Introduction

Gastrointestinal variceal bleeding is a serious complication of cirrhosis. Currently, no score has been validated to assess the prognosis of a bleeding episode in cirrhotic patients. The aim of our study was to evaluate the performance of the CAGIB score for recurrence and mortality following upper gastrointestinal bleeding in cirrhotic patients.

Aims & Methods

We conducted a retrospective study of cirrhotic patients hospitalized for upper gastrointestinal bleeding due to portal hypertension [2012-2022]. We calculated the scores CHILD-PUGH, MELD, MELD-Na, MELD 3.0, ALBI, ROCKALL, GBS, NLR and CAGIB, and compared their performance in terms of early recurrence (5-days) , short-term recurrence ( 6-weeks) and early mortality ( 6-weeks) through the study of ROC curves (SPSS software, P significant if <0.05).

Results

We included 105 patients with a mean age of 63 years and a sex ratio F/M=1.05. The origin of the bleeding was oesophageal varices rupture in 94.28% of cases and gastric varices rupture in 17.14%. Endoscopic treatment was performed in 96 patients, 90 of whom underwent band ligation of esophageal varices. Short-term recurrence was noted in 20% of patients. Early recurrence was noted in 3.8% of patients. Fourteen cases of early death were recorded. The CAGIB score was the best predictor of early recurrence (AUC=0.995, Sensibility=83.3%, Spécificity=99.6%, Odds Ratio=47, p<0.001) but it has a poor prognostic value for short-term recurrence (p=0,08). For early mortality, the CAGIB score performed better than the other scores (AUC=0.891) with a Sensibility=85.7% and Specificity=83.5% for predicting mortality from a cut-off ≥-4.648 with an OR=18.

Conclusion

The CAGIB score had the best predictive value for early recurrence and mortality following an episode of upper gastrointestinal bleeding due to portal hypertension in cirrhosis. We therefore propose it as an easy-to-calculate and reproducible tool, for a cut-off >-4.648.

Introduction

In patients with upper gastrointestinal bleeding (UGIB), the European Society of Gastrointestinal Endoscopy (ESGE) recommends adopting the following definitions regarding the timing of upper GI endoscopy: urgent (6-12h), early (≤24h), and delayed (>24h) (1). There is no consensus definition of emergent endoscopy, but previous publications use the timeline of <6h (2).
Early endoscopy is associated with better outcomes, and guidelines suggest that it should be performed within this time frame (1).
Last ESGE guideline about variceal bleeding (VB) suggests performing urgent endoscopy in this context (3). This is based on a meta-analysis showing lower overall mortality when endoscopy was performed <12h compared to >12h (4). Surprisingly, ESGE concludes that the optimal timing in this setting is controversial due to a lack of high-level evidence. In fact, except for this study, all the others examining this aspect show that performing endoscopy before 12h does not provide benefits (5,6).

Aims & Methods

We aim to compare whether urgent endoscopy (6-12h) provides benefits to VB and explore predictors for mortality.
Methods: Retrospective analysis of a prospective registry of UGIB patients admitted to 'Virgen de las Nieves University Hospital' (2013-2020). VB was defined as that coming from gastric or esophageal varices. Endoscopy timings were defined according to ESGE: emergent (<6h), urgent (6-12h), early (≤24h) and delayed (>24h) (1).
Main outcomes were in-hospital (endoscopy therapy, transfusion, rebleeding, misbalance of chronic condition, hospital stay, and mortality) and delayed-6 months (bleeding, cardiovascular events, mortality). Statistical analysis was performed using SPSS.

Results

1459 UGIB patients were collected, 216 with VB.
Statistical differences in main outcomes are shown in Table 1 (each letter in the subscript denotes column proportions that do not differ significantly from each other). No differences were found for the other outcomes.

Timing (% patients)	<6h (39.7%)	6-12h (28.8%)	12-24h (17.4%)	24h (2.7%)	p
Endoscopy therapy	85.1% a	63.5% b	65.8% b	66.7% b	0.014
Misbalance of chronic condition	48.3% a	30.2% b	23.7% b	50% a	0.026
Rebleeding	22.1% a	7.9% b	7.9% b	16.7% a	0.037
In-hospital mortality	27.4% a	13.6% b	11.1% b	50% a	0.025

We also compared basal characteristics and found differences in MAP(ASH) score≥2 (92.3% vs. 66.7% vs. 77.4% vs. 75%; p=0.003) and GBS≥12 (69% vs. 44.4% vs. 52.6% vs. 83.3%; p= 0.011).
Independent risk factors for in-hospital mortality were MAP(ASH)≥2 (1.26, 95% CI 1.03-1.54), misbalance of chronic condition (OR 9.92, 95% CI 3.56-27.61, p=0.000), and rebleeding (OR 3.95, 95% CI 1.45-10.79, p=0.007). The timing of endoscopy performing was not an independent prognostic factor for mortality.
We also conducted subgroup analysis to assess whether performing endoscopy before 12h provides benefits in other UGIB patients, without finding differences for patients with non-variceal bleeding or in those at higher risk of poor outcomes (GBS≥12, MAP(ASH)≥2, ASA≥3).

