Endoscopic Screening For Esophageal Varices Research Articles

Egyptian revalidation of non-invasive parameters for predicting esophageal varices in cirrhotic patients: A retrospective study

Background and study aimsIn resource-limited countries, non-invasive tests for assessing liver fibrosis are a potential alternative to costly endoscopic screening for esophageal varices. We aimed to validate several non-invasive parameters for predicting the presence of varices. Patients and methodsBetween September 2006 and August 2017, a total of 46,014 patients who underwent upper gastrointestinal endoscopy as one of the perquisites for receiving hepatitis C virus (HCV) therapy were enrolled and divided into group I (without varices) and group II (with varices). Non-invasive parameters of fibrosis, namely Lok index, Bonacini score, liver stiffness, FIB-4, Baveno, and extended Baveno criteria, were validated. ResultsLok index, Bonacini score, liver stiffness, and FIB-4 had areas under the receiver operating characteristic curve (AUCs) of >0.6 (all P < 0.01 for the null hypothesis that the AUC was 0.5) for determination of the presence/absence of varices, with cutoff values of 0.80, 6.5, 21.9 kPa, and 2.94, and sensitivities of 74%, 74%, 66%, and 83%, respectively. The expanded Baveno VI criteria performed better than the Baveno VI criteria (spared endoscopy rate 81% versus 63%). ConclusionThe use of non-invasive methods is of limited value in predicting esophageal varices. The limited accuracy of ≤60% may delay the use of appropriate primary prophylaxis against variceal bleeding in a large proportion of cirrhotic patients.

2D-Shear Wave Elastography in Predicting Esophageal Varices in Patients with Compensated Liver Cirrhosis

Background: Current guidelines require endoscopic screening for esophageal varices. It is a costly and invasive procedure. So, there has always been a search for non-invasive measures that can predict the varices obviating the use of endoscopy. We tried to see whether 2D-Shear wave elastography (2D-SWE) measurements could predict the presence of esophageal varices and high-risk esophageal varices in patients with compensated cirrhosis. Aim: To investigate the diagnostic performance of 2D-SWE in predicting the presence of esophageal varices and high-risk varices in patients with compensated cirrhosis and to compare the diagnostic capabilities of 2D-SWE with those of transient elastography(TE), and other non-invasive parameters. Methods: 108 patients with compensated cirrhosis undergoing B-mode, 2D-SWE, TE, and endoscopy were enrolled. Comparisons of the accuracy of prediction between groups were made by AUROCs. Regression analysis was performed for the multiple variables. Results: There were 64 males and 44 females, with a mean age of 51.73 ± 11.35 years. NASH(40%) and Alcohol(27%) were the main etiologies. Esophageal varices were found in 63 patients. 36 had high-risk varices. The AUROC value of 2D- SWE(0.967) was comparable to that of TE(0.961) but significantly higher than other non-invasive parameters(platelet count, spleen diameter, platelet count/spleen diameter ratio, FIB-4, APRI). 2D-SWE had 92.1% sensitivity, 88.7% specificity, 90.6% PPV, and 88.6% NPV for predicting the presence of varices at an optimal cut-off value > 21.1kPa, and 91.7% sensitivity, 88.6% specificity, 80.2 % PPV, and 95.1% NPV for predicting high-risk varices at an optimal cut-off value > 24.6 kPa. No patient with 2dSWE value <20.3 kPa had varices. Conclusion: In patients with compensated cirrhosis, liver stiffness measured by 2D- SWE is an effective non-invasive diagnostic tool for predicting the presence of esophageal varices and high-risk varices. The diagnostic performance of 2D-SWE is similar to that of TE, but better than other non-invasive parameters.

Machine Learning-based Development and Validation of a Scoring System for Screening High-Risk Esophageal Varices

Many patients with cirrhosis who undergo esophagogastroduodenoscopy (EGD) screening for esophageal varices (EVs) are found to have no or only small EVs. Endoscopic screening for EVs is therefore a potentially deferrable procedure that increases patient risk and healthcare cost. We developed and validated a scoring system, based on readily-available data, to reliably identify patients with EVs that need treatment. We collected data from 238 patients with cirrhosis undergoing screening EGD from January 2016 through December 2017 at 3 separate hospitals in Los Angeles (training cohort). We abstracted data on patient sex, age, race/ethnicity, platelet counts, and levels of hemoglobin, serum sodium, aspartate aminotransferase, alanine aminotransferase, total bilirubin, international normalized ratio, albumin, urea nitrogen, and creatinine. We also included etiology of cirrhosis, presence of ascites, and presence of hepatic encephalopathy. We used a random forest algorithm to identify factors significantly associated with the presence of EVs and varices needing treatment (VNT) and calculated area under the receiver operating characteristic curve (AUROC). We called the resulting formula the EVendo score. We tested the accuracy of EVendo in a prospective study of 109 patients undergoing screening EGDs at the same medical centers from January 2018 through December 2018 (validation cohort). We developed an algorithm that identified patients with EVs and VNT based on international normalized ratio, level of aspartate aminotransferase, platelet counts, urea nitrogen, hemoglobin, and presence of ascites. The EVendo score identified patients with EVs in the training set with an AUROC of 0.84, patients with EVs in the validation set with and AUROC of 0.82, and EVs in patients with cirrhosis Child-Turcotte-Pugh class A (n= 235) with an AUROC of 0.81. The score identified patients with VNT in the training set with an AUROC of 0.74, VNT in the validation set with and AUROC of 0.75, and VNT in patients with cirrhosis Child-Turcotte-Pugh class A with and AUROC of 0.75. An EVendo score below 3.90 would have spared 30.5% patients from EGDs, missing only 2.8% of VNT. The same cutoff would have spared 40.0% of patients with Child-Turcotte-Pugh class A cirrhosis from EGDs, missing only 1.1% of VNT. We algorithmically developed a formula, called the EVendo score, that can be used to predict EVs and VNT based on readily available data in patients with cirrhosis. This score could help patients at low risk for VNT avoid unnecessary EGDs.

Correlation between Platelet Count vs Spleen Bipolar Diameter Ratio and Esophageal Varices in Liver Cirrhosis

Background: Esophageal variceal bleeding is a potentially fatal complication in patients with liver cirrhosis and portal hypertension. In cirrhotic patients, endoscopic screening for esophageal varices (EV)is currently recommended at the time of diagnosis. The present study intends to find out correlation between platelet countspleen bipolar diameter ratio and esophageal varices in liver cirrhosis and prospectively validate its use for the noninvasive diagnosis of EV.Methods: This observational study was done at theDepartment of Gastrointestinal Hepatobiliary and Pancreatic Disorder, BIRDEM General Hospital, Dhaka, during the period of November, 2013 to October, 2014. A total 64 patients with cirrhosis of liver were included. Complete blood count, liver function tests, ultrasonographyof whole abdomenand endoscopy of upper gastro-intestinal tract (GIT)were done in all patients. Statistical analysis was done with SPSS version 16.Results: Among 64 study population EV were detected in 54 patients (84.4%). The platelet count/ spleen bipolar diameter ratio was significantly higher without EV compared with those with EV(1570 ± 493) and (688 ± 227), respectively; (p&lt;0.001).Patients with EV had lower platelet counts (86799.84 ±27389.99/mm3, p&lt;0.001), higher bipolar spleen diameters (127.94±15.14 mm, p&lt;0.001) and lower platelet count/ spleen bipolar diameter ratios (688.79 ±227.13, p&lt;0.001). In this analysis, by applying (ROC)curve the platelet count-spleen bipolar diameter ratio at a cut-of 908.5 maintained high sensitivity (100 %), Robust negative predictive value NPV (100%),specificity (55.6%) and PPV (85.4%), with an overall diagnostic accuracy of 87.50% for the prediction of EV.With advancing Child-Pugh (C-P) class the percentage of patients with varices increased, 33.3% in C-P class A, 85.7% in C-P class B and 91.6% in C-P class C. The presence of EVcorrelated significantly with the severity of liver cirrhosis (p = 0.03) as measured by Child-Pugh score.Conclusion: The identification of non-endoscopic, noninvasive methods that can accurately predict esophageal varicesin cirrhosis of liver has been addressed in several recent studies. This study was yet another attempt to achieve this goal. Predicting the presence of EV by noninvasive means would restrict the performance of endoscopy and reducing the number of unpleasant screening endoscopiesBirdem Med J 2018; 8(2): 159-166

