Presence Of Esophageal Varices Research Articles

Non-invasive Fibrosis Markers for Predicting Esophageal Varices: A Potential Alternative to Endoscopic Screening.

Chronic liver infections and diseases lead to chronic liver injury, which results in fibrosis. Due to this continuous scarring and regeneration, cirrhosis occurs, which is also responsible for several adverse sequelae, including but not limited to esophageal varices. Cirrhosis has resulted in patients' increased morbidity and mortality, especially in low socioeconomic settings such as Pakistan. Endoscopy is the gold standard for measuring the presence or absence of esophageal varices, along with their grade. Currently, some non-invasive markers (aspartate aminotransferase-to-alanine aminotransferase ratio (AAR), fibrosis 4 (FIB-4), AAR to platelet ratio index (AARPRI), aspartate aminotransferase-to-platelet ratio index (APRI), S-index, King's score) are being established that make use of laboratory tests, such as a complete blood profile, liver function profile, and coagulation profile, to estimate the extent of hepatic fibrosis. The objective of this study is to establish a correlation between non-invasive markers of fibrosis and the presence of esophageal varices and to assess their potential as a substitute for gastrointestinal endoscopy screening. Additionally, the study aims to compare these six scores, thereby generating data on their individual and relative accuracy. This was a cross-sectional study conducted at the Shalamar Institute of Health Sciences, Lahore, Pakistan. Outpatient (OPD) data were obtained from the Shalamar online portal system from June 2022 to December 2022. Laboratory tests, abdominal ultrasounds, and endoscopy results were accessed and recorded in the questionnaire. The patient's medical records and contact numbers were also noted in case further questions arose. Data were then compiled into a Microsoft Excel spreadsheet (Microsoft Corp., Redmond, WA) and analyzed after computing the non-invasive procedure formulas. It was analyzed using IBM SPSS Statistics for Windows, version 20.0 (IBM Corp., Armonk, NY). P-values were calculated, and conclusions were drawn. Of the sample size of 100 patients with liver damage and injury, 60% were male and 40% were female. Among males, 15% had a milder (grade 1)degree of esophageal varices, and 45% had a moderate to advanced degree (grades 2-3) of esophageal varices. Among females, 19% had mild (grade 1) varices, while 21% had severe (grade 3) varices. The most common cause of varices in patients who had developed fibrosis and/or cirrhosis was hepatitis C, with a wide margin of other causes. The p-values obtained showed that from the selected list of non-invasive markers of fibrosis, only FIB-4 and AARPRI were statistically significant with p-values of 0.036 and 0.022, respectively. Though endoscopy is currently the gold-standard procedure for detecting the presence or absence and grade of esophageal varices, it is invasive, which makes the patients extremely uncomfortable and apprehensive. It can also lead to post-procedure infection, internal hemorrhages, and trauma due to instrument use. Due to its invasive nature, some patients also tend to refuse this procedure. Non-invasive fibrosis markers can help make a diagnosis without undergoing an endoscopy, which in turn will improve patient compliance and satisfaction. It was observed that FIB-4 and AARPRI can be used together as reliable markers to assess the presence or absence of esophageal varices.

Tissue inhibitor of matrix metalloprotinase-1 and collagen type IV in HCV-associated cirrhosis and grading of esophageal varices

BackgroundEsophageal varices are abnormally dilated submucosal veins of the esophagus which develop as a result of portal hypertension due to cirrhosis. Collagen type IV is upregulated with a 14-fold increase in cirrhosis. Tissue inhibitor of metalloproteinases-1 (TIMP-1) is also upregulated during hepatic fibrogenesis and considered to promote fibrosis in the injured liver. The objective of this research was to study the serum levels of tissue inhibitor of matrix metalloprotinase-1 and serum collagen type IV in patients with post hepatitis C cirrhosis and their relation to the different grades of esophageal varices.Patients and methodsThis study was carried out on one hundred and twenty individuals classified into three groups: Group I included thirty patients with liver cirrhosis without esophageal varices. Group II included sixty patients with liver cirrhosis with esophageal varices. Group III included thirty healthy volunteers as controls.ResultsA significant positive correlation was found between collagen type IV and the presence of esophageal varices in esophageal varices group (p = 0001*). Also, a significant positive correlation was found between TIMP-1 and the presence of esophageal varices in esophageal varices group (p = 0.033*). After conducting multivariate logistic regression analysis, collagen type IV and INR were found to be independent risk factors for esophageal varices in patients with cirrhosis.ConclusionThe serum collagen type IV and TIMP-1 levels are useful markers for predicting of presence of esophageal varices.

