Esophageal Varices In Cirrhotic Patients Research Articles

Correlation Between Esophageal Varices and Lok Score as a Non-invasive Parameter in Liver Cirrhosis Patients

Background: Bleeding from gastro-esophageal varices is the most serious and life-threatening complication of cirrhosis. Endoscopic surveillance of esophageal varices in cirrhotic patients is expensive and uncomfortable for the patients. Therefore, there is a particular need for non-invasive predictors for esophageal varices. The aim of the present study was to evaluate association of esophageal varices and Lok Score as non-invasive parameter in liver cirrhosis patients.Method: This is a cross-sectional study of patients admitted at the Adam Malik hospital Medan between September to December 2014 with a diagnosis of cirrhosis based on clinical, biochemical, ultrasound, and gastroscopy. Lok Score was calculated for all patients, tabulated and analyzed.Results: Among 76 patients with esophageal varices, 55.3% was due to hepatitis B virus (HBV). The majority of patients were Child C with only 13,2% being Child Pugh class A. Majority of the population had F2 esophageal varices (42,1%), F1 (32,9%), and F3 (25%). There is significance difference between Lok Score and grading of esophageal varices, Lok score is higher in Large esophageal varices compared with small esophageal varises (0.92 ± 0.14 vs. 0.70 ± 0.29; p = 0.001). Lok Score cut-off value of 0,9141 was highly predictive in the diagnosis large esophageal varices with a sensitivity of 74.5%, specificity of 72%, positive predictive value of 84%, negative predictive value 58%, and accuracy was 73.7%.Conclusion: Lok Score was significantly associated with esophageal varices. Lok score is a good non-invasive predictor of large esophageal varices in cirrhotic patients.

Forns index as a useful noninvasive predictor of esophageal varices in liver cirrhosis

Background<br />Rupture and bleeding from esophageal varices are major complications of portal hypertension and associated with a high mortality rate. Non-invasive serum markers of liver fibrosis could be used as predictors of esophageal varices in cirrhotic patients. The objective of this study was to assess the performance of Forns index as a noninvasive predictor in diagnosing esophageal varices.<br /><br />Methods<br />A cross-sectional study was done in 51 cirrhotic patients who were admitted to Adam Malik hospital, Medan. Demographic and clinical data were recorded and laboratory tests were performed, so that Forns index could be calculated. The difference between Forns index and size of esophageal varices as determined by endoscopy was tested by independent-t and Mann-Whitney analysis. The diagnostic performance was assessed using sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), accuracy, likelihood ratios and areas under the receiver operating characteristic curves (AUROC). <br /><br />Results<br />Of the 51 patients with esophageal varices included in this study, the size of esophageal varices comprised F2 (37.3%), F3 (33.3), and F1 (29.4%). Most patients were of Child-Plug C type (52.6%). There was a significant difference between Forns index and grade of esophageal varices. The AUROC for Forns index was 0.717 (95% CI: 0.561 - 0.872) and the cut-off >7.92 was highly predictive to diagnose large esophageal varices with a sensitivity of 63.9%, specificity of 73.3%, PPV of 85.2%, NPV of 45.8% and accuracy of 71.7%.<br /><br />Conclusion<br />Forns index was significantly increased in large esophageal varices. Forns index is a good noninvasive predictor of esophageal varices in cirrhotic patients.

Prediction of oesophageal varices in cirrhotic patients by measuring liver stiffness with fibroscan

Background: Repeated endoscopy is required to detect & follow up of esophageal varices (OV) in cirrhotic patients. Objective: For discomfort and unwillingness lo do the endoscopy directed us to evaluate liver stiffness measurement (LSM) for lhe prediclion ofO V. Methods: A cross sectional observational study was conducted between July 2010 to July 2011. A total of 50 patients with cirrhosis were divided into three groups. Group-I patients had no varix (n=4), group-II had Grade-I OV (n=23) and group-UI had Grade-II/III OV (n=23 ) at endoscopy. Liver stiffness was measured by fibroscan & data was analyzed by SPSS.Results: Mean age were 35.20 ± 11.36 years with highest frequency 19 (38 %) in 21-30 years age group. Etiologies were different with leading causes includes HBV (76%) followed by HCV (6%), alcohol (2%) and 14% were unknown. Liver stiffness did not significantly differ from group-I & group-II, but was signifi­cantly higher in group III than group-II & group I. Liver stiffness was nol accurate in the prediction of grade-I oesophageal variees [Arca under the curve (AUC)] = 23.6%. Liver stiffness at a cut off value 32.52 kPa with sensitivity, specificity, positive predictive value, negative predictive value, accuracy respectively 82.6%, 77.8 %, 76 %, 84%, 80% can predict the Grade-II-Ill oesophageal varices (AUROC = 85.2%). Conclusion: Liver stiffness may be suitable for prediction of Grade-II-III oesophageal varices, not for the screening of the presence of oesophageal varices.

