Improved survival after variceal hemorrhage over an 11-year period in the Department of Veterans Affairs

OBJECTIVES: Over the past two decades, several modalities have become widel y used in the management of esophageal variceal hemorrhage. The effectivene ss of these measures on the outcome of patients with this type of hemorrhag e remains unknown. METHODS: Using the Department of Veterans Affairs (VA) Patient Treatment Fi le, we identified two cohorts of patients diagnosed with an initial varicea l hemorrhage: an early cohort during 1981-1982 (1339 patients), and a late cohort during 1988-1991 (3636 patients). Each cohort was followed for 6 yr for rebleeding and death. Analyses were performed with proportional hazards survival analysis controlling for confounding factors. RESULTS: On presentation, patients in the late cohort were older (57 yr vs 55 yr, p < 0.0001) and had more ascites (25% vs 13%, p < 0.0001), more peri tonitis (4% vs 2%, p < 0.0001), and more encephalopathy (14% vs 9%, p = 0.0 003). The late cohort experienced a significant decline in mortality at 30 days (20.8% vs 29.6%, p = 0.0001) and at 6 yr (69.7% vs 74.5%, p = 0.0001). This improvement was accentuated in multivariate survival analysis when co ntrolling for the more severe illness in the late cohort. For patients who survived the first 30 days, no significant difference in 6-yr mortality was found on univariate analysis between the early cohort (63.7%) and late coh ort (61.8%) (p = 0.25), but survival was slightly better in the late cohort on multivariate analysis (p = 0.01). In the late cohort, patients with scl erotherapy during the initial hospitalization had better 30-day (17%) and 6 -yr mortality (68%) than did the rest of the late cohort. CONCLUSIONS: Between the years 1981-1982 and 1988-1991, improvements in lon g-term survival after an initial episode of esophageal variceal hemorrhage resulted primarily from better short-term mortality. Sclerotherapy offers a partial explanation for improved survival. (C) 2000 by Am. Cell. of Gastro enterology.