Early Feeding Following Ligation of Acute Bleeding Varices
Early Feeding Following Ligation of Acute Bleeding Varices
The impact of feeding after endoscopic treatment of gastroesophageal varices has never been
 investigated. It is still unknown whether early feeding may increase early rebleeding in
 patients with acute esophageal variceal bleeding treated with EVL. It is customary for
 clinicians to institute fasting for 2 or 3 days after emergency EVL. This may be a safe
 approach to watch against early rebleeding. However, many patients would be fasting for a
 longer time and nutrition may be impaired, possibly resulting in aggravation of ascites.
 Thus, the investigators conduct a controlled study to evaluate whether early feeding have a
 bad impact on patients receiving emergency EVL or histoacryl injection for bleeding gastric
 varices.
Acute esophageal variceal hemorrhage is a dreadful complication of portal hypertension. Its
 management evolved rapidly in recent years. Traditional managements include vasoconstrictor
 and balloon tamponade. Vasoconstrictors have been shown to control approximately 80% of
 bleeding episodes, are generally used as a first line therapy. Following the use of
 vasoconstrictor, endoscopic therapy is often employed to arrest the bleeding varices as well
 as preventing early rebleeding. Meta-analysis showed that the combination of vasoconstrictor
 and endoscopic therapy is superior to endoscopic therapy alone in the control of acute
 esophageal variceal hemorrhage. Our previous study showed that endoscopic variceal ligation
 (EVL) is superior to Endoscopic injection sclerotherapy (EIS) in the control of active
 variceal hemorrhage. It is thus recommended that EVL is the first enscopic treatment of
 choice for acute esophageal variceal bleeding. Moreover, apart from the control of acute
 variceal bleeding, prophylactic antibiotics has been proven to be helpful in the prevention
 of bacterial infection as well as preventing early variceal bleeding. With the advent of new
 treatment modalities and measures taken to approach patients with acute esophageal variceal
 bleeding, the mortality of acute esophageal variceal bleeding is significantly reduced in
 recent years.

 On the other hand, early rebleeding due to ligation-induced ulcer may be encountered. The
 impact of feeding after endoscopic treatment of gastroesophageal varices has never been
 investigated. It is still unknown whether early feeding may increase early rebleeding in
 patients with acute esophageal variceal bleeding treated with EVL. It is customary for
 clinicians to institute fasting for 2 or 3 days after emergency EVL. This may be a safe
 approach to watch against early rebleeding. However, many patients would be fasting for a
 longer time and nutrition may be impaired, possibly resulting in aggravation of ascites.
 Thus, we conduct a controlled study to evaluate whether early feeding have a bad impact on
 patients receiving emergency EVL or histoacryl injection for bleeding gastric varices.

 Methods of treatment:

 Enrolled Criteria:

 1. The etiology of portal hypertension is cirrhosis.

 2. Age ranges between 20-80 y/o.

 3. Patients presenting with acute gastroesophageal variceal bleeding proven by emergency
 endoscopy within 12 hours. (Acute esophageal variceal bleeding was defined as: 1) when
 blood was directly seen by endoscopy to issue from an esophageal varix (active
 bleeding), or 2) when patients presented with red color signs on their esophageal
 varices with blood in esophagus or stomach and no other potential site of bleeding
 identified (inactive bleeding). Gastric variceal bleeding is defined as active spurting
 from a gastric varix or presence of red spots on a gastric varix.

 4. EVL is performed after confirmation of acute esophageal variceal bleeding. Histoacryl
 injection is performed if acute gastric variceal bleeding is diagnosed. Bleeding is
 arrested on the spot.

 Exclusion criteria:

 1) association with severe systemic illness, such as sepsis, COPD, uremia, HCC, > BCLC stage
 B 3)failure in the control of bleeding by emergency endoscopic treatment. 4)moribund
 patients, died within 12 hours of enrollment 5)Uncooperative 6) Ever received EIS, EVL within
 one month prior to index bleeding 7)Child-Pugh's scores > 13 8) Deep jaundice (serum
 bilirubin > 10 mg/dl), presence of encephalopathy > stage II or massive ascites

 Eligible subjects will receive vasoconstrictor for 3 days (either terlipressin or
 somatostatin), prophylactic antibiotics for 5 days (cephazolin or norfloxacin 400mg bid),
 lactulose. Eligible subjects will be randomized to 2 groups. Group 1 will be allowed to take
 liquid diet (fruit juice, soy bean juice, milk, rice in liquid form) for 3 days within 4
 hours after endoscopic treatment. Additionally, intravenous fluid less than 500 cc per day
 will be given. Subsequently, soft diet will be given for 4 days, and on regular diet on the
 8th day after endoscopic treatment.

 Group 2 will be fasting for 48 hours after endoscopic treatment and intravenous fluids
 (normal saline or glucose water) 1500 cc per day with electrolytes will be administered for 2
 days. After 2 days of fasting, if rebleeding does not occur, liquid diet will be given for
 one day, subsequently, soft diet for 4 days, and on regular diet on the 8th day after
 endoscopic treatment.
Inclusion Criteria:

 1. The etiology of portal hypertension is cirrhosis.

 2. Age ranges between 20-80 y/o.

 3. Patients presenting with acute gastroesophageal variceal bleeding proven by emergency
 endoscopy within 12 hours. (Acute esophageal variceal bleeding was defined as: 1) when
 blood was directly seen by endoscopy to issue from an esophageal varix (active
 bleeding), or 2) when patients presented with red color signs on their esophageal
 varices with blood in esophagus or stomach and no other potential site of bleeding
 identified (inactive bleeding). Gastric variceal bleeding is defined as active
 spurting from a gastric varix or presence of red spots on a gastric varix.

 4. EVL is performed after confirmation of acute esophageal variceal bleeding. Histoacryl
 injection is performed if acute gastric variceal bleeding is diagnosed. Bleeding is
 arrested on the spot.

 Exclusion Criteria:

 1. association with severe systemic illness, such as sepsis, COPD, uremia, HCC, > BCLC
 stage B

 2. failure in the control of bleeding by emergency endoscopic treatment.

 3. moribund patients, died within 12 hours of enrollment

 4. Uncooperative

 5. Ever received EIS, EVL within one month prior to index bleeding

 6. Child-Pugh's scores > 13

 7. Deep jaundice (serum bilirubin > 10 mg/dl), presence of encephalopathy > stage II or
 massive ascites