Esophageal Varices Research Articles

Cost effectiveness of esophageal varices screening strategies of cirrhotic patients with portal hypertension

ObjectivesIn France, screening for esophageal varices (EVs) in cirrhotic patients with portal hypertension (PH) is performed by esophagogastroduodenoscopy (EGD). Though proven effective, EGD screening may be unpleasant for some patients. Our study sought to compare the cost-effectiveness of PillCam (Medtronic, Minneapolis, USA) esophageal capsule endoscopy (ECE), a less invasive test, versus EGD, for EV screening, from the perspective of the French national health system (NHS). In secondary objectives we compared the cost-effectiveness of ECE versus no screening for patients not compliant with EGD screening, and the cost-effectiveness of a screening strategy (ECE or EGD) versus no screening strategy at all. MethodsWe constructed a Markov model with data from the literature, applying it to two simulated cohorts of adult patients with cirrhosis and PH not previously screened for EVs. These patients were divided into EGD and ECE screening arms and tracked over a virtual 10-year period. Cost-effectiveness was defined as cost (in euros) per quality-adjusted life year (QALY). ResultsIn the base-case analysis, ECE is more expensive than EGD (€3,606 vs. €3,030) and less effective by 0.0098 QALY (5.2099 vs. 5.2197 QALYs). Probabilistic sensitivity analysis shows that ECE has only a 2.1% probability of being cost-effective at willingness-to-pay (WTP) of €30,000/QALY. ConclusionsAlthough patient compliance is apparently higher with ECE, it is not cost-effective at a WTP of €30,000/QALY and should not be considered in all patients with PH. Its cost-effectiveness should be reevaluated in the event of patient refusal of EGD follow-up. Public Interest SummaryEsophagogastroduodenoscopy (EGD) is gold standard to screen cirrhotic patients with portal hypertension for esophageal varices, but its unpleasantness lowers compliance. We evaluated the cost-effectiveness of a more acceptable alternative for patients: the esophageal capsule endoscopy (ECE).Our results show that screening by ECE is more expensive and less effective than by EGD from the perspective of the French national health system. It cannot be used as an alternative for all patients suffering from PH in France. Further investigations could be conducted to assess the effectiveness of ECE for the sub population of patients with PH who are totally refractory to EGD and may suffer from inadequate follow-up due to lack of screening.

Esophageal Varices Detection and Bleeding Risk Assessment with Artificial Intelligence: A Systematic Review

Esophageal Varices Detection and Bleeding Risk Assessment with Artificial Intelligence: A Systematic Review

S631 Esophageal Variceal Ligation Ulcer Bleeding: Outcomes of Different Modalities Used for Treatment

S631 Esophageal Variceal Ligation Ulcer Bleeding: Outcomes of Different Modalities Used for Treatment

S977 Comparison of Odds of Variceal GI Bleed and Mortality in Inpatients With Alcoholic and Nonalcoholic Liver Cirrhosis After Propensity Score-Matching Using National Inpatient Sample (NIS) Database

S977 Comparison of Odds of Variceal GI Bleed and Mortality in Inpatients With Alcoholic and Nonalcoholic Liver Cirrhosis After Propensity Score-Matching Using National Inpatient Sample (NIS) Database

S962 Navigating Barriers: Bridging Gaps in Secondary Prevention for Gastroesophogeal Variceal Bleeding in Cirrhotic Patients

S962 Navigating Barriers: Bridging Gaps in Secondary Prevention for Gastroesophogeal Variceal Bleeding in Cirrhotic Patients

S1041 The Impact of Hospital Size on the Outcomes of Patients Admitted with Esophageal Variceal Bleeding

S1041 The Impact of Hospital Size on the Outcomes of Patients Admitted with Esophageal Variceal Bleeding

Endoscopic ultrasound-guided vascular interventions: A review (with videos).