Non-invasive Diagnosis of Oesophageal Varices Using Systemic Haemodynamic Measurements by Finometry: Comparison with Other Non-invasive Predictive Scores

Cirrhosis and portal hypertension are characterised by a hyperdynamic circulation, which is independently associated with variceal size. Non-invasive techniques for measurement of systemic haemodynamics are now available. The aim of the study was to prospectively assess the accuracy of systemic haemodynamics measured non-invasively for the detection of oesophageal varices in cirrhotic patients as compared to other currently available non-invasive methods. In a study of 29 cirrhotic patients, systemic haemodynamics were studied non-invasively using the Finometer® (mean arterial pressure (MAP), cardiac output (CO)/index, heart rate (HR), peripheral vascular resistance) and portal pressure was assessed by hepatic venous pressure gradient. Sensitivity, specificity, predictive values and area under the receiver operating characteristic (ROC) curves were assessed for predicting presence of varices and large oesophageal varices. Results were compared to child's classification, platelet/spleen ratio and ALT/AST ratios as predictors of the presence of large varices. Using finometry large oesophageal varices were correctly predicted in 83% of patients compared to other non-invasive techniques (range 66-76%). Non-invasive assessment of systemic haemodynamics using finometry could aid the identification of patients who do not immediately require variceal surveillance reducing the numbers of endoscopies and ensuring services are provided to those most likely to benefit.

Evaluation of large esophageal varices in cirrhotic patients by transient elastography: a meta-analysis.

Transient elastography (TE) has been shown to be a valuable tool for the prediction of large esophageal varices. However, the conclusions have not been always consistent throughout the different studies. Therefore, we performed a further meta-analysis in order to evaluate the diagnostic accuracy of transient elastography for the prediction of large esophageal varices. We performed a systematic literature search in PubMed, EMBASE, Web of Science, and CENTRAL in The Cochrane Library without time restriction. The strategy we used was "(fibroscan OR transient elastography OR stiffness) AND esophageal varices". Accuracy measures such as pooled sensitivity, specificity, among others, were calculated using Meta-DiSc statistical software. Twenty studies (2,994 patients) were included in our meta-analysis. The values of pooled sensitivity, specificity, positive and negative likelihood ratios and diagnostic odds ratio were as follows: 0.81 (95% CI, 0.79-0.84), 0.71 (95% CI, 0.69-0.73), 2.63 (95% CI, 2.15-3.23), 0.27 (95% CI, 0.22-0.34) and 10.30 (95% CI, 7.33-14.47). The area under the receiver operating characteristics curve was 0.83. The Spearman correlation coefficient was 0.246 with a p-value of 0.296, indicating the absence of any significant threshold effects. In our subgroup analysis, the heterogeneity could be partially explained by the geographical origin of the study or etiology; or it could be partially explained blindingly, through the appropriate interval and cut-off value of the liver stiffness (LS). Transient elastography could be used as a valuable non-invasive screening tool for the prediction of large esophageal varices. However, since LS cut-off values vary throughout the different studies and significant heterogeneity also exists among them, we need more reasonable approaches or flow diagram in order to improve the operability of this technology.

The Role of Spleen Stiffness in Determining the Severity and Bleeding Risk of Esophageal Varices in Cirrhotic Patients.

