Esophageal Varices Research Articles

Early Dynamics of Portal Pressure Gradient After TIPS Insertion Predict Mortality

ABSTRACTBackgroundTransjugular intrahepatic portosystemic shunt (TIPS) placement leads to a reduction in portal pressure and an improvement in survival in patients with recurrent and refractory ascites and variceal haemorrhage. Prediction of post‐TIPS survival is primarily determined by factors identified before the TIPS procedure, as data collected during or after TIPS implantation are limited. The aim of the study was to evaluate the influence of early hemodynamic changes after TIPS placement on survival, in order to refine post TIPS management.MethodsIn this prospective bicentric study, consecutive patients (n = 105) undergoing TIPS placement for ascites or variceal haemorrhage underwent measurement of portal pressure gradient (PPG) immediately at TIPS insertion (PPG0) and 24 h later (PPG24h) and the ΔPPG was calculated from PPG24h and PPG0 (ΔPPG = PPG24h‐PPG0). Kaplan–Meier survival analysis and uni‐ and multivariable regression analyses were conducted to identify survival predictors.ResultsPatients with lack of increased ΔPPG exhibited poorer 90‐day and 1‐year survival compared to patients with increased ΔPPG. This worse survival was independent of The Model for End‐Stage Liver Disease (MELD) score, Child‐Pugh score, bilirubin levels, creatinine and the Freiburg index of post‐TIPS survival (FIPS) > 0.92. Among these patients with poorer outcome, elevated bilirubin (> 25 μmol/L) further distinguished survivors from non‐survivors.ConclusionLack of increased ΔPPG post‐TIPS insertion identifies a high‐risk patient group with worse survival. We propose incorporating this second PPG measurement and determining ΔPPG into clinical practice to identify these patients early and tailor post‐TIPS patient care.

Diagnosis and Treatment Options for Cirrhosis With Unexplained Upper Gastrointestinal Bleeding: An Observational Study Based on Endoscopic Ultrasonography.

To investigate the role of endoscopic ultrasonography (EUS) in the diagnosis and treatment of upper gastrointestinal bleeding of unknown origin in liver cirrhosis, focusing on patients with recurrent treatment of esophageal and gastric varices who failed to identify the bleeding site under direct endoscopy. Esophagogastric variceal bleeding is one of the severe complications of decompensated liver cirrhosis, and serial endoscopic therapy can improve the long-term quality of life of patients. Most acute bleeding can be detected under direct endoscopy with thrombus or active bleeding, but there are still some patients with recurrent bleeding after repeated treatments, and it is difficult to find the bleeding site, especially in gastric variceal bleeding. Therefore, it is of great significance to identify the bleeding site. A total of 88 patients with liver cirrhosis bleeding diagnosed and treated under EUS were collected in this study, including 26 patients who failed to identify the bleeding site under direct endoscopy. EUS was used to scan the bleeding site, and EUS-guided treatment was performed. The characteristics of the bleeding site under direct endoscopy and EUS and the follow-up results after surgery were analyzed. Among the 26 patients, 16 patients (16/26, 61.5%) showed red color signs of gastric fundus mucosa under direct endoscopy, 5 patients (5/26, 19.2%) showed punctate erosion, and the remaining 5 patients (5/26, 19.2%) showed no abnormal mucosal manifestations. All patients could find anechoic blood vessels under EUS, and blood flow signals could be detected within. Among them, 23 patients (23/26, 88.5%) chose EUS-guided treatment, and no rebleeding occurred after surgery. Another 3 patients (3/26, 11.5%) were given endoscopic variceal ligation due to small esophageal and gastric varices and inability to perform intravascular injection. The median follow-up time was 86 days. Adverse reactions included 5 cases of retrosternal pain (5/23, 21.7%), and 1 case of fever (1/23, 4.3%). EUS can detect submucosal varices in the gastric mucosa, and these bleeding sites may present as red color signs or punctate erosion under direct endoscopy.

Prognostic model for esophagogastric variceal rebleeding after endoscopic treatment in liver cirrhosis: A Chinese multicenter study.