Endoscopic ultrasound (EUS) has evolved from a diagnostic to an interventional modality, allowing precise vascular access and therapy. EUS-guided vascular access of the portal vein has received increasing attention in recent years as a diagnostic and therapeutic tool. EUS-guided portal pressure gradient directly measures the hepatic vein portal pressure gradient and is crucial for understanding of liver function and prognostication of liver disease. EUS facilitates the sampling of portal venous blood to obtain circulating tumor cells (CTCs) in pancreatobiliary malignancies. This technique aids in the diagnosis and staging of cancers. EUS-guided interventions have a substantial potential for diagnosing portal vein tumor thrombus (PVTT) in patients with hepatocellular carcinoma. EUS-guided coil and glue embolization have higher efficacy for the treatment of gastric varices than direct endoscopic glue. Pseudoaneurysm (PsA), a rare vascular complication of acute and chronic pancreatitis, is typically managed with interventional radiology (IR)-guided embolization and surgery. EUS is increasingly used in specialized centers for non-variceal gastrointestinal bleeding, particularly for pseudoaneurysm-related bleeding. There is limited data on EUS-guided intervention for bleeding ectopic varices, rectal varices and Dieulafoy lesions, but it is becoming more widely accepted. In this extensive review, we evaluated both current and potential future applications of EUS-guided vascular interventions, including EUS-guided gastric variceal bleed therapy, rectal and ectopic varices, pseudoaneurysmal bleeding, splenic artery embolization, portal pressure gradient measurement, portal vein sampling for CTCs, fine needle aspiration of PVTT, intrahepatic portosystemic shunt placement, liver tumor ablation and EUS-guided cardiac intervention.

S963 Efficacy of Carvedilol Plus Variceal Band Ligation Compared to Carvedilol Alone in Primary Prophylaxis of Variceal Bleed in Cirrhosis With High-Risk Varices: A Single Center Randomized Controlled Study

S963 Efficacy of Carvedilol Plus Variceal Band Ligation Compared to Carvedilol Alone in Primary Prophylaxis of Variceal Bleed in Cirrhosis With High-Risk Varices: A Single Center Randomized Controlled Study

S4417 Pregnancy Under Pressure: Addressing Variceal Bleeding During Gestation

S4417 Pregnancy Under Pressure: Addressing Variceal Bleeding During Gestation

S4447 Esophageal and Gastric Variceal Hemorrhage Lead to Discovery of Isolated Hepatic Decompensation Secondary to A1AT Deficiency

S4447 Esophageal and Gastric Variceal Hemorrhage Lead to Discovery of Isolated Hepatic Decompensation Secondary to A1AT Deficiency

High Blood Ammonia Level Is a Predictor of Medium and Large Size Esophageal Varices In Cirrhotic Patients

Background: The development of esophageal varices (EV) and rupture of them are the most serious complications of portal hypertension. Upper gastrointestinal endoscopy is the gold standard for diagnosis of EV but it is a costly and troublesome invasive procedure. To find a non-invasive method for detection of size of EV and to predict the bleeding risk is appealing and would decrease the indications cost and discomfort of upper GI endoscopy. The aim of the study is to evaluate high blood ammonia level is a predictor of medium and large size of esophageal varices in Cirrhotic patients. Methods: This was an observational Cross-sectional study conducted on 40 cirrhotic patients in Department of Gastroenterology, BSMMU using a pre-designed data collection sheet. Information about clinical profile, laboratory parameters- blood ammonia, serum bilirubin, serum albumin, prothrombin time, and ultrasonography of abdomen, endoscopy upper GIT was collected and recorded. The collected data was analyzed by computer with the help of SPSS version 22. Statistical analysis was done by using appropriate statistical tool like Chi-square test, Student’s t- test. P value < 0.05 was considered as significant. Diagnostic efficacy of blood ammonia was calculated by using a value. Results: A total of 40 patients with cirrhosis. Mean age of cirrhotic patients were 47.47±12.98 years. Mean blood ammonia of small size EV of cirrhotic patients was 73.70±32.11 (μmol/L) and medium and large size EV was 118.3±38.37 (μmol/L) (P< .001). At the level of 78.5 (μmol/L), sensitivity and specificity of blood ammonia was 95% and 65% respectively in detection of size of EV. Conclusion: Blood ammonia estimation could be a good tool for identifying individuals with medium and large size esophageal who will need to undergo endoscopy more frequently. Bangladesh J Medicine 2024; 35: 167-172

A longitudinal 5-year study for the prediction of HCC, death and liver decompensation by ARFI elastography.