Esophageal varix and its hemorrhage are serious complications of liver cirrhosis. Recent studies have focused on noninvasive prediction of esophageal varices. We attempted to evaluate the association of liver and spleen stiffness (LS and SS) as measured by acoustic radiation force impulse imaging, with the presence and severity of esophageal varices and variceal hemorrhage in cirrhotic patients.We measured LS and SS, along with endoscopic examination of esophageal varices for a total of 125 cirrhotic patients at a single referral hospital in this prospective observational study. The diagnostic utility of noninvasive methods for identifying varices and their bleeding risk was compared, including LS, SS, spleen length, Child-Pugh score, and various serum fibrosis indices.Esophageal varices were present in 77 patients (61.6%). SS was significantly higher in patients with varices than in those without varices (3.58 ± 0.47 vs 3.02 ± 0.49; P < 0.001). A tendency toward increasing SS levels was observed with increasing severity of varices (no varix, 3.02 ± 0.49; F1, 3.39 ± 0.51; F2, 3.60 ± 0.42; F3, 3.85 ± 0.37; P < 0.001). SS was significantly higher in patients who experienced variceal hemorrhage than in those who did not (3.80 ± 0.36 vs 3.20 ± 0.51; P = 0.002). An optimal cut-off value of SS for high-risk varices (≥F2) or variceal hemorrhage was 3.40 m/s.SS was significantly correlated with the presence, severity, and bleeding risk of esophageal varices. Prompt endoscopic evaluation of variceal status and prophylactic measures based on the SS may be warranted for cirrhotic patients.

O019 : The value of different non-invasive tests for predicting the presence of clinically significant portal hypertension and esophageal varices in cirrhotic patients

O019 : The value of different non-invasive tests for predicting the presence of clinically significant portal hypertension and esophageal varices in cirrhotic patients

Prediction of esophageal varices in cirrhotic patients with apparent diffusion coefficient of the spleen.

To predict esophageal varices in cirrhotic patients with apparent diffusion coefficient (ADC) of the spleen and to correlate the ADC with clinical and laboratory biomarkers of esophageal varices. This study was conducted upon 40 patients (28 male, 12 female; age ranged 19-45 years; mean age = 33 years) with biopsy-proven cirrhotic liver. Twenty age- and sex-matched healthy volunteers were included as a control group. Patients with varices (n = 15) and without varices (n = 25) and volunteers underwent echo-planar diffusion-weighted MR imaging of the abdomen with b factors of 0, 400, and 800 s/mm(2). The ADC maps of the abdomen were reconstructed. The ADC values of the spleen were calculated and correlated with the Child score, platelet count, and prothrombin time. The mean ADC value of the spleen in cirrhotic patients (1.34 ± 0.05 × 10(-3) mm(2)/s) was significantly different (P = 0.001) from that of volunteers (0.87 ± 0.04 × 10(-3) mm(2)/s). The ADC of the spleen in cirrhotic patients with varices (1.49 ± 0.05 × 10(-3) mm(2)/s) was significantly different (P = 0.001) from that of patients without varices (1.11 ± 0.06 × 10(-3) mm(2)/s). The cut-off ADC value of the spleen used for prediction of cirrhosis and varices was 1.15 and 1.29 × 10(-3) mm(2)/s with areas under the curve were 0.872 and 0.889, respectively. The ADC value of the spleen was correlated with the splenic volume (r = 0.862; P = 0.001), Child score (r = 0.742; P = 0.001), platelet count (r = -0.698; P = 0.01), and prothrombin time (r = 0.684; P = 0.01). The ADC value of the spleen can predict esophageal varices in cirrhotic patients and is well correlated with the clinical and laboratory biomarkers of esophageal varices.

Predictive Value of Non-Invasive Blood Ammonia Level for the Presence of Oesophageal Varices in Egyptian Patients With Liver Cirrhosis

AIM: Although recent guidelines recommend screening of cirrhotic patients by upper endoscopy for oesophageal varices prediction, Non-invasive parameters are needed due to high endoscopy cost and burden on endoscopic units particularly in poor countries. The aim of this study is to evaluate the accuracy of using ammonia blood level as potential non-invasive predictor of oesophageal varices in cirrhotic patients. Methods: This prospective study was conducted on 150 Egyptian participants. Patients were categorized as group I which included 100 with oesophageal varices and group II included 30 patients without varices. There were 20 healthy control participants served as a control group (group III). All patients underwent for full clinical and laboratory workup, abdominal ultrasound and upper gastrointestinal endoscopy. Venous ammonia blood levels were calculated for all the contributors of this study. Results: The mean ammonia level was higher in group I (88.29±42.82 µmol/L) than in group II (82.77±49.76 µmol/L) with no statistical significant difference between the two groups (p=0.34). Ammonia level in group III was 73.37±30.36 µmol/L with no statistical significant difference with the other groups (p>0.05). In group I; ammonia level is positively correlated with the splenic vein diameter with r = 0.22 (p=0.026) but did not correlate with the grade of oesophageal varices r =0.031 (p-value=0.762). In multivariate analysis; ammonia combined with platelets, Age, PT and PC shared in a significant prediction model (I) for esophageal varices grading (p=0.002). Prediction model (II) including portal and splenic veins diameters and the liver size was developed (p=0.016). Conclusion: Non-invasive means could be used to monitor cirrhotic patients and consider treatment. Ammonia level can not be used alone but its use within a significant prediction model can help restricting the use of endoscopic screening in patients with a high probability of esophageal varices.

