Presence Of Esophageal Varices Research Articles

Assessment of portal hypertensive enteropathy in patients with liver cirrhosis

Background Portal hypertensive enteropathy remains difficult to diagnose in patients with cirrhosis and portal hypertension (PHT). Limited test choices exist for the inspection of the small bowel in these patients. Small-bowel endoscopy like double-balloon enteroscopy (DBE) is ideal in this situation but rarely performed. We aimed to determine the prevalence of portal hypertensive enteropathy using DBE in the patient population with PHT and correlate its presence with clinical, radiological, and histological findings. Patients and methods Thirty-two patients with PHT were included along with 10 controls without the criteria of PHT. All patients and control groups underwent blood tests, ultrasonography, gastroscopy, and enteroscopy. The small-bowel findings by DBE were categorized as inflammatory-like and vascular lesions. The small-bowel changes either endoscopically or histologically were analyzed to find out any association with various demographic, clinical, ultrasonographic, and endoscopic variables. Results The frequency of portal enteropathy in our study was 65.6% (21 patients out of 32) and it had positive correlation with the presence of esophageal varices, PHG, and Child-Pugh score. We found that there is statistically significant difference between the results of histology among patients and control groups not only in the jejunal specimen but also in the gastric and duodenal ones. The correlation with the endoscopic picture was statistically not significant. Conclusion Small-bowel mucosal and vascular changes related to PHT were seen in a significantly higher number of patients with cirrhosis and PHT.

Non-invasive assessment of liver fibrosis in alcoholic liver disease.

Aim of the studyTo assess the severity of fibrosis in patients with alcoholic liver disease (ALD) by a non-invasive method (transient elastography – TE).Material and methodsA cross sectional study was conducted on 130 cases of ALD over a period of 2 years. Upper gastrointestinal (GI) endoscopy and transient elastography were done. Liver fibrosis was staged with the METAVIR system and severity of fibrosis was correlated with complications, duration of alcohol abuse, aspartate transaminase (AST) to platelet ratio index (APRI) and Child-Turcotte-Pugh (CTP) score. To establish the relationship between various parameters, Spearman’s correlation coefficient (r) and their associated probability (p) were used.ResultsDistribution in 130 patients according to the METAVIR stage (median liver stiffness measurement [LSM]) was: F0: n = 16 (5.08 kPa); F1: n = 19 (6.6 kPa); F2: n = 9 (9.3 kPa); F3: n = 26 (16.3 kPa) and F4: n = 60 (50.5 kPa) (p < 0.0001). Liver stiffness measurement (LSM) score was significantly correlated with CTP score (r = 0.492, p < 0.0001), APRI (r = 0.435, p < 0.0001), duration of alcohol consumption (r = 0.816, p < 0.0001), presence of ascites (r = 0.756, p < 0.0001), presence of esophageal varices (r = 0.567, p < 0.0001), and presence of variceal bleeding (r = 0.383, p < 0.0001).ConclusionsTE is an inexpensive and non-invasive modality to assess the severity of liver fibrosis in ALD. It can be used as a good screening tool to identify patients with cirrhosis without the use of invasive liver biopsy, enabling better prognostication for the development of complications.

Fibroscan and FIB-4 Assessment Versus Lymphocyte / Monocyte Ratio as Predictors of Post-Hepatectomy Liver Failure in HCV Egyptian Patients with Hepatocellular Carcinoma

Background: Post-hepatectomy liver failure (PHLF) is the most leading cause of mortality in patients diagnosed with hepatocellular carcinoma (HCC) and undergoing resection of the affected part of the liver. Objectives: This research aimed to determine the value of the lymphocyte to monocyte ratio (LMR), fibrosis score 4 (FIB-4) and liver stiffness measurements (LSM) using Fibroscan as pre-operative predictors of PHLF in Egyptian patients with post- hepatitis C virus (HCV) liver cirrhosis and HCC. Methods: In this prospective cohort study definition of PHLF was done according to the “50-50 criteria”. Multivariate analysis was done to identify PHLF independent predictors. The predictive accuracy of the pre-operative LMR, FIB-4 and LSM with Fibroscan were evaluated by receiver operating characteristic (ROC) curve. Results: Enrollment of fifty Egyptian patients was done. 14 patients (28%) experienced PHLF. The presence of oesophageal varices, serum AST, serum albumin, LMR, FIB-4 score, and LSM (P<0.05) were independent pre-operative predictors for PHLF. According to ROC curve analysis, LMR yielded the best accuracy for predicting PHLF at cutoff <3.33 [AUC = 0.940; sensitivity = 93.65%; specificity = 94.44%; positive predictive value = 86.67%; negative predictive value = 97.14%]. FIB-4 score and LSM had lower AUC (0.886 and 0.875) respectively. Conclusion: The pre-operative LMR has a higher predictive ability for PHLF in patients with HCV-related HCC undergoing hepatectomy compared with FIB-4 score and LSM using Fibroscan.