Numerous studies have evaluated elastography for the staging of liver fibrosis. Fewer studies were performed investigating the prognostic relevance using transient elastography (TE), although with promising results. This study was designed to evaluate the prognostic relevance of ARFI elastography. Patients receiving ARFI elastography in our ultrasound department between 2010 and 2012 were initially screened for an ARFI examination with a clinical follow-up of at least 5 years. The following events were recorded: liver related death, liver unrelated death, HCC, liver decompensation/ variceal bleeding. A total of 335 patients were included in the final analysis with an ARFI examination of the liver and a follow-up of 60 months. Within the observation interval the number of events with corresponding AUROCs (shown with 95% confidence interval) were: overall death (n=49, 0.76 [0.69 - 0.83]), liver related death (n=25, 0.85 [0.77 - 0.93]), liver unrelated death (n=24, 0.66 [0.55 - 0.77]), HCC (n=15, 0.80 [0.72 - 0.87]), liver related complications/variceal bleeding (n=34, 0.87 [0.82 - 0.93]). In the group of patients with ARFI values suggestive of cirrhosis (equal to or above 1.80 m/s; n=110) higher values (<2.5 m/s vs. >= 2.5 m/s) where associated with a significant decline in liver related survival (p=0.007). ARFI elastography seems to have a good diagnostic accuracy for the prediction of liver related death and decompensation. Further it seems to allow a risk stratification in patients with cirrhosis suspicious elastography values.

Terlipressin-induced skin necrosis in cirrhotic patients-A case report and comprehensive literature review.

The occurrence of terlipressin-induced skin necrosis in cirrhotic patients is a rare but serious adverse event that warrants further investigation. Clinicians should be aware of this potential complication in cirrhotic patients receiving terlipressin therapy and closely monitor for any signs of skin necrosis. Early recognition and prompt intervention are crucial in preventing further complications and improving patient outcomes. Further research is needed to better understand the risk factors associated with terlipressin-induced skin necrosis and to develop effective preventive strategies. Overall, healthcare providers should exercise caution when prescribing terlipressin to cirrhotic patients, weighing the potential benefits against the risks of this rare but significant adverse event. Terlipressin is commonly used to manage conditions related to portal hypertension, such as hepatorenal syndrome and esophageal variceal bleeding. Despite its therapeutic benefits, terlipressin can rarely lead to severe ischemic complications involving the skin vasculature, known as terlipressin-induced skin necrosis. We present a 50-year-old male with cirrhosis and acute variceal bleeding who developed skin necrosis following terlipressin administration. We performed a comprehensive review of the literature by analyzing 18 case reports/case series comprising 22 cirrhotic patients with terlipressin-induced skin necrosis. Among these individuals, we found a mean age of 51 years with a male predominance (78%). Further analysis showed that the onset of skin necrosis ranged from 2 to 5 days post-terlipressin initiation, with bolus administration being predominant (85.7%). The underlying pathophysiological mechanisms of terlipressin-induced skin ischemia are still elusive but primarily attributed to the vasoconstrictive and thrombogenic effects. Management involves terlipressin discontinuation and supportive care. Physicians should be aware of this potential complication in patients receiving terlipressin and closely observe for any signs of skin rash.

Effects of Transjugular Intrahepatic Portosystemic Shunt on Renal and Pulmonary Function in Hepatic Decompensation with and without Hepatorenal and Hepatopulmonary Syndromes: A Review.

