Introduction

Acute variceal bleeding (AVB) is a common and life-threatening complication of cirrhosis and portal hypertension. Despite advances in therapeutic strategies, the 6-week mortality rate remains high, ranging from 10% to 20%. Current clinical guidelines recommend standard treatment for cirrhotic patients with AVB, including vasoactive agents, prophylactic antibiotics, and endoscopic intervention. However, real-world clinical practices are often influenced by physician awareness, institutional resources, and patient preferences. In late 2019, West China Hospital of Sichuan University established a multidisciplinary rapid-response pathway for the emergency management of high-risk upper gastrointestinal bleeding (UGIB). This initiative aimed to improve the treatment protocol, integrate endoscopic and interventional resources, and finally improve the outcomes.

Aims & Methods

The present study evaluates the impact of this rapid-response pathway on clinical outcomes in cirrhotic patients with AVB. This retrospective study included consecutive patients admitted for acute UGIB to West China Hospital between January 2016 and November 2022. Inclusion criteria were: (1) cirrhosis; and (2) presentation with hematemesis and/or melena within five days before admission. Exclusion criteria included: (1) non-variceal bleeding or an unconfirmed bleeding source on endoscopy; and (2) less than six weeks of follow-up. Patients were categorized into two groups based on the timing of rapid-response pathway implementation: Group A (2016–2019, pre-implementation) and Group B (2020–2022, post-implementation). Primary outcomes were 6-week mortality and 5-day treatment failure. Propensity score matching (PSM) was applied to adjust for baseline confounders: a 1:1 PSM was used to compare Group A and B.

Results

A total of 1,529 cirrhotic patients with AVB were included. Following 1:1 PSM, Groups A and B comprised 654 patients each. The most common etiology of cirrhosis is chronic hepatitis B virus infection. No significant intergroup differences were observed in Child-Pugh score, MELD score, MELD-Na score, prevalence of PVT, HCC, infection, ascites, or hepatic encephalopathy (all P > 0.05). Group B had a higher rate of prophylactic antibiotics, early endoscopic or interventional treatment use, and less balloon tamponade and intubation. Group B demonstrated significantly lower 6-week mortality compared to Group A [52 (8.0%) vs. 88 (13.5%), P = 0.001]. Multivariate Cox regression identified Child-Pugh score (HR = 1.203), MELD-Na score (HR = 1.040), PVT (HR = 1.733), HCC (HR = 2.398), and 5-day treatment failure (HR = 4.385) as independent risk factors for 6-week mortality. Similarly, Group B exhibited a significantly reduced 5-day treatment failure rate [64 (9.8%) vs. 137 (20.9%), P < 0.001]. While no significant differences in overall 6-week mortality or 5-day treatment failure were observed between the PVT and non-PVT groups, patients with coPVT had significantly higher 6-week mortality compared to non-PVT patients (HR = 4.81).

Conclusion

The implementation of a multidisciplinary rapid-response pathway significantly improved early intervention, endoscopy utilization, and TIPS procedures in cirrhotic patients with AVB. These changes were associated with marked reductions in both 6-week mortality and 5-day treatment failure. Key independent predictors of 6-week mortality included Child-Pugh score, MELD-Na score, HCC, PVT, and 5-day treatment failure.

Introduction

Patients with acute-on-chronic liver failure (ACLF) have traditionally been considered with a tendecy for bleeding however, they frequently display a paradoxical prothrombotic state. ACLF is characterized systemic inflammation and an increased risk of both bleeding and thrombosis. Bleeding arises from decreased pro-coagulation factors and platelet sequestration due to portal hypertension, while thrombosis is exacerbated by endothelial dysfunction and elevated heparinoids, thrombomodulin, or von Willebrand factor.

Aims & Methods

The aim of this study was to evaluate platelet aggregation pattern in patients with ACLF compared to acute decompensated (AD) liver cirrhosis.
The study took place in between the 1^st of July 2024- 31^st of January 2025 and we prospectively included cirrhotic patients, divided in two groups: ACLF group and AD group. The exclusion criteria were people with compensated liver cirrhosis, antiaggregant or anticoagulant treatment and patients with hepatocellular carcinoma or other malignancies. We investigated platelet aggregability in whole blood, by using multiplate aggregometry. For analysis, platelet aggregometry was performed induced by: adenosine diphosphate (ADP), arachidonic acid (ASPI), prostaglandin E2 (PGE2) and thrombin receptor-activated peptide (TRAP-6) as agonist were determined. TRAP‑6 is a peptide that stimulates protease-activated receptor 1 (PAR1) on platelet membrane.