Rebleeding after recovery from esophagogastric variceal bleeding (EGVB) is a severe complication that is associated with high rates of both incidence and mortality. Despite its clinical importance, recognized prognostic models that can effectively predict esophagogastric variceal rebleeding in patients with liver cirrhosis are lacking. To construct and externally validate a reliable prognostic model for predicting the occurrence of esophagogastric variceal rebleeding. This study included 477 EGVB patients across 2 cohorts: The derivation cohort (n = 322) and the validation cohort (n = 155). The primary outcome was rebleeding events within 1 year. The least absolute shrinkage and selection operator was applied for predictor selection, and multivariate Cox regression analysis was used to construct the prognostic model. Internal validation was performed with bootstrap resampling. We assessed the discrimination, calibration and accuracy of the model, and performed patient risk stratification. Six predictors, including albumin and aspartate aminotransferase concentrations, white blood cell count, and the presence of ascites, portal vein thrombosis, and bleeding signs, were selected for the rebleeding event prediction following endoscopic treatment (REPET) model. In predicting rebleeding within 1 year, the REPET model exhibited a concordance index of 0.775 and a Brier score of 0.143 in the derivation cohort, alongside 0.862 and 0.127 in the validation cohort. Furthermore, the REPET model revealed a significant difference in rebleeding rates (P < 0.01) between low-risk patients and intermediate- to high-risk patients in both cohorts. We constructed and validated a new prognostic model for variceal rebleeding with excellent predictive performance, which will improve the clinical management of rebleeding in EGVB patients.

July effect in hospitalized cirrhosis patients: A US nationwide study using difference-in-differences analysis.

The July effect in US teaching hospitals has been studied with conflicting results. We aimed to evaluate the effect of physician turnover in July on the clinical outcomes of patients hospitalized with cirrhosis. We utilized the Nationwide Inpatient Sample database (2016-2019) to identify patients hospitalized with cirrhosis and liver-related complications (variceal bleeding, hepatorenal syndrome, acute-on-chronic liver failure). We used difference-in-differences analysis to compare teaching and non-teaching hospital differences in mortality and length of stay (LOS) in May and July, and trends in outcomes in other months before and after July. We included 78,371 hospitalizations in teaching and 23,518 in non-teaching hospitals in May and July. Teaching hospital admissions had overall higher complication rates and mortality compared to non-teaching hospitals. We did not find a difference in mortality between teaching and non-teaching hospitals in all cirrhotic patients (adjusted odds ratio 1.01, 95%CI [0.88-1.16]) or in those with severe complications (0.87, [0.72-1.06]). There was greater LOS in July vs. May in teaching hospitals relative to non-teaching hospitals for all patients with cirrhosis (adjusted rate ratio 1.03, 95%CI [1.02-1.05]) and for those with severe complications (1.19, [1.17-1.21]). The months after July were associated with longer LOS in teaching hospitals, with the effect gradually diminishing over the subsequent months. Our study suggests trainee turnover in July did not affect mortality, but lengthened hospital stays for patients with cirrhosis, highlighting the need for effective supervision of new trainees and strategies to mitigate operational disruptions for improved clinical management.

Long-term follow-up of a randomised clinical trial: standard of care versus pre-emptive transjugular intrahepatic portosystemic shunt (TIPSS) in patients with cirrhosis and oesophageal variceal bleeding

Background and aimsPre-emptive transjugular intrahepatic portosystemic shunt (pTIPSS) within 72 hours following acute oesophageal variceal bleeding has potential survival benefit. However, there is uncertainty whether pTIPSS is advantageous over standard...

Primary prophylaxis of acute variceal bleeding in patients with severe cirrhosis: Time for combination therapy?

Primary prophylaxis of acute variceal bleeding in patients with severe cirrhosis: Time for combination therapy?

Acute upper gastrointestinal bleeding: Analysis of 462 hospitalized Chinese patients in Shanghai.

