Prediction of Early Rebleeding and Mortality after Acute Esophageal Variceal Hemorrhage among Yemeni Patients in Major Hospitals—Sana’a

Abstract

Background and aims: Acute variceal hemorrhage (AVH) is the most serious encountered complication of liver cirrhosis and carries high mortality rate. Several risk factors that predict early rebleeding and mortality have been studied and there is no similar study in our country, so the aim of this study was to identify the risk factors of early rebleeding and mortality after bleeding episode in cirrhotic patients in Yemen. Patients and Method: It was a prospective study of cirrhotic patients with AVH who were admitted to the main public hospitals in Sana’a between April 2014 and March 2015. Demographic information, medical histories, physical examination findings, and laboratory test results were collected. Endoscopic and pharmacologic treatment was performed. The patients were followed up since admission and up to 6 weeks for the occurrence of rebleeding and mortality after the acute attack. Univariate and multivariate analyses were performed to identify independent risk factors for rebleeding and mortality. Survival analysis was estimated using the Kaplan-Meier method. Result: A total of 102 patients were analyzed. 26 patients (25.5%) rebleeded within 6 weeks period. The predictive factors significantly associated with rebleeding within 6 weeks period in univariate analysis were clot on varix at index endoscope (P < 0.0001), high serum bilirubin (P = 0.02), CTP score (P < 0.05) and MELD score (P < 0.05). Independent risks factors remained in multivariate analysis as significant predictors of early rebleeding were clot on varix (OR: 11.6, CI: 2.87 - 47.29, P = 0.001) and high serum bilirubin (<3) (OR: 1.1, CI: 1.02 - 1.19, P = 0.01). Sixteen patients died (15.7%) within 6 weeks period. Predictors of mortality with significant difference in univariate analysis were hypovolemic shock (P = 0.001), high WBCs count (P < 0.0001), low serum sodium (P = 0.04), high AST (P < 0.0001), high ALT (P = 0.02), high INR (P < 0.0001), high serum bilirubin (P < 0.0001), low serum albumin (P = 0.005), ascites (P = 0.001), CTP score (P < 0.0001) and MELD score (P < 0.0001). By multiple regression analysis high MELD score (≥19) (OR: 1.3, CI: 1.12 - 1.41, P < 0.0001) and WBCs over 10.3 × 10 9 /l (OR: 1.2, CI: 1.02 - 1.40, P < 0.05) were independent risk factors for mortality within 6 weeks period. Conclusion: Early rebleeding in cirrhotic patients with AVH was associated with clot on varix at endoscope and high serum bilirubin more than 3 mg/dl. Early mortality rate was associated with high MELD score (≥19) and WBCs over 10.3 × 10 9 /l.