Assessing the Severity of Portal Hypertension: Is Liver or Spleen Stiffness Measurement an Alternative to the Gold Standard, Hepatic Vein or Porto-Systemic Pressure Gradient?

Introduction: Liver stiffness measurement (LSM) and spleen stiffness measurement (SSM) are increased in patients with cirrhosis and portal hypertension (PH). However, increased SSM values are associated with presence of esophageal varices. Currently, the gold standard for risk stratification in patients with compensated advanced chronic liver disease (cACLD) is by measurement of portal pressure through assessment of hepatic vein or porto-systemic pressure gradient (HVPG and PSPG). However, these procedures are invasive, and either LSM or SSM may be a non-invasive alternative.
 Aim: We aimed to investigate the relationship between LSM or SSM and HVPG/PSPG and examined the diagnostic accuracy for identification of clinically significant PH (≥10 mm Hg) or severe PH (≥12 mm Hg).
 Methods: A retrospective study (IRB Protocol #19230) allowed us to identify patients who had who undergone portal pressure measurements (HVPG or PSPG). A total of 36 patients also had SSM values. Of these, 29 patients carried a hepatic cause of PH, while the remaining had pre-hepatic (n=4) and post-hepatic (n=3) etiology.
 Results: The median age was 58 years (range: 25-71) with 52% male and 83% with cirrhosis. The median LSM and SSM were 35.7 kPa (range:7.4-75.0, normal ≤7.0 kPa) and 43.8 kPa (range: 20.7-100, normal ≤ 21.0 kPa). Both LSM (r = 0.42, P-value = 0.02) and SSM (r = 0.45, P-value: 0.01) correlated significantly with HVPG/PSPG. The diagnostic accuracy for both LSM and SSM for clinically significant PH was good for LSM (AUROC 0.76, 95% CI:0.58-0.94) and excellent for SSM (AUROC: 0.81, 95% CI:0.65-0.98). The diagnostic accuracy of LSM and SSM was lower for severe PH [AUROC 0.71 (P-value = 0.06) and 0.67 (P-value = 0.1) for LSM and SSM, respectively].
 Conclusion: Both LSM and SSM correlate with portal pressure measurements and provide diagnostic accuracy to identify patients with clinically significant, but not severe, PH.

Portal-hypertension features are associated with ascites occurrence and survival in patients with hepatocellular carcinoma treated by external radiotherapy.

We studied the impact of Portal hypertension (PHT) on ascites occurrence and on radiotherapy outcome in cirrhotic patients with hepatocellular carcinoma (HCC). All cirrhotic patients that received radiotherapy for HCC between 2012 and 2022 were included. Portal hypertension-Score was built using univariate analysis with the presence of esophageal varices (EV), platelet count, history of acute variceal bleeding (AVB) and spleen size. Time-to-events data were estimated using Kaplan-Meier method with log-rank and Cox-models. 60 patients were included (female 27%, age 67 years-old, Child-Pugh A 82%, alcoholic/non-alcoholic steatohepatitis/hepatitis C virus 55/40/32%). 38% and 15% presented history of ascites and AVB respectively, 25% had large EV, 53.5% presented PHT score ≥ 5. 92% were BCLC-0/A, median tumor size was 30mm. At 6months, ascites incidence was 19% and precluded access to further HCC treatment for all patients with HCC recurrence. All PHT parameters included in the score and PHT score ≥ 5 (hazard ratio (HR)=14.07, p=0.01) were associated with ascites occurrence. Transplantation free survival and recurrence free survival at 1year were 56% and 47% respectively. Albi grade 3 (HR=3.01; p=0.04) was independently associated with Transplantation free survival. Radiotherapy should be cautiously performed in patients with PHT score ≥ 5 because of ascites occurrence risk precluding access to further HCC treatments.