Combination of albumin-bilirubin grade and platelets to predict a compensated patient with hepatocellular carcinoma who does not require endoscopic screening for esophageal varices

There is no consensus on screening for high-risk esophageal varices (HRV) in patients with hepatocellular carcinoma (HCC). Here, we aimed to investigate the prevalence and risk factors of HRV in patients with HCC and to assess the combination of albumin-bilirubin grade and platelet count (ALBI-PLT score) for predicting compensated patients who do not need unnecessary endoscopic screening for HRV. The ALBI-PLT score was calculated by adding the ALBI grade and points for platelet count (1 point if platelet count >150,000/mm3 and 2 points if ≤150,000/mm3). The predictive value of the ALBI-PLT score for HRV was analyzed in 887 compensated patients enrolled from October 2007 to April 2014 (study cohort). This was validated in 215 compensated patients from May 2014 to December 2015 (validation cohort). In the study cohort, the rates of HRV were 2.9% and 21.1% in compensated HCC patients with an ALBI-PLT score of 2 and >2, respectively. The negative predictive values of the ALBI-PLT score for predicting HRV were 97.1% and 98.1% in the study and validation cohorts, respectively. For compensated patients who did not receive endoscopic screening at the time of HCC diagnosis, the 5-year cumulative variceal hemorrhage rate was lower in patients with an ALBI-PLT score of 2 than in those with an ALBI-PLT score >2 (1.7% vs 9.1%, P= .007). In patients with HCC with compensated liver function, an ALBI-PLT score of 2 predicted a very low risk of HRV and variceal hemorrhage; therefore, endoscopic screening for esophageal varices is not recommended for these patients.

THU-047 - Not all of the patients with hepatitis B-related hepatocellular carcinoma require endoscopic screening for esophageal varices: a large cohort study

THU-047 - Not all of the patients with hepatitis B-related hepatocellular carcinoma require endoscopic screening for esophageal varices: a large cohort study

Combined platelet count with sCD163 and genetic variants optimizes esophageal varices prediction in cirrhotic patients

Endoscopic screening for esophageal varices (EVs) is expensive and invasive. Besides traditional noninvasive markers, we explore additional candidate markers including portal hypertension serum marker-soluble CD136 (sCD163) and genetic variants of splanchnic vasodilatation and revascularization pathways for prediction of EVs in cirrhotic patients. A total of 951 cirrhotic patients without history of variceal bleeding and an independent validation cirrhotic cohort were enrolled to evaluate the association between the presence of EVs and patients' clinical and genetic characteristics. Cirrhotic patients with EVs had higher serum sCD163 and heme oxygenase-1 (HO-1) level, which was positively correlated with the number of risk alleles of HO-1 (S, A), vascular endothelial growth factor (VEGF [G, T]) and VEGF receptor-2 (VEGFR2 [Ile]) genes, than those without EVs. Multivariate analysis showed that EVs in cirrhotic patients was predicted by low platelet count, high sCD163 level, splenomegaly, HO-1 AS and the VEGF GT risk haplotypes. Additive effects in relation to predict EVs were observed in the simultaneous presence of HO-1 AS and VEGF GT risk haplotypes. Combining low platelet count with high sCD163/risk haplotypes significantly increased the predictability of EVs. Furthermore, cirrhotic patients carrying both HO-1 AS and VEGF GT risk haplotypes had lower probability of being free of EVs bleeding compared to patients without above risk haplotypes. This study suggested that high sCD163 levels and genetic risk variants are additional markers that can be combined with low platelet count to optimize assessment of EVs and bleeding in cirrhotic patients.