Cirrhosis is often characterized by decreased liver function, ranging from a compensated, typically asymptomatic phase to a decompensated phase characterized by the appearance of ascites or variceal bleeding, and ultimately hepatorenal syndrome (HRS) or hepatopulmonary syndrome (HPS). The latter two complications are associated with a poor prognosis and limited treatment efficacy. In cases of ascites or variceal bleeding resistant to medical therapy, transjugular intrahepatic portosystemic shunt (TIPS) is effective and safe. Shunting blood by TIPS diverts portal blood to the systemic circulation, potentially increasing systemic blood volume and benefiting renal function. However, TIPS could also divert nitric oxide to the systemic circulation, potentially worsening systemic hypotension and perfusion, which could be detrimental to renal function. Available evidence indicates that TIPS often improves renal function in patients with portal hypertension, with or without HRS. No studies have shown persistently decreased renal function after TIPS. However, these data are insufficient to support a recommendation for the use of TIPS specifically for HRS. In patients without pre-existing HPS, TIPS does not appear to significantly affect pulmonary gas exchange. Results of TIPS in HPS have been inconsistent; some studies have shown improvement, but effects were transient. No studies have shown a persistent decline in pulmonary function after TIPS. The evidence supports the need for large randomized controlled trials to investigate the beneficial effects of TIPS for HRS. Similar pulmonary function data are less clear regarding TIPS for HPS. The aim of the current report was to review the literature regarding the effects of TIPS on renal and pulmonary function in hepatic decompensation, with or without the development of HRS or HPS.

Computed tomography-based multi-organ radiomics nomogram model for predicting the risk of esophagogastric variceal bleeding in cirrhosis.

Radiomics has been used in the diagnosis of cirrhosis and prediction of its associated complications. However, most current studies predict the risk of esophageal variceal bleeding (EVB) based on image features at a single level, which results in incomplete data. Few studies have explored the use of global multi-organ radiomics for non-invasive prediction of EVB secondary to cirrhosis. To develop a model based on clinical and multi-organ radiomic features to predict the risk of first-instance secondary EVB in patients with cirrhosis. In this study, 208 patients with cirrhosis were retrospectively evaluated and randomly split into training (n = 145) and validation (n = 63) cohorts. Three areas were chosen as regions of interest for extraction of multi-organ radiomic features: The whole liver, whole spleen, and lower esophagus-gastric fundus region. In the training cohort, radiomic score (Rad-score) was created by screening radiomic features using the inter-observer and intra-observer correlation coefficients and the least absolute shrinkage and selection operator method. Independent clinical risk factors were selected using multivariate logistic regression analyses. The radiomic features and clinical risk variables were combined to create a new radiomics-clinical model (RC model). The established models were validated using the validation cohort. The RC model yielded the best predictive performance and accurately predicted the EVB risk of patients with cirrhosis. Ascites, portal vein thrombosis, and plasma prothrombin time were identified as independent clinical risk factors. The area under the receiver operating characteristic curve (AUC) values for the RC model, Rad-score (liver + spleen + esophagus), Rad-score (liver), Rad-score (spleen), Rad-score (esophagus), and clinical model in the training cohort were 0.951, 0.930, 0.801, 0.831, 0.864, and 0.727, respectively. The corresponding AUC values in the validation cohort were 0.930, 0.886, 0.763, 0.792, 0.857, and 0.692. In patients with cirrhosis, combined multi-organ radiomics and clinical model can be used to non-invasively predict the probability of the first secondary EVB.

Research status and hotspots in transjugular intrahepatic portosystemic shunts based on CiteSpace bibliometric analysis.