While acute upper gastrointestinal bleeding (AUGIB) remains clinically critical, the etiology of bleeding and risk factors for mortality remain uncertain. This study aimed to evaluate the underlying causes of AUGIB and identify risk factors associated with fatality. A retrospective survey was conducted in a major clinical hospital in Shanghai, where inpatients diagnosed with AUGIB were meticulously collected and analyzed. This retrospective, single-center study encompassed 462 patients diagnosed with AUGIB from the emergency department of Changhai Hospital between January 1, 2019 to November 30, 2021. The analysis involved various aspects including epidemiology, gastroscopy, imaging, laboratory tests and data, clinical features, and hospital mortality. Among the 462 patients studied, 87% (400 out of 462) were afflicted with noncirrhotic hemorrhage (up to 38% with peptic ulcer), and 4 patients required digital subtraction angiography embolization (two died). The mortality rate was 12% (49/400), of which 49% (24/49) of patients died of malignant tumors. Mortality did not differ according to sex (χ2 = 0. 851, P = .356) but was significantly influenced by age (χ2 = 18.292, P = .001), hemoglobin levels (χ2 = 22.908, P = .001), and comorbidity (χ2 = 17.355, P = .001). In patients with esophageal and gastric variceal bleeding, the mortality rate was as high as 25% (16/62). Their mortality did not vary with sex (χ2 = 0.318, P = .573), hemoglobin levels (χ2 = 4.139, P = .247), or age (χ2 = 7.674, P = .087), but was predominantly associated with hemorrhagic shock (88%, 14/16). Esophageal and gastric variceal bleeding and noncirrhotic hemorrhage patients observed significantly different mortality rates (P = .004). Peptic ulcers remained the primary cause of AUGIB. Old age, low hemoglobin levels, and comorbidities were the main risk factors contributing to mortality; nearly half of the patients died from malignant tumors. Hemorrhagic shock was independently associated with a high risk of in-hospital mortality in patients with cirrhotic hemorrhage.

Safety and Efficacy of Portal Vein Recanalization with Creation of Intrahepatic Portosystemic Shunt (PVR-TIPS) to Treat Chronic Portal Vein Thrombosis in Non-cirrhotic Patients.

This study assesses the efficacy and safety of Portal Vein Recanalization with Intrahepatic Portosystemic Shunt (PVR-TIPS) in non-cirrhotic patients with chronic portal vein occlusion (CPVO), cavernomatous transformation, and symptomatic portal hypertension (PH) and/or portal vein thrombotic progression. Medical records of 21 non-cirrhotic patients with CPVO and portal cavernoma undergoing PVR-TIPS were analyzed. Hemodynamic (intraprocedural reduction in portosystemic pressure gradient), clinical (data on gastrointestinal bleeding, abdominal pain, ascites, and presence of esophageal varices from imaging exams) and technical success (PVR-TIPS) assessed efficacy. Safety was determined through complications classified according to the CIRSE Classification System. PVR-TIPS was successfully performed in all patients, resulting in a significant reduction in portal pressure gradient by 10mmHg (21.475 ± 9.7mmHg - 11.454 ± 5,4mmHg, p < 0.001), alleviating portal hypertension symptoms without thrombotic progression. Clinical success included resolution or reduction of ascites (p = 0.016), gastroesophageal varices (p = 0.004), abdominal pain (p = 0.0021), and cessation of gastrointestinal bleeding (p = 0.021). Complications occurred in 33% of patients, including six grade III events (1 perioperative liver bleeding, 5 delayed stent occlusions) and one grade VI event resulting in death (4.8%). Primary patency rate was 76% (21.3months, range:0.2-82), secondary patency 100% (4months, range:3.8-40.8). Survival at follow-up was 90.4%, with one unrelated death. One patient underwent liver transplantation, three became eligible post-recanalization. PVR-TIPS proves effective and safe in reducing portal pressure gradient, thereby alleviating PH symptoms without evidence of portal thrombosis progression in non-cirrhotic patients with CPVO and portal cavernoma. It expands therapeutic options, including liver transplantation.

Real-world effectiveness and safety of bulevirtide monotherapy for up to 96 weeks in patients with HDV-related cirrhosis.

