A predictive model for failure to control bleeding during acute variceal haemorrhage

Background/Aims: Variceal bleeding is a frequent complication of cirrhosis and is associated with a high risk of early rebleeding. In patients with pe ptic ulcers, continued bleeding or early rebleeding are risk factors for mo rtality and can be predicted by statistical models; however, no such models exist for acute variceal bleeding. Methods: We prospectively evaluated failure to control bleeding in 695 cons ecutive patients with cirrhosis, admitted for haematemesis and/or melaena. Criteria were defined for failure to control bleeding, which comprised both continued bleeding or early rebleeding within 5 days of admission. There w ere 2 sequential groups of patients: (i) those with variceal bleeding initi ally treated with blood transfusion and vasoactive drugs, and if these fail ed followed by sclerotherapy (n=385); (ii) those with variceal bleeding tre ated with injection sclerotherapy at diagnostic endoscopy (n=144). The thir d group was those with bleeding from other sources related to portal hypert ension (n=166). Results: Failure to control bleeding was noted in 169 (44%) patients in gro up 1, 55 (38%) in group 2 and 44 (25%) in group 3. Twenty variables that we re evaluable within 6 h of admission, pertaining to severity of bleeding, s everity of type of liver disease, mode of admission, and time of diagnostic endoscopy, were entered into a multivariate Cox model. Independent predict ors of early rebleeding in group 1 were: active bleeding at endoscopy (irre spective of interval from admission) (p<0.0001), encephalopathy (p=0.007), platelet count (p=0.002), history of alcoholism (p= 0.002), presentation wi th haematemesis (p=0.02), log urea (p=0.03) and (shorter) interval to admis sion (p=0.007). The variables predictive of 30-day mortality were: early bl eeding (p<0.0007), bilirubin (p=0.0006), encephalopathy (p<0.0001), (shorte r) interval to admission (p<0.0001), and log urea (p=0.004); a model based on these variables was also a good predictor of mortality in the other 2 gr oups. However, the model derived from group 1 for failure to control varice al bleeding was different in group 2, despite similar patient characteristi cs and a similar failure rate (following a single injection). This could su ggest that sclerotherapy may induce bleeding in some patients independently of the baseline risk for failure to control bleeding. Conclusions: In cirrhotic patients who present with haematemesis or melaena , active variceal bleeding at diagnostic endoscopy is predictive of failure to control bleeding (continued bleeding or early rebleeding within 5 days of admission), and this failure is predictive of 30-day mortality.