Clinical features of rebleeding after secondary prevention for esophagogastric variceal bleeding in cirrhotic portal hypertension

ObjectiveTo investigate the clinical manifestations, emergency endoscopic diagnosis and treatment, and prognosis of rebleeding after different secondary prevention measures for esophagogastric variceal bleeding in cirrhotic portal hypertension. MethodsA retrospective analysis was performed for the clinical data of 254 patients with rebleeding after secondary prevention (endoscopic therapy, surgical treatment, or interventional prevention) for esophagogastric variceal bleeding who underwent emergency endoscopic diagnosis and treatment in The Fifth Medical Center of Chinese PLA General Hospital from January 2018 to April 2019, and 419 patients who received medication alone for the prevention of rebleeding during the same period of time were enrolled as controls. Clinical features were observed and compared between groups. An analysis of variance was used for comparison of normally distributed continuous data between groups, and the Kruskal-Wallis H test was used for comparison of continuous data with heterogeneity of variance between groups. The least significant difference Bonferroni test was used for further comparison between two groups. The chi-square test  was used for comparison of categorical data between groups. ResultsAmong the 254 patients with rebleeding after secondary prevention, 144 (56.69%) received endoscopic prevention, 40 (15.75%) received surgical prevention, 33 (12.99%) received interventional prevention, and 37(14.57%) received prevention with endoscopy combined with other prevention measures. As for the time from last prevention to bleeding, 57.50% in the surgical prevention group had a time of more than 5 years, and 69.70% in the interventional prevention group experienced bleeding within 1 year after transjugular intrahepatic portosystemic shunt; 40.28% in the endoscopic prevention group and 35.14% in the combined prevention group experienced rebleeding within 1 year after prevention ended. During rebleeding, the interventional prevention group and the combined prevention group had a significantly higher incidence rate of hepatic encephalopathy than the other groups (all P＜0.001), and the interventional prevention group had significantly better controlled ascites than the other groups (all P＜0.05). There were significant differences in various clinical indices between these groups during rebleeding (all P＜0.001), and the endoscopic prevention group had significantly higher levels of hemoglobin and albumin than the surgical prevention group (P＜0.001 and P=0.001) and the medication prevention group (P=0.001 and P＜0.001). The surgical prevention group had a significantly higher platelet count than the interventional prevention group (P=0.037), the combined prevention group (P＜0.001), and the medication prevention group (P=0.012). The medication prevention group had a significantly higher level of bilirubin than the endoscopic prevention group (P=0.037), the interventional prevention group (P=0.025), and the combined prevention group (P＜0.001); the surgical prevention group had a significantly higher level of creatinine than the other four groups (all P＜0.05); the combined prevention group had significantly better coagulation parameters prothrombin time and international normalized ratio than the medication prevention group (both P=0.002). The medication prevention group had a significantly higher proportion of patients with active bleeding than the endoscopic prevention group (P＜0.001), the interventional prevention group (P=0.004), and the combined prevention group (P=0.008). The surgical prevention group and the medication prevention group had a significantly higher proportion of patients with esophageal variceal bleeding than the other groups (all P＜0.05), and the interventional prevention group had a significantly higher proportion of patients with peptic ulcer and bleeding than the other four groups (all P＜0.05). The medication prevention group had significantly higher dissatisfaction rate and failure rate of endoscopic treatment than the endoscopic prevention group (P＜0.001), the interventional prevention group (P=0.007), and the combined prevention group (P＜0.001). The medication prevention group had significantly higher rebleeding rate and mortality rate within 42 days than the other four groups (all P＜0.05). Conclusion Compared with medication prevention alone, interventional prevention, endoscopic prevention, or combined secondary prevention can significantly alleviate the degree of esophagogastric variceal rebleeding, improve the hemostatic rate of emergency endoscopy, and significantly reduce rebleeding rate and mortality rate within 42 days. The clinical features of rebleeding after different secondary prevention measures should be considered to perform individualized treatment of patients with rebleeding after secondary prevention for esophagogastric variceal bleeding.