The transjugular intrahepatic portosystemic shunt (TIPS) is an important technique for treating complications related to portal hypertension in patients with cirrhosis, and the number of publications in the TIPS field continues to rise. To facilitate an understanding of the research status and hotspots in the field of TIPS using CiteSpace bibliometric analysis. CiteSpace is a software that depicts the strength of relationships through graphics and connections with diverse functionalities and can be used to analyze the status and hotspots of areas of research. Articles on TIPS in the Web of Science Core Collection were retrieved, and CiteSpace software was used to visualize and analyze the number of publications, journals, countries, institutions, authors, keywords, and citations. A total of 985 relevant documents were included in the analysis. From January 2013 to December 2022, the number of publications increased annually. The journal, institution, and author with the greatest number of publications in the field of TIPS are the Journal of Vascular and Interventional Radiology, the University of Bonn, and Jonel Trebicka, respectively. The main keywords used in this field are "transjugular intrahepatic portosystemic shunt", "portal hypertension", "cirrhosis", "management", "stent", "hepatic encephalopathy", "refractory ascite", "survival", "risk", and "variceal bleeding". The greatest obstacle to TIPS placement is currently the occurrence of hepatic encephalopathy. The research hotspots are the mechanism, risk factors, management, and control of hepatic encephalopathy. This bibliometric analysis reported the research status and hotspots of TIPS. Research on postoperative hepatic encephalopathy is the research hotspot in this field.

Transjugular intrahepatic portosystemic shunt for esophagogastric variceal bleeding in patients with hepatocellular carcinoma and portal vein tumor thrombus.

Whether hepatocellular carcinoma (HCC) with portal vein tumor thrombus (PVTT) and acute esophagogastric variceal bleeding (EGVB) can improve the success rate of endoscopic hemostasis and overall survival (OS) from transjugular intrahepatic portosystemic shunt (TIPS) remains controversial. To compare the clinical outcomes between TIPS and standard treatment for such HCC patients. This monocenter, retrospective cohort study included patients diagnosed as HCC with PVTT and upper gastrointestinal bleeding. Patients were grouped by the treatment (TIPS or standard conservative treatment). The success rate of endoscopic hemostasis, OS, rebleeding rates, and main causes of death were analyzed. Between July 2015 and September 2021, a total of 77 patients (29 with TIPS and 48 with standard treatment) were included. The success rate of endoscopic hemostasis was 96.6% in the TIPS group and 95.8% in the standard treatment group. All the 29 patients in TIPS group successful underwent TIPS procedure and had a better OS compared with standard treatment within the first 160 days after treatment (68 days vs 43 days, P = 0.022), but shorter OS after 160 days (298 days vs 472 days, P = 0.022). Cheng's Classification of PVTT, total bilirubin and Child-Pugh class were independently negative associated with OS (all P < 0.05). The main causes of death were liver failure or hepatic encephalopathy (75.9%) in the TIPS group and rebleeding (68.8%) in the standard treatment. TIPS could reduce the risk of early death due to rebleeding and prolong short-term survival in HCC patients with PVTT and acute EGVB, which deserves further investigation.

Enhancing transjugular intrahepatic portosystemic shunt procedure efficiency with digital subtraction angiography image overlay technology in esophagogastric variceal bleeding.

Transjugular intrahepatic portosystemic shunt (TIPS) is a pivotal intervention for managing esophagogastric variceal bleeding in patients with chronic hepatic schistosomiasis. To evaluate the efficacy of digital subtraction angiography image overlay technology (DIT) in guiding the TIPS procedure. We conducted a retrospective analysis of patients who underwent TIPS at our hospital, comparing outcomes between an ultrasound-guided group and a DIT-guided group. Our analysis focused on the duration of the portosystemic shunt puncture, the number of punctures needed, the total surgical time, and various clinical indicators related to the surgery. The study included 52 patients with esophagogastric varices due to chronic hepatic schistosomiasis. Results demonstrated that the DIT-guided group experienced significantly shorter puncture times (P < 0.001) and surgical durations (P = 0.022) compared to the ultrasound-guided group. Additionally, postoperative assessments showed significant reductions in aspartate aminotransferase, B-type natriuretic peptide, and portal vein pressure in both groups. Notably, the DIT-guided group also showed significant reductions in total bilirubin (P = 0.001) and alanine aminotransferase (P = 0.023). The use of DIT for guiding TIPS procedures highlights its potential to enhance procedural efficiency and reduce surgical times in the treatment of esophagogastric variceal bleeding in patients with chronic hepatic schistosomiasis.