Prevalence and Indicators of Portal Hypertension in Patients With Nonalcoholic Fatty Liver Disease

Little is known about the prevalence and severity of portal hypertension in patients with nonalcoholic fatty liver disease (NAFLD). We investigated the prevalence and noninvasive predictors of portal hypertension in patients with NAFLD. Signs of portal hypertension, including esophageal varices, splenomegaly, portosystemic encephalopathy, and ascites, were investigated in 354 patients with NAFLD. One hundred patients had portal hypertension at the time of NAFLD diagnosis (28.2%), 88 of these patients had septal fibrosis or cirrhosis (88%). Fibrosis stage correlated with presence (r = 0.41, P < .0001) and number of findings (r = 0.48, P = .006) of portal hypertension. Of the 204 patients with no or mild fibrosis (stages, 0-2), 12 patients had portal hypertension (6%); they had a significantly higher grade of steatosis, based on biopsy analysis, compared with the 192 patients without portal hypertension (94%). Thrombocytopenia, hyperbilirubinemia, cirrhosis, and obesity were associated independently with portal hypertension. Esophageal varices were found in 57 of the 128 patients undergoing endoscopic screening (44.5%) and were associated independently with thrombocytopenia, type 2 diabetes, and splenomegaly. Signs of portal hypertension were present in 25% of patients at the time of diagnosis of NAFLD; most had advanced fibrosis or cirrhosis. Portal hypertension can occur in a small proportion of patients with mild or no fibrosis and is associated with the extent of steatosis. Features of advanced liver disease and insulin resistance might identify patients with NAFLD and portal hypertension, and those expected to derive the most benefit from endoscopic screening for esophageal varices.

Risk Assessment of Esophageal Variceal Bleeding in B-Viral Liver Cirrhosis by a Liver Stiffness Measurement-Based Model

Periodic endoscopic screening for esophageal varices (EVs) and prophylactic treatment for high-risk EVs (HEVs; (i) medium/large EVs and (ii) small EVs with red sign or decompensated cirrhosis) are recommended for cirrhotic patients. We assessed cumulative risks of future EV bleeding (EVB) using the liver stiffness measurement (LSM)-based model, LSM-spleen diameter to platelet ratio score (LSPS=LSM×spleen diameter/platelet count). We prospectively enrolled 577 consecutive B-viral cirrhosis patients from 2005 to 2009, none of whom experienced EVB. All underwent laboratory workups, endoscopy, LSM, and ultrasonography. Those with HEVs took nonselective β-blockers as prophylaxis for EVB after diagnosis, if not contraindicated. The major end point was the first EVB event, examined using Kaplan-Meier and Cox-regression methods. Among whole population, 95.9% negative- /93.5% positive-predictive value by LSPS<3.5/LSPS≥5.5 were provided for predicting the presence of HEV at enrollment, respectively. Among patients with HEV (n=150), 25 experienced their first EVBs during follow-up (median, 29 months). To differentiate EVB risk, we divided them into subgroup 1 (LSPS<6.5) and 2 (LSPS≥6.5) according to LSPS 6.5, a point with maximum sum of sensitivity and specificity from time-dependent receiver-operating characteristic (ROC) curves (area under ROC curve=0.929). EVB risk was higher in subgroup 2 than subgroup 1 (P<0.001). Multivariate analysis found higher LSPS (P=0.003) a significant predictor, alongside large variceal sizes (P=0.004) and Child-Pugh classifications B/C (P=0.001). Notably, EVB risk of subgroup 1 was as low as that of low-risk EVs (P=0.507). LSPS is a reliable predictor for EVB risk. According to risk stratification, different prophylactic treatments should be considered for subgroups with LSPS≥6.5.