Non-Invasive Predictors of Esophageal Varices in Alcoholic Chronic Liver Disease

Background: Alcohol is widely consumed socially accepted recreational beverage, that is toxic and affects directly or indirectly almost every organ. Spectrum of alcoholic liver disease ranges from fatty liver to cirrhosis. One of the complications of the later spectrum is portal hypertension, around 50% develops varices and bleeding depends on the size of the varices. Predicting varices without endoscopic is difficult but few non-invasive parameters are available.&#x0D; Materials and Methods: It was a prospective cross-sectional study done in Nobel Medical College Teaching Hospital, Biratnagar, Nepal from September 2018 to August 2019. Approval was acquired from Institutional Review Committee. Patients with chronic ethanol ingestion and features suggestive of chronic liver disease clinically and investigation wise were enrolled in the study. History, physical examinations along with platelet count, prothrombin time was taken and ultrasonography abdomen and upper gastrointestinal endoscopy was done to see the splenic diameter, and varices.&#x0D; Results: Esophageal varices were present in 53%. Mean platelet count with variceswas 122566 ± 36024.8 /mm3, splenic diameter was 133.1 ± 21.3 mm, prothrombintime (PT) time was 19.3 ± 5.0 sec andratio of platelet per spleen diameter was 930.2 ± 259.4 /mm3/mm.Platelet count &lt; 163500/mm3 has sensitivity and specificity 83.0% and 83.0% respectively. Ratio of platelet per splenic diameter ratio cutoff 1293.7 has 88.7% sensitivity and 85.1% specificity for predicting varices.&#x0D; Conclusion: In chronic alcoholic liver disease patients low platelet count, increased splenicdiameter, low platelet per splenic diameter ratio are useful in predicting presence of esophageal varices.

The magnitude and correlates of esophageal Varices among newly diagnosed cirrhotic patients undergoing screening fibre optic endoscope before incident bleeding in North-Western Tanzania; a cross-sectional study

BackgroundBleeding esophageal varices is a deadly complication of liver cirrhosis. Guidelines recommend an early diagnosis of esophageal varices before incident bleeding by screening all patients diagnosed with liver cirrhosis. Though it has been reported elsewhere that the presence of esophageal varices varies widely among cirrhotic patients this has not been assessed in Tanzania since endoscopy is not readily available for routine use in our setting. This study was designed to determine the prevalence of esophageal varices and assess the utility of clinical parameters in predicting the presence of varices among cirrhotic patients in northwestern Tanzania.MethodsA cross-sectional analysis of adult patients with liver cirrhosis was done at Bugando Medical Centre. Demographic, clinical, laboratory and endoscopic data were collected and analyzed using STATA 13. The presence of esophageal varices was detected using endoscopic examination and associated factors were assessed by logistic regression. The predictive value of clinical predictors was also assessed by calculating sensitivity and specificity.ResultsA total of 223 patients were enrolled, where 88 (39.5%; 95%CI: 33.0–45.9) had esophageal varices. The varices were independently associated with increased age (OR: 1.02; 95%CI: 1.0–1.04; p = 0.030); increased splenic diameter (OR:1.3; 95%CI:1.2–1.5; p < 0.001), increased portal vein diameter (OR:1.2; 95%CI: 1.07–1.4; p = 0.003), having ascites (OR: 3.0; 95%CI: 1.01–8.7; p = 0.046), and advanced liver disease (OR: 2.9; 95%CI: 1.3–6.7; p = 0.008). PSDR least performed in predicting varices, (AUC: 0.382; 95%CI: 0.304–0.459; cutoff: < 640; Sensitivity: 58.0%; 95%CI: 46.9–68.4; specificity: 57.0%; 95%CI: 48.2–65.5). SPD had better prediction; (AUC: 0.713; 95%CI: 0.646–0.781; cut off: > 15.2 cm; sensitivity: 65.9%; (95% CI: 55–75.7 and specificity:65.2%; 95%CI: 56.5–73.2), followed by PVD, (AUC: 0.6392; 95%CI: 0.566–0.712;cutoff: > 1.45 cm; sensitivity: 62.5%; 95CI: 51.5–72.6; specificity: 61.5%; 95%CI: 52.7–69.7).ConclusionEsophageal varices were prevalent among cirrhotic patients, most of which were at risk of bleeding. The non-invasive prediction of varices was not strong enough to replace endoscopic diagnosis. However, the predictors in this study can potentially assist in the selection of patients at high risk of having varices and prioritize them for endoscopic screening and appropriate management.

942 Low Incidence of Bleeding Complications in Patients With Cirrhosis Undergoing Transesophageal Echocardiography: A Systematic Review and Meta-Analysis

INTRODUCTION: The presence of esophageal varices is considered a relative contraindication to transesophageal echocardiography (TEE) by some professional societies, so gastroenterologists are often consulted to perform upper endoscopy prior to TEE in patients with cirrhosis. Our study’s aim was to perform a systematic review and meta-analysis to quantify the risk of bleeding complications in cirrhosis patients following TEE. METHODS: Two reviewers searched MEDLINE and EMBASE databases from January 1992 to January 2019 for studies reporting bleeding complications following TEE in patients with cirrhosis. Data was extracted by two authors using standardized forms. The pooled incidence rate was calculated using the DerSimonian and Laird method for a random-effects model. The modified Newcastle-Ottawa Scale (NOS) was used to assess study quality. This study was conducted in accordance with Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) guidelines. RESULTS: We identified 16 studies meeting inclusion criteria comprising 3415 unique cirrhosis patients. Nine studies (n = 3009) assessed risk of intraoperative TEE during LT and 7 studies (n = 406) included cirrhosis patients undergoing TEE for other indications; upper endoscopy was performed prior to TEE in 3 out of 9 and 7 out of 7 of those studies, respectively. The pooled risk of bleeding complications post-TEE was 1.0% (95%CI 0.0 – 2.0%) across all studies. The proportion of patients with bleeding complications was similar among patients undergoing intraoperative TEE during LT compared to those undergoing TEE for other reasons (1.1% vs 2.2%, P = 0.06). Further, bleeding rates were similar among patients in the subgroup of studies with mean MELD &gt; 18 compared to studies with mean MELD &lt; 18 (1.9% vs 1.3%, P = 0.31). