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A Novel Nomogram for Predicting Early Rebleeding After Endoscopic Treatment of Esophagogastric Variceal Hemorrhage

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Abstract

Background

Early rebleeding is a significant complication of endoscopic treatment for esophagogastric variceal hemorrhage (EGVH). However, a reliable predictive model is currently lacking.

Aims

To identify risk factors for rebleeding within 6 weeks and establish a nomogram for predicting early rebleeding after endoscopic treatment of EVGH.

Methods

Demographic information, comorbidities, preoperative evaluation, endoscopic features, and laboratory tests were collected from 119 patients who were first endoscopic treatment for EGVH. Independent risk factors for early rebleeding were determined through least absolute shrinkage and selection operator logistic regression. The discrimination, calibration, and clinical utility of the nomogram were assessed and compared with the model for end-stage liver disease (MELD), Child–Pugh, and albumin-bilirubin (ALBI) scores using receiver-operating characteristic (ROC) curves, calibration plots, and decision curve analyses (DCA).

Results

Early rebleeding occurred in 39 patients (32.8%) within 6 weeks after endoscopic treatment. Independent early rebleeding factors included gastric variceal hemorrhage (GVH), concomitant hepatocellular carcinoma (HCC), international normalized ratio (INR), and creatinine. The nomogram demonstrated exceptional calibration and discrimination capability. The area under the curve for the nomogram was 0.758 (95% CI 0.668–0.848), and it was validated at 0.71 through cross-validation and bootstrapping validation. The DCA and ROC curves demonstrated that the nomogram outperformed the MELD, Child–Pugh, and ALBI scores.

Conclusions

Compared with existing prediction scores, the nomogram demonstrated superior discrimination, calibration, and clinical applicability for predicting rebleeding in patients with EGVH after endoscopic treatment. Therefore, it may assist clinicians in the early implementation of aggressive treatment and follow-up.

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Abbreviations

ALBIscore:

Albumin-bilirubin score

ALT:

Alanine aminotransferase

AST:

Aspartate aminotransferase

AUC:

Area under the ROC curve

BROT:

Balloon-occluded retrograde transvenous obliteration

DCA:

Decision curve analysis

EBL:

Endoscopic band ligation

EGVH:

Esophagogastric variceal hemorrhage

EVH:

Esophageal variceal hemorrhage

GOV1:

Type 1 gastroesophageal varices

GOV2:

Type 2 gastroesophageal varices

GVH:

Gastric variceal hemorrhage

HVPG:

Hepatic venous pressure gradient

IGV1:

Type 1 isolated gastric varices

INR:

International normalized ratio

IQR:

Interquartile range

LASSO:

Least absolute shrinkage and selection operator

MELD score:

Model for end-stage liver disease score

NSBB:

Non-selective beta blocker

RBC:

Red blood cells

ROC:

Receiver-operating characteristic curve

SBP:

Systolic blood pressure

TIPS:

Transjugular intrahepatic portosystemic shunt

VIF:

Variance inflation factor

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Acknowledgments

We thank our colleagues from the Department of Gastroenterology and Endoscopy Center for their strong support and cooperation in this experiment.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Author information

Authors and Affiliations

  1. Department of Gastroenterology, Wushan County People’s Hospital of Chongqing, No.168, Guangdongxi Road, Wushan County, Chongqing, 404700, People’s Republic of China

    Yongqi Dong & Gang Zhao

  2. Department of Infectious Diseases, The Second Affiliated Hospital of Chongqing Medical University, NO.76, Linjiang Road, Chongqing, 400010, People’s Republic of China

    Hongyan Xu

  3. Department of Rheumatology and Immunology, The Second Affiliated Hospital of Chongqing Medical University, NO.76, Linjiang Road, Chongqing, 400010, People’s Republic of China

    Zhihuan Zhang

  4. Department of Gastroenterology, The Second Affiliated Hospital of Chongqing Medical University, NO.76, Linjiang Road, Chongqing, 400010, People’s Republic of China

    Zhihang Zhou

  5. Department of Gastroenterology, Chengdu Second People’s Hospital, NO.10, Yunnan Road, Chengdu, 610017, People’s Republic of China

    Haiyan Cao

  6. Department of Clinical Nutrition, Wushan County People’s Hospital of Chongqing, No.168, Guangdongxi Road, Wushan County, Chongqing, 404700, People’s Republic of China

    Shiyong Xiao

Authors
  1. Yongqi Dong
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Contributions

DYQ, XHY, ZZH, ZG contributed to the study idea and design, drafting of the manuscript, and data analysis; CHY and DYQ were involved in data collection; ZZH and XSY contributed to critical revision of the manuscript; All authors approved the final manuscript for submission.

Corresponding author

Correspondence to Shiyong Xiao.

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Conflict of interest

The authors declare that there are no conflicts of interest regarding the publication of this article.

Ethical approval

This study was approved by the Medical Ethics Committee of the Second Affiliated Hospital of Chongqing Medical University. The study adhered to the ethical principles outlined in the Declaration of Helsinki. Considering the retrospective nature of this study, the ethics committee waived the requirement for informed consent. Furthermore, all sensitive patient information underwent a process of anonymization and deidentification prior to analysis.

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Supplementary Information

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Figure S1. Correlation heatmap of predicted variables.

Abbreviations: ALBI score: Albumin-Bilirubin score; ALT: alanine aminotransferase; AST: aspartate aminotransferase; CKD: chronic kidney disease; Cr: creatinine; HCC: hepatocellular carcinoma; HE: hepatic encephalopathy; HR: heart rate; INR: international normalized ratio; MELD score: model for end-stage liver disease score; NET: non-endoscopic treatment; RBC: red blood cells; SBP: systolic blood pressure; WN: white nipple sign or overlying clot. (TIFF 774 kb)

Figure S2. (A) ROC curves for nomogram and other models; (B) Decision curves for nomogram and other models.

Abbreviations: ALBI score: Albumin-Bilirubin score; AUC: area under the ROC curve; CTP score: Child Turcotte Pugh score; ROC: receiver-operating characteristic curve; MELD score: model for end-stage liver disease score. (JPG 201 kb)

Table S1. univariate and multivariate logistic regression analysis of the selected variables.

Abbreviations: CI: confidence interval; HCC: hepatocellular carcinoma; INR: international normalized ratio; OR: odds ratio. (XLSX 10 kb)

Table S2. The VIF of independent predictors included in the nomogram.

Abbreviations: HCC: hepatocellular carcinoma; INR: international normalized ratio; VIF: variance inflation factor. (XLSX 10 kb)

Table S3. The TRIPOD Checklist of the study.

(DOCX 25 kb)

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Dong, Y., Xu, H., Zhang, Z. et al. A Novel Nomogram for Predicting Early Rebleeding After Endoscopic Treatment of Esophagogastric Variceal Hemorrhage. Dig Dis Sci (2024). https://doi.org/10.1007/s10620-024-08382-0

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