Bulevirtide (BLV) 2 mg/day is EMA approved for treatment of compensated chronic hepatitis due to Delta virus (HDV) infection, however real-life data in large cohorts of patients with cirrhosis are lacking. Consecutive HDV-infected patients with cirrhosis starting BLV 2 mg/day since September 2019 were included in a European retrospective multicenter real-life study (SAVE-D). Patient characteristics before and during BLV treatment were collected. Virological, biochemical, combined responses, adverse events and liver-related events (HCC, decompensation, liver transplant) were assessed. 244 patients with HDV-related cirrhosis receiving BLV monotherapy for a median of 92 (IQR 71-96) weeks were included: at BLV start, median (IQR) age was 49 (40-58) years, 61% men, ALT 80 (55-130) U/L, liver stiffness measurement (LSM) 18.3 (13.0-26.3) kPa, platelets 94 (67-145) x 103/mm3, 54% with esophageal varices, 95% Child Pugh score A, 10% HIV-coinfected, 92% on NUC, median HDV RNA 5.4 (4.1-6.5) Log10 IU/mL, HBsAg 3.8 (3.4-4.1) Log10 IU/mL. At weeks (W)48 and 96, virological, biochemical and combined responses were observed in 65% and 79%, 61% and 64%, 44% and 54% of patients, respectively. AST, GGT, albumin, IgG and LSM values significantly improved throughout treatment. Serum bile acid levels increased in most patients, only 10% patients reported mild and transient pruritus, independently of bile acid levels. The W96 cumulative risk of de-novo HCC and decompensation was 3.0% (95% CI 2-6%) and 2.8% (95% CI 1-5%), respectively. Thirteen (5%) patients underwent liver transplantation (n=11 for HCC, n=2 for decompensation). BLV 2 mg/day monotherapy up to 96 weeks was safe and effective in patients with HDV-related cirrhosis. Virological and clinical responses increased over time. Liver-related complications were few.

Pipeline esophageal varices: Insights from clinical cases and models.

While esophageal varices (EVs) are typically treated endoscopically, other options such as interventional radiology or surgical treatment are considered when endoscopic treatment is challenging. Pipeline EVs are difficult to treat endoscopically due to their large diameter, and currently, no specific treatment guidelines have been established. We reviewed cases of pipeline EVs treated at our hospital and analyzed previously reported cases to collect evidence for the formulation of treatment guidelines. Additionally, we created EV simple models to evaluate the safety margin of endoscopic variceal ligation for varices. Our analysis included 14 cases of pipeline EVs (four cases treated at our hospital from 2013 to 2024 and 10 previously reported cases from 1990 to 2024). Endoscopic treatment alone was insufficient in six cases (42.9%), and five cases (35.7%) required interventional radiology or surgical intervention. Using EV simple models with varying diameters, EVL was inadequate for varices with diameters of 20mm or larger. There are few reported cases of pipeline EVs, making it difficult to determine a treatment algorithm. In our study using an EV simple model, it was suggested that endoscopic variceal ligation is effective in blocking blood flow for EVs with a diameter of 15mm or less. It is important that we understand there are EVs, such as pipeline EVs, for which there are limitations to safely occluding blood flow with endoscopic variceal ligation, and it may be necessary to develop treatment strategies that include methods other than endoscopic therapy.

Non selective beta-blockers prevent PHT-related complications occurrence in HCC patients with esophageal varices treated by TACE.

. We aimed to investigate the parameters associated with portal hypertension (PHT)-related complications occurrence in hepatocellular carcinoma (HCC) patients treated by transarterial chemoembolization (TACE), with a focus on non-selective beta blockers (NSBBs) due to their impact on preventing liver decompensation. . We included all patients with HCC for whom endoscopy was available the day of first TACE (2013-2023). The occurrence of PHT-related complications was defined as the appearance of ascites, acute variceal bleeding or hepatic encephalopathy (HE) post-TACE treatment and prior to HCC progression. Inappropriate treatment by NSBBs was defined by the lack of NSBBs in patients with small/large esophageal varices (EV). . 109 patients were included (age 67 years, 80% male) and 65% had EV. No NSBBs prescription despite indication was observed in 32% and 81% of patients with large and small size EV, respectively. Median progression free survival and overall survival were 10 and 23 months, respectively, and 27% of patients underwent LT. During the follow-up, 20 patients presented PHT-related complications with an incidence of 18% at 12months (90% with EV,67% not treated by NSBB while indicated). Among them, 11 presented HCC progression, 2 were transplanted and 78% presented liver decompensation that impaired the access to further HCC treatment. In multivariate analysis, a history of HE (HR=55.39,95%CI[7.42-413.26]) and inappropriate NSBBs treatment (HR=4.16,95%CI[1.45-11.81]) were associated with PHT-related complications occurrence. . The lack of NSBBs was independently associated with PHT-related complications after TACE, precluding access to further HCC treatment in 78% of patients with HCC progression. Appropriate screening and PHT prophylaxis are needed in HCC patients who undergo TACE to improve their outcomes.

Quantitative fibrosis identifies biliary tract involvement and is associated with outcomes in pediatric autoimmune liver disease.

