الفهرس 
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Abstract
Portal hypertension and consequent variceal hemorrhage is one of the most devastating complications of chronic liver disease and is the most common cause of mortality and morbidity in patients with cirrhosis.
One of the difficulties in predicting prognosis in such patients is that their outcome is influenced not only by the severity of the bleeding episode itself, but also by the severity of the underlying liver disease
This study was done to study early rebleeding and mortality in patients with variceal bleeding after band ligation & to correlate these results with serum level of vascular endothelial growth factor.
The study included 200 patients presenting with hematemesis and/or melena due to bleeding oesophageal varices secondary to post-hepatitis C liver cirrhosis. All patients were subjected to thorough history taking, clinical examination, and laboratory investigations, abdominal ultrasonography and upper endoscopy. Modified Child-Pugh score and MELD score were calculated for each patient.
The patients were grouped into three groups:
Group I: patients who survived 12 weeks following endoscopic management and did not rebleed during this period (173 patients).
Group II: patients who rebled and survived due to successful resuscitation and endoscopic management within 12 weeks of AVH (15 patients).
Group III: patients who rebled and died from hypovolemic shock after failure of resuscitation within 12 weeks of AVH (12 patients). Control group: Including 32 person apparently healthy 20 male and 12 female in middle aged groups .
• After an informed written consent from patients and control groups.
All patients received the standards of care in the emergency situations and all of them underwent endoscopy .
• Among 200 patients with acute variceal haemorrage,27 (13.5)% of total patients of whom 12 patients (44.4%) died , while no mortality occurred in the negative rebleeder patients
• There was statistically significant difference between the rebleeder and non rebleeder groups as regard the history of previous attack of haematemsis or melena , and the presence of DM .
• There is association of occurrence of rebleeding and lower systolic and diastolic blood pressure , disturbed conscious level , jaundice, pleural effusion, splenomegaly and child –pugh classification Rebleeding was associated with the advanced degree in liver cirrhosis ( in child C > child B) .
• DM, previous attack of bleeding ,jaundice, disturbed conscious level, child –pugh classification ,meld score, were dependently predictor for occurrence of rebleeding and mortality –related rebleeding .
• Significant difference among control group, rebleeding group ,non rebleeding group as regard HB , albumin, bilirubin, prothrombin concentrations ,INR, urea fasting blood sugar and VEGF.
• Serum VEGF was elevated in patient with acute variceal haemorrage rather than control group.It was higher in patients with rebleeder than non rebleeder. Serum VEGF is significantly associated with patients with child C than patients with child B
• By ultrasonography there was statistically significant difference between the two groups as regards liver and splenic size , portal vein diameter, kidney echopattern , but there was no significant difference between the rebleeders and non rebleeders as regards presence of ascites.
• By upper endoscopy, 120 patients (69.4%) of (non rebleeder group ) were grade F2, while in rebleeders,it was in 12 patients (46.2%) . And 53 patients (30.6%) were grade F3 (non rebleeder group) while 15 patient (53%) in the bleeder group were grade F3 which was statistically significant, Also, there is statistically significant difference as regard the grading of varices , number of cords , extension of varices ,number of used rubber bands between rebleeders and non rebleeders .
• There was statistically significant difference as regard risky signs in general; white nipple sign , and presence of active bleeding during endoscopy between the rebleeder and non rebleeder groups. while there was no significant difference between them as regard the presence of cherry red spots and number of sessions
• Absence of GOVS was in (82.7%) of non rebleeder group and (29.6%) of rebleeder group . Type 1 (GOV) was in 15.6% , and 44.4% in rebleeder group. While type II ( GOVS) was in (1.7%) non rebleeder group and (25.9 %) of rebleeder group with Portal hypertensive gastropathy was significantly different between rebleeder and non rebleeder.
• VEGF is independent predictor of the number of cords,extensions, bands,nipple sign .
• The accuracy of VEGF to predict the rebleeding and mortality by using Roc curve was 94.5 and 93.6 at Cut off 3.25 and 2.85 with sensitivity 96.2 and 94.7 ,specificity 95.4 and 92.2 , positive predictive value 91.3 and 90.7 and negative predictive value 90.5 and 84.6 respectively .
• Patients who have MELD score ≥21 Active bleeding during endescopy and white nipple sign and transfused with more than 4 units of PRBCs, were at higher risk of mortality after acute variceal haemorrage.