151 LIVER COLLAGEN PROPORTIONATE AREA CORRELATES WITH ESOPHAGEAL VARICES AND SVR IN PATIENTS WITH COMPENSATED HCV CIRRHOSIS

Background: Albeit cirrhosis evolves through clinical stages to decompensation and death, the relation between the amount of fibrosis and the disease course is unknown. Digital image analysis of stained biopsy sections quantifies fibrosis, using segmentation of digital images to measure areas of collagen and to produce a collagen proportionate area (CPA). Aim: To correlate CPA with esophageal varices (EV) at baseline and SVR to SoC therapy in patients with compensated HCV cirrhosis. Patients and Methods: Eighty-six HCV-RNA positive, compensated patients with an histology of cirrhosis (Scheuer’s stage 4) were included. Biopsies were stained with Sirius-red to calculate CPA, excluding samples <15mm. All patients underwent endoscopic screening for EV before SoC treatment with Peg-IFN alfa-2b and Ribavirin. Mean follow up was 37±12 months. Results: Twenty-nine patients (33.7%) had EV. Seven biopsies were suboptimal. In 79 assessable patients, the mean value of CPA was 15.6±6.7%. Mean CPA was significantly different among patients with or without EV (17.9±7.9 vs 13.7±5.9; p = 0.010). By univariate analysis CPA (p =0.007) and albumin (p =0.096) were associated to EV but by multivariate logistic analysis CPA was the only variable associated with EV (OR: 1.086 95%CI: 1.005–1.172; p =0.036). By AUROC the best CPA cut-off value for EV was 14.1% (Sensitivity:80%; Specificity:70%; PPV:60%; NPV 83%). Nineteen patients (24.1%) had SVR. Mean CPA value in patients with SVR was lower than in nonSVR patients (16.6±6.4% vs 12.5±6.9%, p = 0.021). The best CPA cut-off value for SVR was 13% (Sensitivity:74%; Specificity:67%; PPV:40%; NPV:89%). At univariate analysis, CPA and PLT were associated to SVR, but only CPA was associated with SVR at multivariate analysis (OR: 1.012, 95%CI: 0.82–0.99; p = 0.046). Conclusion: The amount of fibrosis in a cirrhotic liver, quantified by CPA, correlates closely to the degree of portal hypertension. The inverse relation between CPA and likelihood of SVR to SoC may suggest use of the former as an additional parameter to indicate which patients with compensated HCV cirrhosis should receive therapy.

Prediction of large esophageal varices in cirrhotic patients using classification and regression tree analysis

OBJECTIVES:Recent guidelines recommend that all cirrhotic patients should undergo endoscopic screening for esophageal varices. That identifying cirrhotic patients with esophageal varices by noninvasive predictors would allow for the restriction of the performance of endoscopy to patients with a high risk of having varices. This study aimed to develop a decision model based on classification and regression tree analysis for the prediction of large esophageal varices in cirrhotic patients.METHODS:309 cirrhotic patients (training sample, 187 patients; test sample 122 patients) were included. Within the training sample, the classification and regression tree analysis was used to identify predictors and prediction model of large esophageal varices. The prediction model was then further evaluated in the test sample and different Child‐Pugh classes.RESULTS:The prevalence of large esophageal varices in cirrhotic patients was 50.8%. A tree model that was consisted of spleen width, portal vein diameter and prothrombin time was developed by classification and regression tree analysis achieved a diagnostic accuracy of 84% for prediction of large esophageal varices. When reconstructed into two groups, the rate of varices was 83.2% for high‐risk group and 15.2% for low‐risk group. Accuracy of the tree model was maintained in the test sample and different Child‐Pugh classes.CONCLUSIONS:A decision tree model that consists of spleen width, portal vein diameter and prothrombin time may be useful for prediction of large esophageal varices in cirrhotic patients.