FRI-279 - Presence of esophageal varices regardless their size is associated with overall survival in patients with advanced HCC treated with Atezolizumab/Bevacizumab

FRI-279 - Presence of esophageal varices regardless their size is associated with overall survival in patients with advanced HCC treated with Atezolizumab/Bevacizumab

Portal Hypertensive Gastropathy and its Association among the Patients with Decompensated Chronic Liver Disease

Background: Although portal hypertension remains the crucial factor for the development of PHG, other factors should be considered in the development and progression of this condition like hepatic function, oesophageal varices, type of hepatitis virus and hypersplenism as evidenced by haematological variables (Anemia, leucopenia and thrombocytopenia). Aim & Objectives: To study the frequency of portal hypertensive gastropathy and its correlation with haematological and biochemical parameters and other endoscopic findings. Materials and methods: A prospective, hospital based, time bound study of 100 patients, admitted with decompensated chronic liver disease (diagnosed based on the evidence of sonography criteria) in a tertiary care center. Patients aged > 18 years and above admitted in SDM medical college and hospital were considered, demographic data, physical examination was done, basic investigations, hematological, biochemical (renal function test and liver function test) , coagulation profile, serology were evaluated. Upper gastrointestinal endoscopy procedure was done and data was collected in a pre designed performa. Results: The frequency of PHG in our study was 64%.Presence of PHG had significant association with SBP, DBP, haemoglobin, TLC. We also found significant association between PHG and grade 1 and 3 of esophageal varices, gastric varices and erosive gastritis. Conclusion: The frequency of PHG was 64% in the studied group and the presence of PHG correlates with presence of esophageal varices, erosive gastritis and gastric varices suggesting a common pathophysiology.

Landscape of alcohol-related hepatocellular carcinoma in the last 15 years highlights the need to expand surveillance programs

Alcohol abuse and metabolic disorders are leading causes of hepatocellular carcinoma (HCC) worldwide. Alcohol-related aetiology is associated with a worse prognosis compared with viral agents, because of the lower percentage of patients diagnosed with HCC under routine surveillance and a higher burden of comorbidity in alcohol abusers. This study aimed to describe the evolving clinical scenario of alcohol-related HCC over 15 years (2006-2020) in Italy. Data from the Italian Liver Cancer (ITA.LI.CA) registry were used: 1,391 patients were allocated to three groups based on the year of HCC diagnosis (2006-2010; 2011-2015; 2016-2020). Patient characteristics, HCC treatment, and overall survival were compared among groups. Survival predictors were also investigated. Approximately 80% of alcohol-related HCCs were classified as cases of metabolic dysfunction-associated fatty liver disease. Throughout the quinquennia, <50% of HCCs were detected by surveillance programmes. The tumour burden at diagnosis was slightly reduced but not enough to change the distribution of the ITA.LI.CA cancer stages. Intra-arterial and targeted systemic therapies increased across quinquennia. A modest improvement in survival was observed in the last quinquennia, particularly after 12 months of patient observation. Cancer stage, HCC treatment, and presence of oesophageal varices were independent predictors of survival. In the past 15 years, modest improvements have been obtained in outcomes of alcohol-related HCC, attributed mainly to underuse of surveillance programmes and the consequent low amenability to curative treatments. Metabolic dysfunction-associated fatty liver disease is a widespread condition in alcohol abusers, but its presence did not show a pivotal prognostic role once HCC had developed. Instead, the presence of oesophageal varices, an independent poor prognosticator, should be considered in patient management and refining of prognostic systems. Alcohol abuse is a leading and growing cause of hepatocellular carcinoma (HCC) worldwide and is associated with a worse prognosis compared with other aetiologies. We assessed the evolutionary landscape of alcohol-related HCC over 15 years in Italy. A high cumulative prevalence (78%) of metabolic dysfunction-associated fatty liver disease, with signs of metabolic dysfunction, was observed in HCC patients with unhealthy excessive alcohol consumption. The alcohol+ metabolic dysfunction-associated fatty liver disease condition tended to progressively increase over time. A modest improvement in survival occurred over the study period, likely because of the persistent underuse of surveillance programmes and, consequently, the lack of improvement in the cancer stage at diagnosis and the patients' eligibility for curative treatments. Alongside the known prognostic factors for HCC (cancer stage and treatment), the presence of oesophageal varices was an independent predictor of poor survival, suggesting that this clinical feature should be carefully considered in patient management and should be included in prognostic systems/scores for HCC to improve their performance.

The Use of Albumin-to-bilirubin Score in Predicting Variceal Bleed: A Pilot Study from Pakistan.

Majid Z, Khan SA, Akbar N, et al. The Use of Albumin-to-bilirubin Score in Predicting Variceal Bleed: A Pilot Study from Pakistan. Euroasian J Hepato-Gastroenterol 2022;12(2):77-80.

Obliterative portal venopathy: A neglected and probably misdiagnosed disease with peculiar etiology in South America.

Obliterative portal venopathy (OPV) is one of the causes of non-cirrhotic portal hypertension. However, many aspects of OPV remain unclear, including the etiology, pathogenesis, and natural history. The aim of this study was to describe the clinical features of OPV in a series of patients in Brazil in whom OPV was diagnosed through liver biopsy. Forty-three consecutive adult patients with OPV were retrospectively selected as a case series based on histologic criteria, defined by the presence of at least portal fibrosis, phlebosclerosis, disappearance and/or reduction of the caliber of portal vein branches, and exclusion of cirrhosis. Clinical and laboratory data were analyzed. Clinically significant portal hypertension was considered in the presence of esophageal varices and/or ascites. The mean age of patients at diagnosis was 44.5 ± 11 years, who were predominantly female (81%). Clinically significant portal hypertension was found in 28% of cases. The most frequent indication for liver biopsy was the elevation of liver enzymes, mostly γ-glutamyl transferase (GGT) in 76% of patients, averaging 222 IU/L (upper limit of normality up to 40 IU/L) and alanine aminotransferase (ALT) in 64%, mean 84 IU/L (38 IU/L). One-third of our patients had exposure to medications, especially herbal medicines, at the time of enzymatic changes. Other risk factors highlighted were features of autoimmunity in 25% of patients or thrombophilia in 20%. OPV can be diagnosed even before the onset of portal hypertension, ALT elevation, and especially GGT elevation in most cases. Its etiology is not defined, but autoimmune diseases, thrombophilia, and the use of medications or herbal medicines may play a role.

S1400 The Complexity of NASH Cirrhosis Clinical Trials: Screen Failure Reasons and Baseline Patient Characteristics

Introduction: Patients with NASH cirrhosis has the highest likelihood of developing major adverse liver related events and an unmet need in terms of therapeutic options. Several drugs are being tested in patients with NASH cirrhosis in phase 2 trials. Screen failure (SF) reasons in non-cirrhotic NASH trials have been described; however, limited data exists on the reason for screen failure reasons in NASH cirrhosis trials. The aim of this study was to understand the reasons for screen failure in 5 NASH cirrhosis trials and to describe the patient's characteristics of both screens failed subjects and those who randomised. Methods: Data on patients who were presented for screening visits for five phase 2 NASH cirrhosis trials at one research site were analysed. The reasons for screen failure were divided into 4 major categories: 1. Biopsy, 2. Laboratory tests, 3. Imaging tests, 4. Other. Baseline characteristics including demographics, clinical history, lab values, findings from imaging tests and biopsy were collected. Characteristics of patients that screen failed were compared to those who randomised using 2-sided t-test, p value < 0.05 was considered statistically significant. Results: 68 patients were included in the analysis. 23 randomised (33.8%) and 45 screen failed (66.17%). The mean age was 57.98 years with 45% (31) of the population being male. Mean BMI in the whole population was 38.38 Kg/m2. 51.47% (35) of the patients were found to have type 2 diabetes. The reasons for screen failure were as follows: 4 (8.8%) on biopsy, 12 (26.6%) on labs, 11 (24.4%) in imaging tests, 15 (33.3%) for other reasons. The top 4 causes included in the other category were patients outside of the screening window, using prohibited medications, subject dropping out and presence of esophageal varices. There was no significant difference between the screen failure group and the randomised group in terms of platelet count, INR, bilirubin, FIB4 score and AGILE4 score (p > 0.05 for all). (Figure) Conclusion: NASH cirrhosis trials have similar screen failure rates compared to non-cirrhotic trials; however, the reasons for screen failure are different. In NASH cirrhosis trials, fewer patients screen failed because of not meeting histologic criteria on liver biopsy which has been the major reason for screen failure in non-cirrhotic trials. Baseline laboratory and imaging tests were not different between patients who screen failed and those who randomised. (Table)Figure 1.: Minor causes of screen failure Table 1. - Comparison chart showing basic characteristics of randomised and screen failure population 2 sided T Test Mean Mean Mean Total Population Randomised population Screen Failure population T-Test Age 58.31 60.95 56.88 BMI 37.38 39.88 37.05 Hba1C 6.42 6.43 6.46 % Diabetes 52.90% 48.50% 51.40% Platelets 177.23 159.26 187.30 0.13 Bilirubin 0.795 0.83 0.76 0.52 INR 1.13 1.15 1.12 0.24 kPa 23.31 24.03 22.24 0.79 Agile 4 0.44 0.518 0.42 0.23 CAP score 302.35 310.33 297.57 0.59 Fib 4 3.12 2.95 3.41 0.53