Children with autoimmune liver disease (AILD) may develop fibrosis-related complications necessitating a liver transplant. We hypothesize that tissue-based analysis of liver fibrosis by second harmonic generation (SHG) microscopy with artificial intelligence analysis can yield prognostic biomarkers in AILD. Patients from single-center studies with unstained slides from clinically obtained liver biopsies at AILD diagnosis were identified. Baseline demographics and liver biochemistries at diagnosis and 1 year were collected. Clinical endpoints studied included the presence of varices, variceal bleeding, ascites, HE, and liver transplant. In collaboration with HistoIndex, unstained slides underwent SHG/artificial intelligence analysis to map fibrosis according to 10 quantitative fibrosis parameters based on tissue location, including total, periportal, perisinusoidal, and pericentral area and length of strings. Sixty-three patients with AIH (51%), primary sclerosing cholangitis (30%), or autoimmune sclerosing cholangitis (19%) at a median of 14 years old (range: 3-24) were included. An unsupervised analysis of quantitative fibrosis parameters representing total and portal fibrosis identified a patient cluster with more primary sclerosing cholangitis/autoimmune sclerosing cholangitis. This group had more fibrosis at diagnosis by METAVIR classification of histopathological review of biopsies (2.5 vs. 2; p = 0.006). This quantitative fibrosis pattern also predicted abnormal 12-month ALT with an OR of 3.6 (1.3-10, p = 0.014), liver complications with an HR of 3.2 (1.3-7.9, p = 0.01), and liver transplantation with an HR of 20.1 (3-135.7, p = 0.002). The application of SHG/artificial intelligence algorithms in pediatric-onset AILD provides improved insight into liver histopathology through fibrosis mapping. SHG allows objective identification of patients with biliary tract involvement, which may be associated with a higher risk for refractory disease.

The prognostic value of anti-gp210 and anti-centromere antibodies in patients with primary biliary cholangitis: Enhancing the prognostic utility on the GLOBE scoring system.

Positivity for anti-gp210 and anti-centromeric antibodies (ACA) in patients with primary biliary cholangitis (PBC) have been associated with the progression of liver failure and portal hypertension (PH), respectively. The value of combining risk autoantibody assessments with prognostic scoring systems in improving risk assessment in patients with PBC remains unclear. To investigate the prognostic significance of various combinations of anti-gp210 and ACA statuses and their enhancing the prognostic utility on the GLOBE scoring system. Stepwise Cox regression was used to estimate the relationship between anti-gp210 antibodies or ACA and liver transplant (LT)-free survival. The GLOBE scoring system was used to stratify the patients. A total of 1412 patients with confirmed PBC were included in the study. The anti-gp210+ status was a significant risk factor for LT/liver-related death, whereas the ACA+ status was a significant risk factor for variceal bleeding (P = 0.002 and 0.007, respectively). The anti-gp210 + ACA + status was a risk indicator for the entire cohort independent of the GLOBE score (P = 0.001, hazard ratio [HR]: 2.649, 95 % confidence interval [CI]: 1.492-4.703) and liver stiffness measurements (LSM; P = 0.039, HR: 4.969, 95 % CI: 1.088-22.692). A significant difference was observed in the area under the receiver operating characteristic curve between the fitted scoring model (consisting of the GLOBE score, anti-gp210 + ACA+ status, and albumin level) and the GLOBE scoring system alone (P = 0.034). When enrolled patients were classified as high-, medium-, and low-risk by the GLOBE scoring system (1.8 and 0.5), the anti-gp210 + ACA+ status was associated with a 1.6- and 3.3-fold higher 5-year incidence of LT/liver-related death in the high- and medium-risk groups, respectively, in comparison with the anti-gp210 + ACA- cases. The anti-gp210 + ACA+ status was also a risk indicator for the presentation of the hepatic failure phenotype in comparison with the anti-gp210- status (P = 0.007, odds ratio [OR]: 6.419, 95 % CI: 1.645-25.042), and the presentation of PH phenotype in comparison with the anti-ACA- status (OR: 3.473, 95 % CI: 1.328-9.018, P = 0.011). The anti-gp210 + ACA+ status was an independent prognostic marker that could predict a poor prognosis in patients with PBC at diagnosis and may further optimise risk stratification in combination with the GLOBE scoring system.