A pilot study of capsule endoscopy after a standard meal for the detection and grading of oesophageal varices in cirrhotic patients

BackgroundCapsule endoscopy has been proposed as an alternative to fibreoptic endoscopy for oesophageal varices evaluation in cirrhotics. However, it shows only moderate sensitivity compared to fibreoptic endoscopy. AimTo compare post-meal capsule endoscopy to fibreoptic endoscopy, based on the hypothesis that meal-induced increase of portal pressure can enhance its sensitivity. MethodsTwenty-five patients were submitted to fibreoptic endoscopy and, after a standard meal, capsule endoscopy. ResultsPost-meal capsule endoscopy detected varices in the 18 patients in whom fibreoptic endoscopy detected varices plus 3 more subjects (sensitivity 100%, specificity 70%); large varices in the 4 patients in whom fibreoptic endoscopy graded varices as large, plus 5 more subjects; red markers in the 5 patients in whom fibreoptic endoscopy detected red markers, plus 3 more subjects. High-risk varices were identified in 11 patients by post-meal capsule endoscopy and in 10 by fibreoptic endoscopy (sensitivity 100%, specificity 93.8%). ConclusionsPost-meal capsule endoscopy identified more varices, large varices and red markers than fibreoptic endoscopy. The two methods detected similar proportions of high-risk varices. These data suggest that a standard meal can enhance the sensitivity of capsule endoscopy in the detection and grading of oesophageal varices in cirrhotics.

Role of portal haemodynamic parameters in prediction of oesophageal varices in cirrhotic patients

Background and study aimsScreening all cirrhotic patients by endoscopy for detection of varices is not cost-effective as the number of patients increases by time and half of them still would not have developed varices 10years after being diagnosed with cirrhosis. Therefore, this study aimed to evaluate hepatic haemodynamic Doppler parameters in predicting the presence of oesophageal varices (OVs) in cirrhotic patients for better selection of those actually needed for screening endoscopy. Patients and methodsEighty-one patients with liver cirrhosis, 32 females and 49 males, with a mean age of 50.7±11.7years were recruited for the study. They included 61 patients with OVs and 20 patients without varices. The diagnosis of liver cirrhosis was based on clinical history, examination, and investigations. Liver function and kidney function tests and complete blood count (CBC) were performed for all patients. All patients underwent abdominal ultrasound (US), upper endoscopy, and hepatic Doppler US examination. ResultsThe portal vein velocity (PVV) and liver vascular index (LVI) showed statistically significantly lower values in patients with OVs than those without OVs (p value=0.02 and 0.000, respectively). The congestion index (CI) of the portal vein, the portal hypertension index (PHI), and the splenoportal index (SPI) showed statistically significantly higher values in patients with OVs than those without OVs (p value=0.006, 0.001, and 0.001, respectively). CI and SPI were the best parameters that could predict the presence of OVs with high sensitivity, specificity, and diagnostic accuracy when cutoff values were set at >0.069 and 3.57, respectively (area under the curve=0.864 and 0.894, respectively). ConclusionsThe CI of the portal vein and SPI are good predictors for the presence of OVs in cirrhotic patients, and could be used noninvasively to decrease the burden on the upper endoscopy unit by proper selection of those who are candidates for screening endoscopy.

