Esophageal Varices On Computed Tomography Predicts Variceal Hemorrhage

Abstract

Background: Prior studies suggest good agreement between grading of esophageal varices (EV) by endoscopy and measurement by computed tomography (CT). No studies to date have correlated markers of portal hypertension on CT imaging and variceal hemorrhage (VH). Methods: A case-cohort study was performed using patients from San Francisco Veterans Affairs Medical Center with advanced liver disease identified by ICD-9 codes and an outpatient CT between January 2000 and December 2007. Twenty-four patients with an outpatient CT scan prior to sustaining a VH served as cases. Twenty five subjects with no history of VH and an outpatient CT and upper endoscopy within 90 days of each other from calendar 2005 served as controls. Patients were excluded if they had a prior history of band ligation, portal venous thrombosis, or suspected hepatocellular carcinoma. VH was confirmed by chart review, including typical clinical presentation and endoscopic findings at the time of hospitalization. CT scans were reviewed by an experienced radiologist for measurements of various markers of portal hypertension. Results: Patients with VH were more likely to have findings of portal hypertension. The most prominent factors associated with VH included EV tortuosity (100% vs. 40%, OR=∞, p<0.0001), any detectable EV (95.8% vs. 16%, OR=121, p<0.0001), and ascites (79% vs. 28%, OR=9.8, p=0.0003). Presence of paraesophageal varices, recanalized umbilical vein, and enlargement of the coronary vein were less strongly associated with VH. The size of the largest EV was significantly larger in patients experiencing a VH (4.89 mm vs. 0.68 mm, difference=4.2 mm, p<0.0001). The diameter of the portal vein, spleen size, MELD score, and age was not significantly different between the cases and the controls. The number of EV was the only independent predictor of VH in a multivariable logistic model (OR 3.90, range 0-6, p=0.018). The number of EV discriminated well between patients with VH versus those without VH (c statistic 0.95, 95% CI 0.89 - 1.0). Conclusion: The number of EV visualized by CT imaging discriminate well patients with advanced liver disease who are at elevated risk for VH.