Variceal Bleeding a Predictor of Mortality in Patient Admitted with Liver Cirrhosis

This study aims to assess the risk of mortality in cirrhotic patients with acute variceal bleeding at a tertiary care hospital. Variceal bleeding is a common and life-threatening complication in liver cirrhosis, significantly contributing to early mortality. The study utilized a cohort design with 128 patients, divided into two groups: those with acute variceal bleeding (exposed) and those without (unexposed). Baseline clinical data, including Child-Pugh and MELD scores, were collected. The primary outcome was 30-day mortality. Key findings include a mean age of 55.7 ± 22.1 years, with 52.8% males and 56.3% from rural areas. The average Child-Pugh score was 10.1 ± 3.2, and the mean MELD score was 24.1 ± 10.1. The frequency of hematemesis and melena as presenting complaints was evenly split at 50%. Mortality was observed in 49.2% of the patients with variceal bleeding. Statistical analysis using chi-square tests revealed a significant association between variceal bleeding and increased mortality (p &lt; 0.05). Confounding factors such as age, gender, and comorbid conditions were controlled through stratification, with relative risk calculations confirming the elevated mortality risk. This study highlights the critical need for timely interventions in cirrhotic patients with variceal bleeding and underscores the importance of comprehensive management strategies to reduce mortality in this high-risk population.

A rare case of esophageal variceal bleeding from portal hypertension due to extrahepatic portal vein obstruction in a two-year-old

Extrahepatic portal vein obstruction (EHPVO) is a type of liver vascular disease characterized by cavernomatous transformation and obstruction in the portal veins. Congenital defects, numerous transfusions, trauma, sepsis, dehydration, and hypercoagulable disorders are important risk factors. Since most patients have no symptoms, acute extrahepatic portal vein obstruction is frequently disregarded. Hematemesis and splenomegaly without hepatic decompensation are among the symptoms that might occur in subacute and chronic stages. Imaging studies aid in the diagnosis; Doppler imaging is added to ultrasonography to visualize portal vein blood flow. MRI and CT scans are used to visualize portal vein blockage. Prevention of acute bleeding is the cornerstone in the management. Studies have shown that transhepatic thrombolysis is the preferred choice to avoid systemic side effects. Treatment for extrahepatic portal venous thrombosis involves an intrahepatic portosystemic shunt, which is usually followed by conservative measures to stop variceal haemorrhage. When other forms of therapy are ineffective, liver transplantation is carried out. This case report describes a rare instance of EHPVO in a two-year-old boy who was hospitalized due to recurrent fever, increased belly circumference, and a persistent feeling of fullness in the abdomen. The patient had a surgically placed splenorenal shunt, which helped him respond well to treatment.

Construction and validation of a predictive model for the risk of rebleeding in patients with esophageal and gastric varices hemorrhage

Construction and validation of a predictive model for the risk of rebleeding in patients with esophageal and gastric varices hemorrhage

Application of machine learning methods for predicting esophageal variceal bleeding in patients with cirrhosis.

To develop and compare machine learning models based on CT morphology features, serum biomarkers, and basic physical conditions to predict esophageal variceal bleeding. Two hundred twenty-four cirrhotic patients with esophageal variceal bleeding and non-bleeding were included in the retrospective study. Clinical and serum biomarkers were used in our study. In addition, the open-access segmentation model was used to generate segmentation masks of the liver and spleen. Four machine learning models based on selected features are used for building prediction models, and the diagnostic performances of models were measured using the receiver operator characteristic analysis. Two hundred twenty-four cirrhosis patients with esophageal varices, including 112 patients with bleeding (mean age 52.8 ± 11.5 years, range 18-80 years) and 112 patients with non-bleeding (mean age 57.3 ± 10.5 years, range 34-85 years). The two groups showed significant differences in standardized spleen volume, fibrinogen, alanine aminotransferase, aspartate aminotransferase, D-dimer, platelet, and age. The ratio of the training set to the test set was 8:2in our research, and the 5-fold cross-validation was used in the research. The AUCs of linear regression, random forest, support vector machine, and adaptive boosting were, respectively, 0.742, 0.854, 0.719, and 0.821 in the training set. For the test set, the AUCs of models were, respectively, 0.763, 0.818, 0.648, and 0.804. Our study used CT morphological measurements, serum biomarkers, and age to build machine learning models, and the random forest and adaptive boosting had potential added value in predictive model construction. Question Esophageal variceal bleeding is an intractable complication of liver cirrhosis. Early prediction and prevention of esophageal variceal bleeding is important for patients with liver cirrhosis. Findings It was feasible and clinically meaningful to construct machine learning models based on CT morphology features, serum biomarkers, and physical conditions to predict variceal bleeding. Clinical relevance Our study may provide a promising tool with which clinicians can conduct therapeutic decisions on fewer invasive procedures for the prediction of esophageal variceal bleeding.

