Presence Of Esophageal Varices Research Articles

Factors of Prognostic Importance in Primary Biliary Cirrhosis

To determine survival and the risk factors of death in primary biliary cirrhosis, data from 52 symptomatic and 13 asymptomatic patients were analyzed. The mean follow-up time was 6.3 years (range, 0.4-23 years). The average length of survival was 18 years for the symptomatic and 8.4 years for the asymptomatic patients. By a univariate analysis, ascites, presence of esophageal varices, gastrointestinal bleeding, jaundice, hepatomegaly and the logarithms of albumin and bilirubin were all associated with a poor prognosis. A multivariate analysis of the clinical features showed that the presence of bleeding from esophageal varices and the logarithm of bilirubin were the only predictors for poor prognosis. The survival of the symptomatic patients is longer than reported previously, while the life expectancy for the asymptomatic patients seems no better than for the symptomatic group.

Pulmonary hypertension complicating portal hypertension: findings on chest radiographs.

Pulmonary hypertension is a rare but well-established complication of portal hypertension with a prevalence of 0.73% in one large autopsy series. In this report, we review the findings on chest radiographs in eight patients with this complication. Portal hypertension in these patients was evidenced by the presence of esophageal varices and/or ascites. The causes of portal hypertension were liver cirrhosis in seven patients and portal venous thrombosis in one patient. Pulmonary hypertension was established by right heart catheterization and pressure measurement. Qualitative assessment of the radiographs showed that four patients had the classic findings of pulmonary hypertension including prominent central pulmonary arteries and right ventricular enlargement, three had subtle abnormalities, and one had only cardiomegaly. Measurements of the width of the right descending pulmonary artery and the pulmonary lobar diameter/transverse thoracic diameter ratio were made in five of the patients in whom postero-anterior radiographs were available. The results confirmed our qualitative analysis, although they did not establish the diagnosis in borderline cases. We also observed that pulmonary vascular redistribution to the upper lobes was present in four patients, a finding that has been reported in patients with other causes of pulmonary hypertension. We conclude that the possibility of pulmonary hypertension should be raised in patients with portal hypertension, even when only subtle chest radiographic findings are present to suggest that diagnosis.

IgA antibodies to dietary antigens in liver cirrhosis.

Antibodies to dietary antigens (ovalbumin, beta-lactoglobulin, casein) have been detected by a micro-ELISA test in 47-50% of serum samples from patients with alcoholic liver cirrhosis, in 27-36% with non-alcoholic cirrhosis (HBV-related, autoimmune and primary biliary) and in 50-70% of cirrhotic patients with portacaval shunt. Dietary antibodies were mainly confined to the IgA class (90%). In patients with chronic active hepatitis dietary antibodies showed a low positivity (11%), similar to that of subjects with alcohol abuse without liver injury and of healthy subjects. Dietary antibodies were significantly associated with portal hypertension (evaluated on the presence of esophageal varices and/or ascites) both in alcoholic and non-alcoholic cirrhosis. The absence of dietary antibodies in the duodenal juice of cirrhotic patients positive for serum antibodies confirms that the intestinal mucosa is normal or slightly altered in liver cirrhosis. Unlike cirrhotics, untreated celiac patients showed a high prevalence of dietary antibodies also in the duodenal juice (55%).

Haematemesis and melaena at St. Vincent's Hospital, Melbourne.

One hundred and fifty-three patients with haematemesis and melaena were studied retrospectively. The majority were managed in general medical units. Fifty-one per cent had a past history of peptic ulcer and/or bleeding, and only 9% had no identifiable predisposing factors. Endoscopy was the major diagnostic tool, with a diagnostic rate of 85%. Nineteen per cent of patients had no diagnostic investigations performed for varied reasons. The operative rate was 15% overall, with an operative mortality of 17%. The presence of other serious disease states concomitant with the haematemesis and melaena, and the presence of oesophageal varices as the aetiology, were both shown to be associated with statistically worse prognoses. Age of greater than 50 years and transfusion of four or more units of blood were also associated with a worse prognosis. Overall mortality was 14%, comparable to or less than that at several institutions, but more than double that of a Haematemesis and Melaena Unit in another Melbourne hospital [Br. Med. J. 1, 1238-40 (1979)] Patient population should be considered closely when comparing mortalities from different series. It is felt that results could be improved using a combined medical and surgical approach, and a set protocol of management, and that such changes should be monitored via a prospective study.

