The management of varices in acute on chronic liver failure: a systematic review of guidelines and investigation of local practice

Kesavan, Saumiya

Abstract

Varices are a complication of chronic liver disease and are associated with a high mortality if they haemorrhage. Patients need to be managed using the best available evidence to improve their outcomes. This thesis is formed of two parts: a systematic review appraising the quality of international guidelines on the management of varices, and a service evaluation, assessing guideline adherence in managing acute upper gastro-intestinal variceal haemorrhage at the University Hospital North Midlands NHS Trust (UHNM).

Following a systematic search in accordance with the predefined protocol, 49 international guidelines were included in the systematic review and underwent data extraction and quality appraisal against Domain 1 (Scope and Purpose) of the AGREE II checklist. Those that performed moderately or highly in Domain 1 underwent Domain 3 (Rigour of Development) appraisal. Twenty-one guidelines were assessed against Domain 3. The recommendations made by the 28 excluded guidelines and those retained were similar. Some interventions that are used in clinical practice are not supported by high quality evidence, but 19 recommendations were put forward following this review as they are supported by high quality evidence.

Four of the six recommendations put forward from the systematic review specifically for the management of active variceal haemorrhage were used as standards for the service evaluation. These were: terlipressin administration; antibiotic prophylaxis administration; endoscopy within 24 hours; endoscopic band ligation for oesophageal varices. In 149 patients, 37.6% received all recommendation-adherent treatments. Sicker patients (denoted by their Child-Turcotte- Pugh class) were more likely to receive terlipressin and antibiotics; patients presenting out of hours were more likely to receive endoscopy within 24 hours; and patients with grade one varices were less likely to receive banding. Generally, adherence to terlipressin and antibiotic administration were high. Improvements could be made to improve adherence to the target of endoscopy within 24 hours.
This project highlights potential for improvements in making and applying guidelines in this field.

Citation

Kesavan, S. (2023). The management of varices in acute on chronic liver failure: a systematic review of guidelines and investigation of local practice. (Thesis). Keele University. Retrieved from https://keele-repository.worktribe.com/output/515604

• Thesis Type: Thesis
• Deposit Date: Jul 11, 2023
• Publicly Available Date: Jul 11, 2023
• Public URL: https://keele-repository.worktribe.com/output/515604
• Award Date: 2023-06