AGA Clinical Practice Update on Management of Portal Vein Thrombosis in Patients With Cirrhosis: Expert Review.

Portal vein thromboses (PVTs) are common in patients with cirrhosis and are associated with advanced portal hypertension and mortality. The treatment of PVTs remains a clinical challenge due to limited evidence and competing risks of PVT-associated complications vs bleeding risk of anticoagulation. Significant heterogeneity in PVT phenotype based on anatomic, host, and disease characteristics, and an emerging spectrum of therapeutic options further complicate PVT management. This Clinical Practice Update (CPU) aims to provide best practice advice for the evaluation and management of PVT in cirrhosis, including the role of direct oral anticoagulants and endovascular interventions. This expert review was commissioned and approved by the American Gastroenterological Association (AGA) Institute CPU Committee and the AGA Governing Board to provide timely guidance on a topic of high clinical importance to the AGA membership, and underwent internal peer review by the CPU Committee and external peer review through standard procedures of Gastroenterology. These Best Practice Advice statements were drawn from a review of the published literature and from expert opinion. Because systematic reviews were not performed, these Best Practice Advice statements do not carry formal ratings regarding the quality of evidence or strength of the presented considerations. Best Practice Advice Statements BEST PRACTICE ADVICE 1: Asymptomatic patients with compensated cirrhosis do not require routine screening for PVT. BEST PRACTICE ADVICE 2: Patients with cirrhosis with PVTs identified on Doppler ultrasound should undergo cross-sectional imaging with computed tomography or magnetic resonance imaging to confirm the diagnosis, evaluate for malignancy, and document the degree of lumen occlusion, clot extent, and chronicity. BEST PRACTICE ADVICE 3: Patients with cirrhosis and PVT do not require a hypercoagulable workup in the absence of additional thromboemboli or laboratory abnormalities or family history suggestive of thrombophilia. BEST PRACTICE ADVICE 4: Patients with cirrhosis and PVT with evidence of intestinal ischemia require urgent anticoagulation to minimize ischemic injury. If available, these patients should be managed by a multidisciplinary team, including gastroenterology and hepatology, interventional radiology, hematology, and surgery. BEST PRACTICE ADVICE 5: Consider observation, with repeat imaging every 3 months until clot regression, in patients with cirrhosis without intestinal ischemia and recent (<6 months) thrombosis involving the intrahepatic portal vein branches or when there is <50% occlusion of the main portal vein, splenic vein, or mesenteric veins. BEST PRACTICE ADVICE 6: Anticoagulation should be considered in patients with cirrhosis without intestinal ischemia who develop recent (<6 months) PVT that is >50% occlusive or involves the main portal vein or mesenteric vessels. Patients who have increased benefit of recanalization include those with involvement of more than 1 vascular bed, those with thrombus progression, potential liver transplantation candidates, and those with inherited thrombophilia. BEST PRACTICE ADVICE 7: Anticoagulation is not advised for patients with cirrhosis with chronic (>6 months) PVT with complete occlusion with collateralization (cavernous transformation). BEST PRACTICE ADVICE 8: Patients with cirrhosis and PVT warrant endoscopic variceal screening if they are not already on nonselective beta-blocker therapy for bleeding prophylaxis. Avoid delays in the initiation of anticoagulation for PVT, as this decreases the odds of portal vein recanalization. BEST PRACTICE ADVICE 9: Vitamin K antagonists, low-molecular-weight heparin, and direct oral anticoagulants are all reasonable anticoagulant options for patients with cirrhosis and PVT. Decision making should be individualized and informed by patient preference and Child-Turcotte-Pugh class. Direct oral anticoagulants may be considered in patients with compensated Child-Turcotte-Pugh class A and Child-Turcotte-Pugh class B cirrhosis and offer convenience as their dosages are independent of international normalized ratio monitoring. BEST PRACTICE ADVICE 10: Patients with cirrhosis on anticoagulation for PVT should have cross-sectional imaging every 3 months to assess response to treatment. If clot regresses, anticoagulation should be continued until transplantation or at least clot resolution in nontransplantation patients. BEST PRACTICE ADVICE 11: Portal vein revascularization with transjugular intrahepatic portosystemic shunting may be considered for selected patients with cirrhosis and PVT who have additional indications for transjugular intrahepatic portosystemic shunting, such as those with refractory ascites or variceal bleeding. Portal vein revascularization with transjugular intrahepatic portosystemic shunting may also be considered for transplantation candidates if recanalization can facilitate the technical feasibility of transplantation.