Hemodynamic Changes of Hepatic Veins as Predictors of Large Oesophageal Varices in Liver Cirrhotic Patients

Background and study aim: Oesophageal varices (OV) are morbid and mortal complications of portal hypertension. Oesophago-gastroduodenoscopy (OGD) is the main diagnostic yet semi- invasive tool; different non-invasive methods were developed for early prediction and assessment of OV yet not fully evaluated. This work aims at assessment of changes of hepatic venous wave patterns as early predictors of large OV in cirrhotic patients without history of variceal bleeding. Patients and methods: A number of 50 previously diagnosed liver cirrhotic patients were subjected to detailed history taking. After exclusion criteria only 46 patients were included in the study. They were subjected to routine investigations, OGD, abdominal ultrasound (US) and Color Doppler studying of the hepatic veins (HV). Results : Out of the total number (46 liver cirrhotic patients included in the study), the triphasic waves were detected in (26.1%), biphasic waves in (43.5%) and monophasic waves in (30.4 %). Small varices were detected in (65.2 %), while large varices were detected in (34.8 %).The sensitivity of loss of the triphasic waveform in detecting large varices was high (93.8 %), specificity was (36.7 %), the positive predictive value was (44.1 %) and the negative predictive value was high (91.7 %). Conclusion : The loss of hepatic venous triphasic waveform - detected by Color Doppler Abdominal Ultrasound Study- is a weak predictor of large OV in liver cirrhotic patients without history of variceal bleeding

A comparative study of Duplex Doppler ultrasound and blood indices as noninvasive predictors of oesophageal varices in cirrhotic patients

BackgroundEndoscopic surveillance of oesophageal varices (OV) in cirrhotic patients is expensive and uncomfortable for the patients. Therefore, there is a particular need for noninvasive predictors for OV.ObjectiveThe aim of the present study was to evaluate the accuracy of ultrasound indices and blood indices as noninvasive OV predictors among cirrhotic patients.Patients and methodsA total of 61 cirrhotic patients were enrolled in this study and were divided into two groups: 21 patients without OV and 40 patients with OV who were further subdivided into 24 patients with small OV and 16 with large oesophageal varices (LOV). P2/MS, serum fibrosis markers (APRI, FIB4, Lok score, and Forns index), abdominal ultrasonography [portal vein diameter (PVD), splenic index], platelet count/spleen diameter ratio (PC/SD), and Doppler ultrasonography [portal vein velocity, splenoportal index, hepatic and splenic impedance indices, and hepatic venous waveform (HVWF)] were assessed in all patients.ResultsP2/MS was the best predictor of OV and LOV [area under the curve (AUC) 0.88 and 0.787, respectively] followed by PC/SD (AUC 0.77 and 0.715, respectively). PVD, serum fibrosis markers, and serum albumin had the least accuracy for OV prediction. For LOV predictions, Lok score had good accuracy (AUC 0.785) followed by serum albumin, PVD, APRI, and Forns index (AUC 0.72, 0.738, 0.734, and 0.738, respectively). Monophasic HVWF showed a good positive predictive value (85%) and specificity (80.95%) for prediction of OV and good sensitivity (81.25%) and negative predictive value (81.25%) for LOV.ConclusionP2/MS can identify OV and LOV in cirrhosis with high accuracy followed by PC/SD. Monophasic HVWF is a good noninvasive predictor of OV and LOV in cirrhotic patients.

Diagnostic performance of using effervescent powder for detection and grading of esophageal varices by multi-detector computed tomography

PurposeTo investigate the effect of using effervescent powder (EP) on the efficacy of multi-detector computed tomography (MDCT) in detection and grading of esophageal varices in cirrhotic patients by considering endoscopy as the gold standard. Materials and methodsNinety-two cirrhotic patients undergoing biphasic liver MDCT followed by upper gastrointestinal endoscopy within 4 weeks of MDCT were prospectively evaluated. The patients were divided into two groups before MDCT. The first group (n=50) received effervescent powder (EP) before and during MDCT procedure and the second group did not receive (n=42). The presence, size and grade of the esophageal varices were evaluated. MDCT findings were compared with endoscopic results. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and accuracy of MDCT with EP and without EP were calculated and compared. Correlations between the grades of the varices for each group based on MDCT imaging and endoscopic grading were also evaluated. ResultsThe sensitivity, specificity, accuracy, PPV, and NPV of MDCT were 100%, 88%, 96%, 94%, and 100%, respectively, in the EP group, whereas they were 76%, 67%, 74%, 89%, and 43%, respectively, in the non-EP group. Correlations between the grades of the esophageal varices on MDCT and endoscopy were significant in both groups (r=0.94, p<0.001 for EP group and r=0.70, p<0.001 for non-EP group). ConclusionDuring periodic CT scanning of cirrhotic patients, use of EP increases the success rate of MDCT for detection and grading of esophageal varices.

