الفهرس 
Material and methodsOnly 14 pages are availabe for public view
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Abstract
Variceal bleeding is a serious illness met with daily in our practice. Being the only university hospital through out Kalyobia Governorate, it is logic to say that expectedly, we should have the best performance in dealing with patients admitted with variceal bleeding. In addition we should expect to see, the more complicated and serious cases referred from other hospitals all around the Governorate.
The aim of this thesis was to evaluate the performance of
the unit of gastrointestinal endoscopy, division of
gastroenterology and hepatology, department of internal
medicine, Benha university hospitals in dealing with cases of variceal bleeding. Both emergency and elective services were evaluated. The study was one-year prospective study. Studied cases comprised of, 279 patients admitted to the unit as being diagnosed to have variceal bleeding and 112 patients were treated by elective variceal oblitrative therapy. All cases were evaluated as regards, age, sex, aetiology of liver disease, liver functions, previous bleeding attacks or sclerotherapy, triggering factors for bleeding, use of beta blockers. Bleeders were evaluated as regards the value of using somatostatin, vitamin K, tranexamic acid and dicynone. The effect of difference in time of admission and time of performing endoscopy were also
evaluated.
Statistical analysis of the study did show the following:
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Summary and Conclusions
1)Most of bleeders were admitted by their first bleeding attack (52.9%).
2)Still many patients’ presents by repeated attacks. We have reported 3.1% with the third attack and 2% with the fourth
attack.
3)Mean age of the all studied cases was 47+ 3 years.
4)There was dominance of male sex among the studied cases, 74.2% were males and 25.8% were females.
5)Farmers and employee presented the highest incidence of cases, 30.2% and 2.15%, while only 2.3% of cases were
highly educated.
6)None of our cases was alcoholic while, 18.7% of cases were taking NSATDs and or aspirin.
7)Regarding feeding habits, 15.9% of cases reported history of ingestion of hard food while, 12.8% of cases reported a history of ingestion of acids and spices before they develop
the bleeding episodes.
8)No difference in mortality rate was detected in comparing outcome during different working hours in the unit and the
department.
9)We have found also that the earlier is the endoscopic intervention, the less is the mortality rate.
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Summary and Conclusions
10)Regarding transfusion requirements, we have detected that; the patient’s outcome improves with increased transfused units.
11)The value of different haemostatic drugs used in treating bleeding varices was evaluated. We have found no extra value in using, vitamin K, cyclocapron or dicynone.
12)The value of using sandostatin pre and post-endoscopic in treating bleeding oesophageal varices was evaluated and proved no extra value in improving mortality.
13)Regards aetiology of liver cirrhosis we have found increased mortality only among cases with HCV. A similar effect was not detected as regards shistosomiasis or HBV.
14)Among the 279 bleeders we have reported 25 deaths. Thirteen of died during the first 12 hours after endoscopy, while seven cases died within 48 hours. The twenty cases died due to rebleeding. On the contrary, only 4 cases died due to encephalopathy, and one case died during endoscopy.
15)Performing multifactorial linear regression analysis of prognostic factors found to be correlated to the outcome of bleeding attacks (b-blockers, cyclocapron, ascites, number of blood units, time of last bleeding attack, use of sandostatin, HBV, HCV, delay time, number of sessions, grading of oesophageal varices), we have found only four
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Summary and Conclusions
factors with a significant value in bleeding varices. These factors are: use of beta-blockers, cyclocapron, ascites, and blood units required.
16)It was surprising to detect that during the study, we have not lost the follow up of any of the studied cases.
17)The reported mortality rate among our bleeders was 9%, which is one of the least, if not the least reported rates of mortality among patients with variceal bleeding. Many factors might lead to this low mortality rate: the well-trained senior as well as junior staff (who manage cases during the evening and night hours), early endoscopic intervention, and satisfactory transfusion requirements.
18)Finally we conclude that, the performance of each of the Division of gastroenterology and hepatology, the Unit of gastrointestinal endoscopy, and the Department of internal medicine, Benha university hospitals are of high quality and very satisfactory.
We should be proud with these results. To keep and improve this level performance we need the help and support of all the authorities in the university.
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Summary and Conclusions
Recommendations
1)Variceal bleeders should be followed closely after endoscopic therapy as they are in danger of rebleeding for the early days after the initial attack. The establishment of specialized intensive care units for liver patients should be arranged.
2)Improvement of the socio-economic standard as well as the education level of our people will help to improve their health status.
3)The organization and implementation of an educational health program for all liver patients particularly with oesophageal varices is mandatory and should be established as soon as possible. The program should include the drugs to be avoided as well as the quality of diet. Non- steroidal anti-inflammatory drugs as well as aspirin should be prohibited in liver patients and if used should be under close observation. The avoidance of hard and spicy food is also important. The program should be informative for all patients as regards the spectrum of their problem, the importance of follow-up and the necessity to eradicate varices completely. All patients should be informed that they are at high risk of rebleeding as long as they have still residual varices.
4)Though beta-blockers are highly recommended as routine drugs to lower portal pressure and preventing bleeding
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Sunumuy and Conclusions
episodes, yet their use in high-risk varices patients and during the early days after bleeding attacks should be stopped. If users of beta-blockers would bleed, they will face bad outcome due to loss of inner body protective mechanisms.
5)The value of all haemostatic and vasoactive drugs used in treating bleeding varices, should be re-evaluated in Future large multi-center randomized controlled trials.
6)The problem of hepatitis C virus should be of high priority because of its deterious effects among bleeders.
7)Transfusion services should be kept at its higher level in all centers dealing with bleeding varices. With any DROP in the quality of the service, there will be a parallel increased in mortality in cases with bleeding varices.
8)There should be no delay in endoscopic interventions in dealing with variceal bleeding. Early transportation, hospital admission and endoscopy are crucial steps to lower mortality among these patients.
9)The junior staff (registrars and residents) should be trained very well for dealing with variceal bleeders both medically and endoscopically.