ABC score is a better predictor for 30-day mortality in upper gastrointestinal bleeding: A prospective single-center study.

Acute upper gastrointestinal bleeding (UGIB) still has a mortality rate of about 10%. Several pre-endoscopy scoring systems have been developed to predict the outcome, but none accurately predict mortality. The present study was aimed at comparing the new ABC score (age, blood tests and comorbidities) with other pre-existing scoring systems to predict mortality. This prospective single-center study was done at a tertiary hospital in India in 2022-2023. Patients > 18years presenting with UGIB within 48hours were included in the study. They were divided into variceal and non-variceal UGIB cohorts and were followed for 30days after receiving standard-of-care treatment. Out of 296 patients, 168 (56.7%) had variceal (V) bleed, while 128 (43.2%) individuals had a non-variceal (NV) type of GI bleed. The mortality rate was 9.8% (n = 29), which was higher among the V bleed group compared to the NV bleed group (8.7% vs. 1.1%). The area under the receiver operating characteristics(AUROC) for ABC score was the highest (0.75) compared to other scoring systems and was also more significant among deaths related to V bleed (0.76) than NV bleed (0.64). Hypoalbuminemia and > 3 blood transfusions are significant factors in predicting mortality. Our study demonstrates that the ABC score is superior to other scores in predicting 30-day mortality in patients with UGIB. ABC score may be a better predictor of mortality among V bleed patients than NV bleeds.

Two-Dimensional and Point Shear-Wave Elastography to Predict Esophageal Varices and Clinically Significant Portal Hypertension in Patients with Chronic Liver Disease.

Introduction: The non-invasive assessment of disease severity remains pivotal in patients with chronic liver disease (CLD) as it has wide implications in predicting liver-related complications or death. Shear-wave elastography (SWE) is an emerging ultrasound-based method to non-invasively measure liver stiffness. The aim of our study was to evaluate two-dimensional (2D) and point (p) SWE to predict the presence of esophageal varices (EV) or clinically significant portal hypertension (CSPH). Methods: This was a retrospective analysis of a prospectively performed cohort study of patients with CLD treated in the outpatient clinic of the Frankfurt University Hospital. PSWE using the Hitachi HI Vision ASCENDUS system and the Siemens ACUSON S2000TM system or 2D-SWE using the Toshiba APLIO500 system were analyzed at baseline and during follow-up to predict EV or surrogate parameters of CSPH. ROC curves were calculated for pooled liver stiffness measurements (LSMs) using a bootstrap approach. A combined model of SWE and platelet count was created and a mixed-effect logistic regression analysis using log-transformed values was performed. Results: Overall, 511 patients with CLD and 919 consecutive LSMs were included and 315 patients (61.6%) had signs of CSPH. 2D-SWE performed best to predict EV and CSPH, and the addition of platelet count to the predictive model significantly increased test results for EV (AUC 0.83, 95%-CI: 0.76-0.89; difference in AUC 0.11, 95%-CI: 0.03-0.19, p = 0.004), but only marginally for CSPH (AUC 0.75, 95%-CI: 0.64-0.85; difference in AUC 0.06, 95%-CI: 0.02-0.14, p = 0.150). LSM > 18.5 and >20 kPa were indicative of CSPH and EV, while LSM < 10 kPa and <11 kPa ruled out CSPH and EV, respectively. Conclusions: Our study found that 2D-SWE in combination with platelet count performed best (in comparison to the other SWE methods) to predict EV or CSPH in patients with CLD. Future prospective trials are needed to validate our results.