Oesophageal varices in patients with liver cirrhosis

About one third of cirrhotic patients with oesophageal varices (OV) develops an episode of oesophageal hemorrhage, and subsequently has high morbidity and mortality. Early detection and prevention of OV in these patients are crucial to minimizing complications. This study was carried out to determine the prevalence of OV among the cirrhotic patients at our institution. Fifty six patients with liver cirrhosis who had upper gastrointestinal endoscopy done were recruited into the study. The study was carried out at the Ekiti State University Teaching Hospital, Ado –Ekiti, between January 2010 and December 2011. Liver cirrhosis was diagnosed on the basis of liver biopsy, clinical and ultrasound findings. At the point of recruitment, a full medical history was taken. The severity of liver disease was assessed according to Child's classification. All the patients underwent upper gastrointestinal (GIT) endoscopy. The diagnosis of variceal bleeding was confirmed if an actively bleeding varix or a varix with adherent clot was seen. The following endoscopic features were recorded during the procedure: size, colour, and location of varices (oesophageal, fundal or portal gastropathy) and the presence of red signs. Ethical approval for the study was obtained from hospital’s Ethics Committee and all the patients gave their individual signed consent. SPSS version 15.0 (SPSS, Inc., Chicago, Illinois, USA) was deployed for statistical analysis using the t-test for quantitative variables and χ2 test for qualitative variables. Differences were considered to be statistically significant if P value was less than 0.05. Fifty six cirrhotic patients comprising of 37 males and 19 females were recruited into the study. The Male: Female ratio was 1.9:1. The mean age for males was 51.6±10.2, while that of the females was 55.4±10.6. Oesophageal varices were found in 30 of the 56 patients giving an overall prevalence rate of 53.6%. All the varices were oesophageal in location; 73.3% (22/30) were males while 26.7% (8/30) were females. A large proportion (64.3%) of the patients were in Child’s grade A, while 28.5% were in Child’s Grade B and only 7.1% were in Child’s Grade C. Endoscopically, 13 of the varices were small (F1), 10 were medium sized (F2) while 7 were of large size (F3). The statistically significant risk factors for oesophageal varices found in this study were hepatitis B virus infection and tattoo marks. The prevalence of oesophageal varices in cirrhotic patients in this study was 53.6%. Upper gastrointestinal endoscopy is therefore recommended in the cirrhotic patients to ameliorate the risk of bleeding and the related high mortality.

Usefulness of MR elastography for predicting esophageal varices in cirrhotic patients

To evaluate the usefulness of magnetic resonance elastography (MRE) as a noninvasive tool for predicting esophageal varices and identifying high-risk varices. In all, 126 patients with liver cirrhosis, and who underwent both MRI including MRE of the liver as well as upper gastrointestinal endoscopy for variceal screening within 1 month before or after the MRI, were included in this study. The relationship between the liver stiffness values measured by MRE and the degree of esophageal varices was assessed using Spearman's correlation analysis. In addition, the diagnostic performance of MRE for predicting the presence of varices or high-risk varices (grade≥II) was evaluated using the receiver-operating characteristics (ROC) curves. The mean stiffness values of liver parenchyma measured on MRE were well correlated with the grade of esophageal varices (r=0.63). In addition, the MRE-based liver stiffness values were significantly lower in the lower-risk group than in the higher-risk group (P<0.0001). The area under the ROC curve values of MRE for predicting the presence of varices or high-risk varices (grade≥II) were 0.859 and 0.810, respectively. Using a liver stiffness cutoff value of 5.803 kPa, the sensitivity, specificity, positive predictive value, and negative predictive value for predicting high-grade (≥II) esophageal varices were 96%, 60%, 36%, and 98%, respectively. The MRE-based liver stiffness value may be useful for noninvasively predicting esophageal varices and identifying high-risk varices in cirrhotic patients.