Transjugular Intrahepatic Portosystemic Shunt (TIPS) for Treatment of Bleeding from Cardiofundal and Ectopic Varices in Cirrhosis

Acute variceal bleeding in cirrhosis represents a critical clinical event that significantly impacts patient prognosis, with mortality rates increasing further after a second episode. This underscores the need for immediate intervention and optimal prophylaxis. The creation of a transjugular intrahepatic portosystemic shunt (TIPS) has been proven to be highly effective for managing esophageal variceal bleeding. However, the use of TIPS for managing cardiofundal gastric varices and ectopic varices remains debated due to their unique vascular anatomy and the limited data available. These varices, although less prevalent than esophageal varices, are complex and heterogeneous vascular shunts between the splanchnic venous system and the systemic veins. Indeed, while endoscopic therapy with tissue adhesives is widely endorsed for achieving hemostasis in active hemorrhage, there is no consensus regarding the optimal approach for secondary prophylaxis. Recent research emphasizes the efficacy of endovascular techniques over endoscopic treatments, such as TIPS and endovascular variceal embolization techniques. This review examines the use of TIPS in managing acute variceal bleeding in patients with cirrhosis, focusing specifically on cardiofundal gastric varices and ectopic varices, discussing optimal patient care based on the latest evidence, aiming to improve outcomes for this challenging subset of patients.

Insulin‐like growth factor‐1 in cirrhosis is linked to hepatic dysfunction and fibrogenesis and predicts liver‐related mortality

SummaryBackground and AimsWe aimed to characterise insulin‐like growth factor‐1 (IGF‐1) signalling in patients with advanced chronic liver disease (ACLD).MethodsConsecutive patients undergoing hepatic venous pressure gradient [HVPG] measurement were prospectively included. Clinical stages were defined as follows: probable ACLD (pACLD): liver stiffness ≥10 kPa and HVPG ≤5 mmHg, S0: mild PH (HVPG 6–9 mmHg), S1: clinically significant PH (CSPH), S2: CSPH with varices, S3: past variceal bleeding, S4: past/current non‐bleeding hepatic decompensation and S5: further decompensation.ResultsIn total, 269 patients were included; 105 were compensated (pACLD: n = 18; S0: n = 30; S1: n = 20; S2: n = 37), and 164 were decompensated (S3: n = 11; S4: n = 89; S5: n = 64). Median levels of IGF‐1 decreased with progressive cirrhosis (from pACLD: 88.5 ng/mL to S5: 51.0 ng/mL; p &lt; 0.001). Patients with CSPH had significantly lower IGF‐1 levels (63.5 ng/mL vs. 81.0 ng/mL; p = 0.001). IGF‐1 showed an independent negative association with body mass index (BMI; aB: −1.56; p &lt; 0.001), enhanced liver fibrosis (ELF) test (aB: −8.43; p &lt; 0.001), MELD (aB: −1.13; p = 0.042) and age (per 10 years; aB: −6.87; p &lt; 0.001). IGF‐1 exhibited an excellent AUROC (0.856) for the prediction of liver‐related death at 6 months of follow‐up. Lower IGF‐1 (per 10 ng/mL) was linked to higher risk of (further) decompensation (0.90; 95% CI: 0.83–0.98; p = 0.016), acute‐on‐chronic liver failure (ACLF; asHR: 0.80; 95% CI: 0.68–0.93; p = 0.004) and liver‐related death (asHR: 0.76; 95% CI: 0.63–0.91; p = 0.004).ConclusionDecreased levels of IGF‐1 reflect impaired hepatic function and fibrogenesis in patients with cirrhosis, which seems particularly relevant in obesity since low IGF‐1 was independently linked to high BMI. Lower IGF‐1 in cirrhosis predicts decompensation, ACLF and liver‐related death.