Richard T Spence1, Jake Krige2, Marius Hoogerboord1, James Ellsmere1. 1Dalhousie University, 2University of Cape Town
Background: There is currently no consensus which specific risk factors or scores predict early rebleeding and early mortality after a major variceal bleed. The objective of this study was to investigate the relative predictive performances of the Child-Pugh and MELD scores for failure to control bleeding and death in alcoholic cirrhotic patients.
Methods: Prospective cohort study of consecutive adult patients with endoscopically proven acute esophageal variceal bleeding secondary to decompensated alcoholic liver cirrhosis presenting to a specialist surgical gastroenterology unit in South Africa between January 2000 and December 2017. All patients underwent urgent therapeutic upper gastro-intestinal endoscopy as soon as safely possible after admission and resuscitation, which included injection sclerotherapy (IST) and variceal band ligation (VBL). Data for Child-Pugh and MELD scores were prospectively collected. Receiving-operator characteristics (ROC) curve analysis was performed to identify the discriminative capacity of the scores, including a proposed modified Child Pugh classification (A-D), in predicting the risk of (i) rebleeding, and (ii) in-hospital death.
Results: During the 288 month study period, 403 consecutive adult patients were treated for bleeding esophageal varices in our unit of which 225 (175 men, 51 women) were secondary to alcoholic cirrhosis. The cohort had a median age of 50 years (IQR 27-87) and underwent 261 endoscopic variceal emergency treatments. Twenty-four (10.6%) patients were Child-Pugh grade A, 88 (39.1%) were grade B and 113 (50.2%) were grade C when assessed on their first admission to hospital. MELD scores ranged from 3 to 40. Thirty one patients experienced a rebleed (13.8%) and 42 patients died (18.7%).There was no difference in the discriminatory capacity of the Child Pugh (ROC 0.59 95%CI 0.50-0.67) and MELD (ROC 0.62 95% CI 0.51-0.73) to predict rebleeding (p=0.72), or between the Child Pugh (ROC 0.75 95%CI 0.71-0.81) and MELD (ROC 0.71 95% 0.62-0.80) to predict death (p=0.35). A proposed modified Child Pugh classification (A-D) had significantly improved discriminatory capacity (ROC 0.83 95% 0.77-0.89) compared to the original Child Pugh score (A-C) and MELD to predict death (p=0.004), Figure 1.
Conclusion: A proposed modified four category Child Pugh classification outperforms the original Child Pugh and MELD scores to predict death in bleeding esophageal varices in alcoholic cirrhotics. Contemporary scoring systems have poor ability to identify patients at high risk of early rebleeding.
Figure 1:Discriminatory performance of scores to predict mortality in bleeding varices
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 93756
Program Number: S092
Presentation Session: Flexible Endoscopy I
Presentation Type: Podium