S351 Peroral Endoscopic Myotomy in the Presence of Esophageal Varices

S351 Peroral Endoscopic Myotomy in the Presence of Esophageal Varices

Oesophageal Varices And Associated Factors In Cirrhotic Patients With Hepatitis C.

Infection with hepatitis C virus is reported to have infected almost 71 million people worldwide. This study was done to assess the frequency and associated factors leading to oesophageal varices in patients presenting with hepatitis C related liver cirrhosis. A cross-sectional study was conducted at Patel Hospital, Karachi, Pakistan from 9th May to 5th October 2019. Patients of either gender having age >20 years presenting with HCV related liver cirrhosis, and Child Pugh class A, B and C were consecutively enrolled in the study. Data on variables like: age, gender, Childs Pugh Score (A/B/C), smoking status, laboratory characteristics like hemoglobulin (Hb), TLC, platelets, serum albumin level, cholesterol, alkaline phosphate (ALK), alkaline transaminase (ALT), ascites and presence of oesophageal varices was recorded and analysed using SPSS-21.0. Out of 167 patients, mean age was 44.86±14.74 years. Eight-nine (53.3%) of the patients were males. The mean duration of cirrhosis was 5.78±1.10 months. Thrombocytopenia was observed in majority (n=130, 77.8%) of the patients. There were 33 (19.8%) patients with Child Pugh score A while Child-Pugh score B and C was found in 67 (40.1%) each. The frequency of oesophageal varices was 141 (84.4%). A significantly higher proportion of oesophageal varices were found among thrombocytopenic patients (p<0.001), ascites (p-0.024), and having "C" Child-Pugh score (p-0.012). Oesophageal varices were found in a considerable proportion. Thrombocytopenia, ascites and Child-Pugh class C were found as leading contributing factors to oesophageal varices.

Predictors of Esophageal Varices and Risk of Variceal Bleeding in Patients of Liver Cirrhosis

Introduction: Variceal bleeding from esophageal varices has high morbidity and mortality. There are invasive and non invasive methods by which risk of bleeding can be predicted. Upper Gastro-intestinal endoscopy is invasive, uncomfortable and expensive procedure though being the gold standard to screen Esophageal Varices (EV).&#x0D; Aims: To know the role of non-invasive markers for prediction of esophageal varices and variceal bleed with liver cirrhosis.&#x0D; Methods: A prospective hospital based study was carried in the Department of Internal Medicine, Nepalgunj Medical College, Kohalpur from October 2021 to March 2022. A total of 70 patients who met the inclusion criteria were enrolled. The non invasive markers were done and correlated with endoscopy.&#x0D; Results: Our study included 70 patients with liver cirrhosis. The mean age in our study was 63.1±8.346 years. During upper gastrointestinal endoscopy, esophageal varices was present in 46 (65.71%) patients. Child Turcot Pugh Score C (81.43%) was found in majority. Significant association was found between score C (P&lt;0.05), thrombocytopenia, Model for End stage Liver Disease Score (P=0.017) and low albumin level with esophageal varices and variceal bleeding. Similarly, significant alcohol intake was associated with esophageal varices and variceal bleed. However, no association was found between age and esophageal varices.&#x0D; Conclusion: Child Turcot Pugh score, thrombocytopenia, low albumin level and Model for End stage Liver Disease along with significant alcohol intake correlated with presence of esophageal varices and can be considered as non invasive tools for screening of esophageal varices and variceal bleeding in cirrhosis.