A Liver Stiffness Measurement-Based, Noninvasive Prediction Model for High-Risk Esophageal Varices in B-Viral Liver Cirrhosis

Periodic endoscopic screening for esophageal varices (EVs) and prophylactic treatment for high-risk EVs ((HEVs); (1) medium/large EVs and (2) small EVs with red sign or decompensated cirrhosis) are currently recommended for all cirrhotic patients. However, if a simple, noninvasive test is available, many low-risk patients may safely avoid endoscopy. We developed and validated a new liver stiffness measurement (LSM)-based prediction model for HEVs. We prospectively enrolled 280 consecutive B-viral cirrhosis patients from 2005 to 2007 (training set) and 121 from 2007 to 2008 (validation set). All underwent laboratory workups, endoscopy, LSM, and ultrasonography. For detection of HEVs, univariate and multivariate analysis were performed, using chi2-test/t-test and logistic regression, respectively. A prediction model was derived from multivariate predictors. In the training set, 90 had HEVs, and multivariate analysis showed significant differences in LSM, spleen diameter, and platelet count between patients with and without HEVs. We developed LSM-spleen diameter to platelet ratio score (LSPS): LSM x spleen diameter/platelet count. The area under the receiver-operating characteristic curve (AUROC) in the training set was 0.954. At LSPS<3.5, 94.0% negative predictive value (NPV) was provided (184 patients), whereas 94.2% positive predictive value (PPV) was achieved (69 patients) at LSPS>5.5. Overall, the likelihood of HEVs was correctly diagnosed in 253 patients (90.3%). Its predictive values were maintained at similar accuracy in subsequent validation set (AUROC=0.953; 94.7% NPV/93.3% PPV at cutoff 3.5/5.5, respectively). LSPS is a reliable, noninvasive method for detection of HEVs. Patients with LSPS<3.5 may avoid endoscopy safely, whereas those with LSPS>5.5 should be considered for appropriate prophylactic treatments.

The budget impact of endoscopic screening for esophageal varices in cirrhosis

The cost-effectiveness of screening for esophageal varices in cirrhosis remains uncertain. Previous analyses found that screening with upper endoscopy (EGD) may not be cost effective versus empiric beta-blocker (BB) therapy. However, these models were conducted before advances in variceal screening, including capsule endoscopy (CE), and they did not measure the budget impact (vs cost-effectiveness) of variceal screening. To compare the managed care budget impact of variceal screening strategies. Budget impact model. Hypothetical managed care organization with 1 million covered lives. Patients with compensated cirrhosis. Compared 5 strategies: (1) empiric BB, (2) screening EGD followed by BB if varices present (EGD --> BB), (3) EGD followed by endoscopic band ligation if varices present (EGD --> EBL), (4) CE followed by BB if varices present (CE --> BB), and (5) CE followed by EBL if varices present (CE --> EBL). Per-member per-month cost. BB was the least expensive, and CE --> EBL was the most expensive. Substituting CE --> BB in lieu of BB cost each member an additional $0.20 per month to subsidize. Compared with CE --> BB, both EGD-based strategies were more expensive. However, CE was not viable in managed care organizations capable of reducing the cost of endoscopy below $410, unless the cost of CE was reduced in lockstep. Data on CE remain limited. Screening for varices may have an acceptable budget impact but is highly sensitive to local costs of EGD and CE. In managed care organizations willing to subsidize EBL for variceal prophylaxis, it is inefficient to screen with CE compared with EGD.

Noninvasive diagnosis of cirrhosis in chronic hepatitis C based on standard laboratory tests