Conclusion

Our study highlights, in line with the majority of available ones (5,6), that endoscopy before 12h does not provide a benefit in patients with VB. This necessitates a reconsideration of the ESGE recommendation. Patients with endoscopy performed before 6 or after 24h have poor outcomes. However, multivariate analysis shows that the timing of endoscopy is not an independent prognostic factor for mortality. On the other hand, the decompensation of basal chronic disease and the severity of bleeding (determined by MAP(ASH) and rebleeding) are the determinants of patient outcomes.

References

1. Gralnek IM, Stanley AJ, Morris AJ, Camus M, Lau J, Lanas A, et al. Endoscopic diagnosis and management of nonvariceal upper gastrointestinal hemorrhage (NVUGIH): European Society of Gastrointestinal Endoscopy (ESGE) Guideline - Update 2021. Endoscopy. 2021 Mar;53(3):300-332.
2. Laursen SB, Leontiadis GI, Stanley AJ, Møller MH, Hansen JM, Schaffalitzky de Muckadell OB. Relationship between timing of endoscopy and mortality in patients with peptic ulcer bleeding: a nationwide cohort study. Gastrointest Endosc. 2017 May;85(5):936-944.e3.
3. Gralnek IM, Camus Duboc M, Garcia-Pagan JC, Fuccio L, Karstensen JG, Hucl T, et al.. Endoscopic diagnosis and management of esophagogastric variceal hemorrhage: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy. 2022 Nov;54(11):1094-1120.
4. Bai Z, Wang R, Cheng G, Ma D, Ibrahim M, Chawla S, Qi X. Outcomes of early versus delayed endoscopy in cirrhotic patients with acute variceal bleeding: a systematic review with meta-analysis. Eur J Gastroenterol Hepatol. 2021 Dec 1;33(1S Suppl 1):e868-e876.
5. Zhang W, Huang Y, Xiang H, Zhang L, Yuan L, Wang X, et al. Timing of endoscopy for acute variceal bleeding in patients with cirrhosis (CHESS1905): A nationwide cohort study. Hepatol Commun. 2023 May 4;7(5):e0152.

Introduction

Solid-pseudopapillary neoplasm (SPN) is a rare tumor of low malignancy that occurs predominantly in young females. Imaging of SPN is often described as a well-defined and heterogeneous tumor with calcifications or cysts, otherwise small size SPN often shows a homogeneously solid tumor. However, the differential diagnosis between SPN and other cystic tumors is often difficult due to the variety of imaging findings. In this report, we describe the clinical features and preoperative diagnosis of SPN we experienced at our hospital.

Aims & Methods

We studied 18 cases of SPN that were pathologically diagnosed by surgical resection at our hospital between 1997 and 2022.

Results

There were 12 female and 6 male patients, with a median age of 39.5 years (range: 9-67) and a median tumor size of 23 mm (range: 9-66). The tumor location was in the pancreatic head in 4 cases, body in 6 cases, and tail in 8 cases. The median follow-up period was 89.5 months (range: 8-265), and recurrence-free survival was achieved in all cases during the follow-up period. The tumors were incidentally detected in 15 cases during health check-ups (mainly by ultrasonography) or other medical examinations, while the other 3 cases were detected due to subjective symptoms that were thought to be caused by SPN. SPN could be diagnosed by contrast-enhanced CT in 10 of 18 cases (56%) and by EUS in 7 of 12 cases (58%). Contrast-enhanced CT showed enhancing mass in 10 cases, cystic component in 9 cases (50%), and calcification in 8 cases (44%). Among the 8 cases in which SPN could not be diagnosed by contrast-enhanced CT, EUS was performed in 7 cases, and we could diagnose SPN in 2 cases. Both cases had small lesions of less than 13 mm without cystic components, which made the differentiation from other tumors difficult on contrast-enhanced CT, however EUS showed well-circumscribed, well-defined, and homogeneously hypoechogenic tumors. MRI was performed in 12 cases, and could diagnose SPN in 5 cases, but MRI did not improve the diagnostic accuracy compared to contrast-enhanced CT. The diagnostic accuracy of EUS-guided fine needle aspiration (EUS-FNA) was 89% (8/9 cases). There were 5 cases in which SPN could not be diagnosed preoperatively. Among them, 3 cases had small tumor sizes (12-16 mm), and 4 cases lacked calcification, making it difficult to differentiate them from neuroendocrine tumors or solid-cystic neoplasms.

Conclusion

Most cases of SPN are detected incidentally, and regular abdominal ultrasonography during medical check-ups is important for early detection. Diagnosis can be more difficult in cases with small tumor diameter, and no cystic component or calcification. However adding EUS to contrast-enhanced CT imaging may improve accuracy. Furthermore, EUS-FNA contributes to preoperative diagnosis with a high diagnostic accuracy.