Association between severity of chronic liver disease with grading of oesophageal varices in children

Chronic liver disease is a uncommon manifestation in the children and many of them presents with oesophageal varices. The aim of this study was to observe the association between severity of chronic liver diseases determined by Child- Pugh score with grading of oesophageal varices. 62 cases (male, 34) were included in the present study. Mean age of the study population was 9.5±3.3 years. Male to female ratio was 1.2:1. Wilson’s disease was the most common etiology of chronic liver disease (64.5%). Of the 62 children, 30.7% had Child class A, 16.1% had Child class B and the remaining 53.2% had Child class C cirrhosis. Oesophageal varices were found in 43 (69.3%) children. On univariate ananlysis low platelet count and splenomegaly were found to be associated with the presence of esophageal varices. Splenomegaly was found as independent predictor for presence of varices on multivariate analysis (OR; 15.51, 95% CI, 3.7-63.5). Furthermore, splenomegaly was also independent risk factor for large esophageal varices. No association was found between Child-Pugh classification (child A, B, C) with grading of oesophageal varices (Grade - I, II, III, IV). Our study showed no positive association between Child-Pugh classifications with grading of esophageal varices. Splenomegaly predicts the presence of oesophageal varices as well as the presence of large esophageal varices. BSMMU J 2022; 15(1): 29-34

Evaluation of Laboratory and Sonographic Parameters for Detection of Portal Hypertension in Patients with Common Variable Immunodeficiency

Timely detection of portal hypertension as a manifestation in a subgroup of patients with common variable immunodeficiency (CVID) represents a challenge since it is usually not associated with liver cirrhosis. To identify relevant markers for portal hypertension, we evaluated clinical history, laboratory parameters, and abdominal ultrasound including liver elastography and biomarkers of extracellular matrix formation. Twenty seven (6%) of 479 CVID patients presented with clinically significant portal hypertension as defined by either the presence of esophageal varices or ascites. This manifestation occurred late during the course of the disease (11.8 years after first diagnosis of CVID) and was typically part of a multiorgan disease and associated with a high mortality (11/27 patients died during follow up). The strongest association with portal hypertension was found for splenomegaly with a longitudinal diameter of > 16 cm. Similarly, most patients presented with a liver stiffness measurement (LSM) of above 6.5 kPa, and a LSM above 20 kPa was always indicative of manifest portal hypertension. Additionally, many laboratory parameters including Pro-C4 were significantly altered in patients with portal hypertension without clearly increasing the discriminatory power to detect non-cirrhotic portal hypertension in CVID. Our data suggest that a spleen size above 16 cm and an elevated liver stiffness above 6.5 kPa should prompt further evaluation of portal hypertension and its sequelae, but earlier and better liquid biomarkers of this serious secondary complication in CVID are needed.

Value of Non-Invasive Scores and Modalities in Predicting the Presence of Esophageal Varices in Patients with Liver Cirrhosis

Value of Non-Invasive Scores and Modalities in Predicting the Presence of Esophageal Varices in Patients with Liver Cirrhosis

Systematic review with meta-analysis: incidence of variceal hemorrhage in patients with cirrhosis undergoing transesophageal echocardiography.

The presence of esophageal varices is considered a relative contraindication to transesophageal echocardiography (TEE) by cardiology professional societies, so gastroenterologists are often consulted to perform upper endoscopy prior to TEE in patients with cirrhosis. To perform a systematic review to quantify the risk of bleeding complications in patients with cirrhosis following TEE. Two reviewers searched Ovid MEDLINE, MEDLINE In-Process and EMBASE databases from January 1992 to May 2021 for studies reporting bleeding complications from TEE in patients with cirrhosis. We calculated the pooled incidence rate of bleeding events using the metaprop command with a random effect model. We identified 21 studies comprising 4050 unique patients with cirrhosis; 9 studies (n=3015) assessed the risk of intraoperative TEE during liver transplant (LT) and 12 studies (n=1035) assessed bleeding risk in patients undergoing TEE for other indications. The pooled incidence of bleeding post-TEE was 0.37% (95% CI 0.04-0.94%) across all studies. Bleeding complications were low among patients undergoing TEE during LT as well as those undergoing TEE for other diagnostic reasons (0.97% vs. 0.004%) and among studies with mean MELD >18 compared to those with mean MELD <18 (0.43% vs. 0.08%). Few studies had a comparator arm, and data on patient-level factors impacting bleeding complications (including degree of liver dysfunction and coagulopathy) were limited across studies. The risk of bleeding complications following TEE is low in patients with cirrhosis, suggesting TEE is safe and risk stratification with upper endoscopy may not be necessary.

Gastroduodenal ulceration in dogs with liver disease.