Upper gastrointestinal fiberoptic endoscopy in pediatric patients

Upper gastrointestinal fiberendoscopy in pediatric patients is done safely and under local anesthesia in most instances. This study of 47 children confirmed the value of fiberendoscopy in establishing the etiology of upper gastrointestinal hemorrhage and the presence of esophageal varices. It also contributed significantly to the management of patients with disphagia, pyrosis, epigastric pain, and ingestion of foreign bodies. No significant morbidity was caused.

The presence of glucagon in ascitic fluid in cirrhotic patients.

Glucose, insulin, glucagon, and liver profiles were determined simultaneously in plasma and ascitic fluid after an overnight fast in ten cirrhotic patients to assess the role of ascites in hyperglucagonemia and hyperinsulinemia of hepatic cirrhosis and to investigate if glucagon and insulin diffuse freely across the peritoneum. Plasma in ten normal subjects was studied as well. Glucose levels in plasma were normal in all patients; in ascitic fluid they were higher than in plasma in 7 cases and lower in 3 cases. Plasma glucagon was raised in seven patients with advanced liver dysfunction as documented by the presence of jaundice and reversed albumin/ globulin ratio. Plasma insulin was elevated in patients with hepatic dysfunction and/or esophageal varices. In the absence of jaundice and varices, glucagon and insulin concentrations were normal. Ascitic fluid glucagon was always lower than the plasma with a significant correlation. Ascitic fluid insulin was undetectable in three patients. In the remaining patients, the realtionship between plasma and ascitic fluid insulin levels was not significant. No relationship were observed between liver dysfunction and hormonal concentrations in ascitic fluid. These studies suggest that, (1) both glucagon.and insulin may diffuse freely across the peritoneum into the peritoneal cavity, with a consistent glucagon gradient between plasma and ascitic fluid. The apparent lack of such a relationship for insulin is unexplained and may need further evaluation, and (2) in hepatic cirrhosis the presence of ascites may not influence plasma glucagon or insulin concentrations unless accompanied by jaundice and a reversal of albumin/globulin ratio, both indices of advanced liver dysfunction and the presence of esophageal varices, a sign of moderately severe portosystemic shunting.

Diagnosis of esophageal varices by a new radiologic method: a preliminary report.

Until the last few years, the diagnosis of esophageal varices carried a prognosis worse than most other diseases, including coronary occlusion and cancer. The statistics vary but demonstrate similar results. Higgins (1) found that 84 per cent of those entering the hospital complaining of hematemesis died of hemorrhage. Blakemore (2) refers to the experience of Patek, who found that 50 per cent of his patients with Laennec's cirrhosis were dead within one year of the onset of their first hemorrhage. Palmer (3) quotes from Shull's experience: only 37 per cent of 180 cirrhotic patients were alive one year after the diagnosis of esophageal varices was made. The employment of the Sengstaken tube (4) and of relatively new surgical methods, especially the portacaval and splenorenal shunts, in the last few years, have offered hope of improving these statistics considerably, and prophylactic surgery for esophageal varices prior to hemorrhage is being seriously considered as the proper method of management. Therefore, the early diagnosis of esophageal varices has become much more important. Present Diagnostic Methods At the present time, only three acceptable antemortem methods of diagnosis are available: esophagoscopy, splenoportography, and roentgen study of the esophagus. Esophagoscopy offers the most accurate method of diagnosis, although occasionally a roentgen examination of the esophagus with the aid of barium has demonstrated varices which have been overlooked by the esophagoscopist (5). In spite of the fact that there is a morbidity rate (perforation of the esophagus, hemorrhage) of only 2 per cent or less and a mortality rate of 0.5 per cent or less associated with all esophagoscopy (5, 6), many physicians are reluctant to use the procedure in the presence of esophageal varices. In addition, about 8 per cent of patients refuse to undergo this examination (5). Percutaneous splenoportography as yet enjoys only a limited use in the United States, and no large series on the study of esophageal varices by this technic is available. At the present time, it appears to be a less accurate method than esophagoscopy and no more accurate than conventional x-ray examination of the esophagus (7). The advantages of roentgen examination of the esophagus are the absence of associated mortality or morbidity and ease of application. The disadvantage of this method is its low percentage of accuracy, though differences of opinion on this point are found among radiologists, who claim as little as 15 and as much as 50 per cent positive diagnoses in all cases of esophageal varices, both with and without a history of hematemesis (8, 9). A study of this type of examination was made by Brick and Palmer on the basis of a total of 172 patients examined in three separate university radiology departments under the direction of three different radiologists (10).

