carvedilol was more effective and safe to prevent reoccurrence of esophageal variceal bleeding in cirrhotic patients as compared to propanol. Keywords: Cirrhotic patients, Carvedilol, Propanol, Portal vein flow, Mean arterial pressure

Seasonal variation in acute variceal upper gastrointestinal tract bleeding: Experience of one decade from Northern India

Background: There have been several reports of seasonal variations in the incidence of esophageal variceal bleeding but the data available from this part of the world is scanty. Aims and Objective: We aimed to study whether monthly and seasonal climatic changes during the year have an influence on the incidence of variceal bleeding in our setting and whether a particular time in the year can be defined as a high-risk period for variceal bleed. Materials and Methods: Data of all the patients with diagnosis of acute variceal upper gastrointestinal bleed who presented to our endoscopy centre from January 2010 to December 2019 was retrieved and analysed. The demographic data, clinical presentations and seasonal and monthly variation was analysed. Results: Out of a total of 10200 patients presenting with upper gastrointestinal bleed during the study time period, 530 patients had a diagnosis of variceal bleed after esophagogastroduodenoscopy (EGD). The majority of variceal bleed patients (48.5%) were seen between May to August months of the year. Conclusions: Contrary to the most of the literature which shows increased frequency of variceal bleed during winters, our patients bleed more during the months of May and August. This could be explained on the basis of unique socio-cultural and demographic pattern of this part of the world.

Short-course vasoconstrictors are adequate for esophageal variceal bleeding after endoscopic variceal ligation: A systematic review and meta-analysis

Endoscopic variceal ligation (EVL) with vasoconstrictors has been recommended for acute esophageal variceal bleeding. However, the optimal duration of vasoconstrictors after EVL is controversial. This systematic review and meta-analysis was conducted to explore the efficacy of short-course vasoconstrictors (≤3 days) versus standard combination (3–5 days). A comprehensive literature review was conducted using the PubMed, Embase, and Cochrane library databases with subsequent meta-analysis. The primary outcomes were 5-day rebleeding, mortality, and treatment failure rates. A risk ratio (RR) with 95% confidence interval is used for outcome comparison. Nine randomized studies with 838 patients were included. The initial hemostasis (96.8% vs 97.4%, p = 0.919), 5-day rebleeding (11.2% vs 8.3%, RR = 1.05, 95% CI = 0.62–1.76), mortality (0 vs 1.3%, RR = 0.48, 95% CI = 0.10–2.39), and treatment failure (7.4% vs 5.9%, RR = 1.10, 95% CI = 0.48–2.49) were similar in both groups. Subgroup analysis suggested EVL alone had no significant difference of 5-day re-bleeding (15.9% vs 7.1%, RR = 2.25, 95% CI = 0.87–5.77), mortality (0 vs 0.7%, RR = 0.71, 95% CI = 0.08–6.03), treatment failure (9.6% vs 6.7%, RR = 1.43, 95% CI = 0.54–3.75) compared to standard combination. Clinical heterogeneity was found for the rebleeding rate for the subgroup during sensitivity analysis. EVL with short-course vasoconstrictors is highly efficacious for esophageal variceal bleeding. Further studies are required to determine the genuine need of subsequent vasoconstrictor after successful EVL.

Efficacy of Octreotide Versus Terlipressin along with Endoscopic Variceal Ligation (EVL) in Preventing Re-bleeding and Mortality in Acute Bleeding Esophageal Varices in Cirrhosis: A Randomized Prospective Study

Background: Octreotide and terlipressin are two pharmacologic drugs used as an adjuvant therapy in the treatment of acute esophageal variceal bleeding. Large enough clinical trial data is not available, in comparing the efficacy of octreotide versus terlipressin as an adjunct to EVL for control of variceal bleed. Still, there is a scarcity of data on which is the better efficient drug amongst terlipress in and octreotide to control 5 days rebleeding. Aim: To compare efficacy of octreotide versus terlipressin in preventing the 6 weeks mortality (primary outcome) and 5 days rebleeding (secondary outcome) in cases of acute esophageal variceal bleeding. Method: All the patients of cirrhosis of liver presenting with upper gastrointestinal bleeding admitted in the Medicine Intensive Care Unit(MICU) at Acharya Vinoba Bhave Rural Hospital (AVBRH) will be enrolled. In this Randomized Prospective study ,patients presenting with acute esophageal variceal bleed, after diagnostic endoscopy during a period of one year (august 2020 to july 2021) will be randomised into two group by simple randomisation with chits: Group A will receive Terlipressin while Group B will receive Octreotide for 5 days combined with esophageal variceal ligation. These two groups will be compared in terms of hemodynamic effects, child pugh score, MELD (Model for End stage Liver Disease) score to predict 6 weeks mortality as primary outcome and 5 day treatment failure as secondary outcome according to Bavino VI consensus statement. Expected results: From our study we are anticipating that both octreotide and terlipressin will be equally efficacious in controlling the EVB when given along with EVL therapy and also there will be no difference in both the drugs in preventing 6 weeks mortality and 5 days rebleeding. Conclusion: There will be no significant difference between Terlipressin and Octreotide in preventing 6 week mortality and 5 day rebleeding in bleeding esophageal varices when given along with EVL therapy.