BackgroundLiver disease is frequently cited as a cause of gastroduodenal ulceration (GDU) in dogs but studies regarding GDU and liver disease are limited.ObjectivesTo document the presence of GDU in dogs with liver disease.AnimalsForty dogs that underwent liver biopsy, computed tomographic (CT) angiography or both at the University of Florida Small Animal Hospital to diagnose congenital or acquired liver disease.MethodsCross‐sectional study. Dogs had gastroduodenoscopy performed with photographic and video documentation in a standardized fashion. Lesions (hemorrhage, erosions, ulcers) in the esophagus, stomach, and duodenum were scored based on a grading scale. Presence of esophageal varices was recorded. Dogs were categorized into 4 groups according to cause of liver disease (inflammatory disease, cirrhosis, congenital, other). Presence or absence of ulcers, erosions or both as well as total endoscopic scores were compared among groups.ResultsForty dogs were enrolled with the following distribution: 13 congenital, 13 inflammatory, 3 cirrhosis, and 11 other. Four dogs had GDU (10%; 95% confidence interval [CI], 3%‐24%) and 6 dogs had erosions (15%; 95% CI, 6%‐30%). No difference was found in total endoscopic score (P = .21) or in the proportion of dogs with ulcers, erosions or both versus those without (P = .25) among the groups.Conclusions and Clinical ImportanceGastroduodenal ulceration was found in 10% of dogs with liver disease in this population. Additional studies are warranted to confirm these findings in larger numbers of dogs with specific disease etiologies.

Portal Hypertensive Gastropathy in Liver Cirrhosis: Prevalence, Natural History, and Risk Factors.

Objective Portal hypertensive gastropathy (PHG) is a common finding in patients with liver cirrhosis (LC) and may cause both acute and chronic bleeding. A number of risk factors for PHG have been identified. The present study explored the characteristics of Japanese patients with LC who develop PHG.MethodsClinical findings (age, sex, etiology, the presence of esophageal varices, splenomegaly and severity of LC), laboratory data, and whether or not atrophic gastritis was found on endoscopy were retrospectively reviewed in patients with LC who had undergone esophagogastroduodenoscopy. PHG was endoscopically graded as absent, mild, or severe.ResultsOf 262 patients with LC (mean age, 69 years old; 145 men), 158 had no PHG, 41 had mild PHG, and 63 had severe PHG. In a univariate analysis, a younger age, male sex, non-viral etiology, absence of atrophic gastritis, presence of esophageal varices, splenomegaly, severe LC, low platelet count, and low hemoglobin concentration were associated with PHG. A multivariate analysis showed a significant association of PHG with the absence of atrophic gastritis (p<0.048), presence of esophageal varices (p<0.001), non-viral etiology (p<0.033), splenomegaly (p<0.048), and severe LC (p<0.005). There were no cases of massive bleeding from PHG during follow-up.ConclusionEsophageal varices, splenomegaly, severe liver cirrhosis, the absence of atrophic gastritis, and etiology were found to be risk factors for PHG in Japanese patients.

Association of Esophageal Varices with Portal Vein Diameter More Than 13 mm in Chronic Liver Disease Patients

Objective: To determine the frequency and association of esophageal varices with diameter of portal vein more than 13 mm in patients of chronic liver disease (CLD).&#x0D; Study Design: Cross-sectional study.&#x0D; Place and Duration of Study: Department of Gastroenterology, Pak Emirates Military Hospital, Rawalpindi Pakistan, from Feb to Aug 2018.&#x0D; Methodology: The study included one hundred and sixty-one patients of chronic liver disease with portal vein diameter more than 13 mm. Patients with the history of variceal bleeding, prior variceal treatment and liver transplantation were excluded. A consultant radiologist performed the hepatobiliary ultrasound in all the patients to measure the portal vein diameter. The presence of esophageal varices was confirmed on upper GI endoscopy performed by the consultant gastroenterologist.&#x0D; Results: The mean age of the patients was 47.16 ± 9.36 years. Most of the patients included in our study 102 (63.35%) were between 46-65 years of age. Out of the 161 patients, 95 (59.01%) were males and 66 (40.99%) were females. Esophageal varices were found in 128 patients (79.50%) with chronic liver disease with portal vein diameter &gt;13 mm. Age, gender, duration of illness and BMI had no relation with the presence of esophageal varices in our target population.&#x0D; Conclusion: Patients of CLD with portal diameter greater than 13 mm had more chance for the presence of esophageal varices in our study.