Effect of thyroidectomy in rheumatoid arthritis.

<h3>Introduction</h3> The current Baveno VI criteria dictate that cirrhotic patients with a liver stiffness (LF) of less than 20kPa and a platelet count of &gt;150x10^9 are low risk of developing oesophageal varices (OV). Patients with compensated cirrhosis criteria are surveyed every 2–3 years if there is no evidence of OV, or every year if there is evidence of OV. Our aim was to establish whether a tertiary liver unit was appropriately referring patients for an OGD. <h3>Method</h3> We collected the following data from patients with a diagnosis of compensated liver cirrhosis: LF, platelet count, aeitology of liver disease, and results of an index OGD. Data was obtained from 300 patients. The aeitology of liver cirrhosis was as follows: ARLD (49%), NAFLD (19%), ASH+NASH (5%), viral hepatitis (15%), autoimmune (6%), cryptogenic (3%), and unknown/other (3%). <h3>Results</h3> 204 patients (68%) were referred for a fibroscan. Of those, 113 (55%) had a LF of more than 20 kPA, and 86 patients (76%) were referred for an OGD. The findings of the endoscopy are shown in figure 1. 60% of patients had evidence of OV on their index scope. 182 of 300 patients (60%) had platelets &lt;150x10^9, and 149 (82%) were referred for an OGD. The findings of the OGD are shown in figure 2. 60% had evidence of OV on their index scope. 53 patients (18%) had both normal LF and platelet count. Despite this, 25 (47%) were referred for an index OGD for OV surveillance. 22 patients (88%) had a normal examination, and 12% had evidence of OV (see figure 3). 76 patients (25%) had both abnormal LF and platelet count, and 58 (76%) were referred for an index scope. Varices were present in 55% of these cases. There were no risks identified in those not referred for an OGD, when it was clinically indicated. <h3>Discussion</h3> We found that patients with abnormalities in LF and/or platelet count were referred for an index OGD in more than 70% of cases. The presence of OV was identified in 55–60% of cases. 24% of patients with abnormalities in both LF and platelet count were not referred for an OGD. Conversely, despite not meeting Baveno criteria, 18% of patients were referred for an OGD, which was normal in 88%. With current unavoidable delays with surveillance endoscopy, applying the Baveno criteria can avoid unnecessary invasive procedures.

Esophageal varices without hemorrhage in cirrhosis; a proper indication for shunting procedures.

AMONG the first 50 surgical portal decompressions carried out for the treatment of esophageal varices at three university-affiliated hospitals in Washington, 18 patients were operated on in the absence of a history of hemorrhage. From the start of a local program to attack varices by definitive surgical shunt procedures, the attitude was adopted that the mere presence of esophageal varices constitutes such a dangerous threat that they should not be permitted to hemorrhage once to fill the requirements for active therapy. The indication for operation in this group was the presence of varices, not a history of hemorrhage. Considerable opposition . . .