Results

In this study we included 52 patients – 25 patients with ACLF and 27 patients with AD. There were no differences regarding demographic parameters and liver disease etiology between the two study groups. Compared to AD group, patients with ACLF showed an enhanced maximal platelet aggregation with TRAP-6 (AUC 85±12 U vs 45±10 U, p<0.0001). In contrast, we did not detect any differences in platelet aggregation between the two groups after ADP, ASPI or PGE2 activations. We observe that PAR-1 stimulation induces the highest aggregation curve and area under the curve in patients with ACLF and AD, but ACLF patients show the strongest response, highlighting that the degree of liver decompensation influences aggregation results. Severe decompensation correlates with a stronger TRAP response, suggesting that there are more PAR-1 receptors on platelets of this patients.

Conclusion

Our results indirectly indicate that platelet reactivity is higher in patients with ACLF likely due to enhanced PAR-1 receptor activity. Severe decompensation correlates with a stronger TRAP response, suggesting that there are more PAR-1 receptors on platelets of this patients.

References

1. EASL Clinical Practice Guidelines on acute on liver failure; J. Hepatol. 2023
2. Napolitano et al. European Journal of Internal Medicine 2017
3. Tripodi et al. Hepatology 2006
4. Lisman et al. Hepatology 2006
5. Nassar et al. BIOMEDICINES 2023
6. Rogalski et al. Scandinavian Journal of Gastroenterology 2019
7. Zanetto et al. Liver International 2022
8. Vecerzan et al. Cureus 2024
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Introduction

Oesophageal adenocarcinoma (EAC) remains a leading cause of cancer-related mortality, with poor survival outcomes. Early identification and treatment of dysplasia in Barrett’s oesophagus (BE) is critical to reducing the risk of post-endoscopy upper gastrointestinal cancers (PEUGIC). While mucosal cleansing and clear visualisation are recognised as essential, existing evidence also demonstrates that certain procedural factors—such as longer inspection times—can significantly improve dysplasia detection rates (DDR) (2). This raises the possibility that other procedural variables may similarly influence detection outcomes. In this audit, we evaluated whether additional technical and patient-related factors affect dysplasia detection, with the aim of optimising surveillance quality and reducing the risk of Post-Endoscopy Upper GI Cancer (PEUGIC).

Aims & Methods

This audit aimed to assess the impact of procedural variables on dysplasia detection during Barrett’s surveillance endoscopy. A retrospective analysis was conducted in Wales, reviewing 192 patient records from June to December 2023. Factors that may influence dysplasia detection were evaluated including sedation type, use of acetic acid for mucosal enhancement, adherence to the Prague grading system, describing lesions using the Paris classification, NBI use and the Seattle biopsy protocol. Additionally, patient comfort was assessed as it may impact procedural quality and compliance. Analysis was carried out using SPSS (IBM, USA). T-tests were used for parametric data, and Mann Whitney U-tests for non-parametric data. Categorical data were analysed using Chi-square or Fisher’s exact tests. Statistical significance was set at p < 0.01.

Results

Improved imaging quality was significantly associated with higher patient comfort (p = 0.001). Higher doses of midazolam were associated with greater detection of visible lesions, while fentanyl showed less of a significant effect. Additional use of acetic acid and aceto-whitening effect significantly enhanced dysplasia detection, with strong alignment to histological findings (p<0.001). NBI further improved lesion identification when used adjunctively. In procedures performed by expert endoscopists, targeted biopsies identified dysplasia at comparable rates to the Seattle protocol, suggesting limited additional value of the latter in experienced hands.

Conclusion

This study underscores the importance of optimising procedural elements—particularly higher doses midazolam (median 5mg), acetic acid application, and ensuring patient comfort—to improve dysplasia detection in Barrett’s surveillance. Although PEUGIC data seems to show better neoplasia detection rates with combined Midazolam and Fentanyl, we did not demonstrate this(1). seattle protocol may still be helpful for dysplasia detection, but it’s use appears less beneficial than regular use of NBI and acetic acid chromoendoscopy.

References

1. Dhar A. Re: “Dedicated service for Barrett’s oesophagus surveillance endoscopy yields higher dysplasia detection and guideline adherence in a non tertiary setting in the UK: a 5-year comparative cohort study” by Ratcliffe et al. Frontline gastroenterology [Internet]. 2023 Mar;15(3):264. Available from: https://pubmed.ncbi.nlm.nih.gov/38665792/
2. Gupta N, Gaddam S, Wani SB, Bansal A, Rastogi A, Sharma P. Longer inspection time is associated with increased detection of high-grade dysplasia and esophageal adenocarcinoma in Barrett’s esophagus. Gastrointestinal Endoscopy. 2012 Sep;76(3):531–8