Noninvasive assessment of hepatic fibrosis is gaining popularity.1, 2 Several noninvasive tests have been proposed, including indirect markers of liver fibrosis composed of routine laboratory parameters. We read with great interest the article by Lok et al.3 on the use of the regression formula log odds = −5.56 − 0.0089 × platelet (×109/L) + 1.26 × AST/ALT ratio + 5.27 × INR (“model 3”) for prediction or exclusion of cirrhosis (Ishak fibrosis score F5–F6) in patients with chronic hepatitis C (CHC). Although this model was developed in a cohort of nonresponders to previous antiviral treatment that comprised patients with more advanced stages of fibrosis (Ishak fibrosis score F3–F6), it was also applied to 265 treatment-naïve CHC patients previously studied,4 confirming its diagnostic accuracy across a broad range of fibrosis (Ishak fibrosis score F0–F6). We recently evaluated several noninvasive tests based on standard laboratory parameters, including the aspartate aminotransferase to platelet ratio index (APRI) and platelet count per se, in a cohort of 194 treatment-naïve CHC patients.5 For external validation, we applied model 3 in our CHC study cohort and compared its diagnostic accuracy for prediction/exclusion of cirrhosis (Ishak fibrosis score F5–F6) with that of platelet count and APRI. Ishak fibrosis score correlated moderately with platelet count, APRI, and model 3 (Spearman's R −0.50, 0.62, and 0.53, respectively). Evaluation of the overall diagnostic accuracies for the prediction of cirrhosis by receiver-operating characteristic analysis revealed comparable results: areas under the receiver-operating characteristic curves for platelet count, APRI, and model 3 were 0.89, 0.90, and 0.90, respectively. Our findings on the diagnostic accuracy of model 3 for prediction/exclusion of cirrhosis are very similar to the results reported by Lok et al. (Table 1). Each of the noninvasive tests evaluated was more suited for exclusion of cirrhosis than for its prediction. Using the reported cutoff values of ≥150 × 109/L (platelet count), <1.0 (APRI), and <0.2 (model 3), each of the tests reliably excluded cirrhosis with a negative predictive value of 95% or more in 78%, 59%, and 49% of patients, respectively. Conversely, prediction of cirrhosis using a cutoff value of <150 × 109/L (platelet count), ≥2.0 (APRI), and ≥0.5 (model 3) was much less reliable (positive predictive value 56%, 59%, and 58%, respectively). Our data confirm the excellent diagnostic accuracy of model 3 for the exclusion of cirrhosis; however, we would like to point out that the platelet count per se allows the exclusion of cirrhosis with a fair degree of accuracy without the need for a calculator or computer. Exclusion of cirrhosis in patients with CHC is important, because costly diagnostic workup may be avoided, including (1) endoscopic screening for esophageal varices and (2) surveillance for hepatocellular carcinoma via regular ultrasound and α-fetoprotein examinations. In treatment-naïve patients with CHC typically seen in a referral center, cirrhosis can be reliably excluded in a considerable number of patients using simple noninvasive fibrosis tests based on routine laboratory parameters. Carolin Lackner*, Gerd Struber*, Csilla Bankuti , Bernd Bauer , Rudolf E. Stauber , * Department of Pathology, Medical University Graz, Graz, Austria, Department of Internal Medicine, Medical University Graz, Graz, Austria, Department of Internal Medicine, Landeskrankenhaus Hoergas, Gratwein, Austria.

Incidental esophageal varices

Incidental esophageal varices

Prevalence and predictors of esophageal varices in patients with primary sclerosing cholangitis.

Patients with primary sclerosing cholangitis (PSC) may develop and bleed from esophageal varices. However, the exact prevalence of esophageal varices in patients with PSC remains unknown and potential predictors of esophageal varices in this population have not been identified. Our aim was to determine the prevalence of esophageal varices in patients with PSC and the variables that predict their presence. Data were collected on 283 patients with PSC treated for the first time at the Mayo Clinic (Rochester, MN) during 8 consecutive years. Thirty-six percent (102 of 283) of patients had esophageal varices including 56% (57 of 102) with moderate/large varices. After excluding 28 patients with a history of variceal bleeding, data on 183 patients were analyzed to identify independent predictors of esophageal varices and of moderate/large size varices. Platelet count, albumin level, and advanced histologic disease were independent predictors of esophageal varices (area under the receiver operator characteristic [ROC] curve = 0.88). After controlling for the presence of advanced histologic stage and albumin levels, the odds ratios (OR) of platelet count less than 150 x 10(3)/dL for the presence of esophageal varices was 6.3 (95% CI: 2.6-15.8). The diagnostic accuracy of these results was corroborated by cross-validation of the data in an independent set of 72 patients with PSC (area under the ROC = 0.90). In conclusion, in patients with PSC, noninvasive markers of portal hypertension and of advanced liver disease predict the presence of esophageal varices. Our results suggest a clinically applicable and useful approach to identify patients with PSC who are more likely to benefit from endoscopic screening for esophageal varices.