Predicting portal hypertension and variceal bleeding using non-invasive measurements of metabolic variables

Background & aim. This study assessed the involvement of metabolic factors (anthropometric indices, insulin resistance (IR) and adipocytokines) in the prediction of portal hypertension, esophageal varices and risk of variceal bleeding in cirrhotic patients.Material and methods. Two prospective and retrospective cohorts of cirrhotic patients were selected (n = 357). The first prospective cohort (n = 280) enrolled consecutively in three centers, underwent upper gastrointestinal endoscopy, seeking evidence of esophageal varices. Clinical, anthropometric, liver function tests, ultrasonographic, and metabolic features were recorded at the time of endoscopy, patients were followed-up every 6 months until death, liver transplantation or variceal bleeding. The second retrospective cohort (n = 48 patients) had measurements of the hepatic venous pressure gradient (HVPG). Statistical analyses of the data were with the SPSS package.Results. The presence of esophageal varices was independently associated with lower platelet count, raised HOMA index and adiponectin levels. This relationship extended to subset analysis in patients with Child A cirrhosis. HOMA index and adiponectin levels significantly correlated with HVPG. Beside Child-Pugh class, variceal size and glucagonemia, HOMA index but not adiponectin and leptin plasma levels were associated with higher risk of variceal bleeding.Conclusion. In patients with cirrhosis, HOMA score correlates with HVPG and independently predict clinical outcomes. Three simple markers i.e. platelet count, IR assessed by HOMA-IR and adiponectin significantly predict the presence of esophageal varices in cirrhotic patients.

Incidence of Bacteremia After Endoscopic Variceal Ligation of Oesophageal Varices in Cirrhotic Patients

Bacteremia and infectious sequelea are frequent complications after sclerotherapy. As cirrhotic patients are immune deficient, bacteremia occurring as a consequence of endoscopic variceal ligation (EVL) may develop systemic infection. The aim of the study was to see the incidence of bacteremia in cirrhotic patients after EVL. In this study 91 cirrhotic patients with grade II-III oesophageal varices were enrolled and 100 EVL sessions were done. Patients receiving antibiotics, having evidence of infection were excluded. After the completion of EVL, blood samples for culture and sensitivity were collected at 5minute and after 30minute and subculture done in Blood Agar and MacConkey Agar media. We followed the patients for a week. Of the one hundred cases there were 30 subjects in Child A, 48 in Child B and 13 in Child C class. Four patients (4%) had positive blood culture after EVL, three of Child A class and one of Child B class and non in Child C class. All three patients of Child A had culture positive in their 30minute sample and not in 5 minute sample. The Child B patient had culture positive in his 5minute sample and not in 30minute sample. The bacterium isolated was Coagulase negative Staphylococcus, which we considered it as contaminant. None of these patients developed any infectious sequelea. The incidence of bacteremia after EVL is yet to be ascertained. Post EVL antibiotic prophylaxis is not recommended. DOI: http://dx.doi.org/10.3329/medtoday.v24i1.14109 Medicine TODAY Vol.24(1) 2012 pp.20-22

Evaluation of platelet dysfunction in viral liver cirrhosis ( relationship to disease severity)

Background Hepatitis C virus (HCV) is a major health problem in Egypt, which has the highest HCV prevalence worldwide. Cirrhotic patients are known to have acquired platelet hypofunction; however, HCV-induced inflammatory and immunological phenomena are thought to be responsible for in-vivo platelet activation. This study aimed to evaluate the platelet function in patients with HCV-induced liver cirrhosis and also to study the relationship of platelet function to disease severity and various clinical/laboratory findings in cirrhotic patients. Materials and methods Evaluation of platelet function was carried out on 50 patients with HCV-induced liver cirrhosis using the platelet function analyzer-100 (PFA-100), compared with 30 healthy volunteers. Results The study demonstrated the presence of platelet hypofunction reflected by the prolonged PFA-100 closure time in patients of Child–Pugh stage B compared with those of stage A and C, in moderate compared with negative/mild and severe ascites, and in grade II esophageal varices compared with other grades. Patients with Child–Pugh stage B and C, severe ascites, and stage III/IV esophageal varices had significantly lower platelet count/spleen size ratios. Conclusion Chronic HCV-induced liver cirrhosis is implicated in alterations of primary hemostasis, with platelet hypofunction being more evident during relatively earlier disease stages compared with the later ones. PFA-100 closure time and platelet count/spleen size ratio could be used as noninvasive predictors of the grades of esophageal varices in cirrhotic patients. The simplicity of the PFA-100 could facilitate its use as a convenient primary screening test to detect platelet dysfunction in HCV-induced liver cirrhosis.

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.