Is Endoscopic Screening for Esophageal Varices Cost-Effective?

As many as 50% of patients with Child's class A or B cirrhosis have moderate or large esophageal varices; once varices form, the risk for bleeding

Endoscopic screening for esophageal varices in cirrhosis: Is it ever cost effective?

Current guidelines for the management of patients with compensated cirrhosis recommend universal screening endoscopy followed by prophylactic β-blocker therapy to prevent initial hemorrhage in those found to have esophageal varices. However, the cost-effectiveness of this recommendation has not been established. Our objective was to determine whether screening endoscopy is cost-effective compared with empiric medical management in patients with compensated cirrhosis. Decision analysis with Markov modeling was used to calculate the cost-effectiveness of 6 competing strategies: (1) universal screening endoscopy (EGD) followed by β-blocker (BB) therapy (EGD→BB) if varices are present, (2) EGD followed by endoscopic band ligation (EBL) (EGD→EBL) if varices are present, (3) selective screening endoscopy (sEGD) in high risk patients followed by BB therapy if varices are present (sEGD→BB), (4) selective screening endoscopy followed by EBL (sEGD→EBL) if varices are present, (5) empiric β-blocker therapy in all patients, and (6) no prophylactic therapy (“Do Nothing”). Cost estimates were from a third-party payer perspective. The main outcome measure was the cost per initial variceal hemorrhage prevented. The “Do Nothing” strategy was the least expensive yet least effective approach. Compared with the “Do Nothing” strategy, the empiric β-blocker strategy cost an incremental $12,408 per additional variceal bleed prevented. Compared with the empiric β-blocker strategy, in turn, both the EGD→BB and the EGD→EBL strategies cost over $175,000 more per additional bleed prevented. The sEGD→BB and sEGD→EBL strategies were more expensive and less effective than the empiric β-blocker strategy. In conclusion, empiric β-blocker therapy for the primary prophylaxis of variceal hemorrhage is a cost-effective measure, as the use of screening endoscopy to guide therapy adds significant cost with only marginal increase in effectiveness. (H EPATOLOGY 2003;37:366-377.)

Which patients with cirrhosis should undergo endoscopic screening for esophageal varices (EV) detection?

Which patients with cirrhosis should undergo endoscopic screening for esophageal varices (EV) detection?

Which patients with cirrhosis should undergo endoscopic screening for esophageal varices (EV) detection?

Our aims were to develop a noninvasive predictive tool to identify cirrhotic patients with esophageal varices and to evaluate whether portal Doppler ultrasonographic parameters may improve the value of other predictors. One hundred forty-three consecutive compensated cirrhotic patients underwent upper gastrointestinal endoscopy. Fourteen clinical, biochemical, ultrasonographic, and Doppler ultrasonographic parameters of each patient were also recorded. Esophageal varices were detected in 63 of the 143 patients examined (44%; 95% confidence interval [CI] 36.2-52.6). Medium and large esophageal varices were observed in 28 subjects (44%; 95% CI 31.4-58.4). Using stepwise logistic regression, presence of esophageal varices was independently predicted by prothrombin activity less than 70% (odds ratio [OR]: 5.83; 95% CI: 2.6-12.8), ultrasonographic portal vein diameter greater than 13 mm (OR: 2.92; 95% CI: 1.3-6.4), and platelet count less than 100 3 109/L (OR: 2.83; 95% CI: 1.27-6.28). Variables included in the model were used to generate a simple incremental rule to evaluate each individual patient. The discriminating ability of the prediction rule was relevant (area under the curve: 0.80) and did not change by replacing ultrasonographic portal vein diameter with congestion index of portal vein. We concluded that compensated cirrhotic patients should be screened by upper gastrointestinal endoscopy when prothrombin activity less than 70%, platelet count less than 100 3 109/L, and ultrasonographic portal vein diameter greater than13 mm are observed, whereas those without any of these predictors should not undergo endoscopy. The contribution provided by portal Doppler ultrasonographic parameters does not appear of practical utility. (HEPATOLOGY 2001;33:333-338.)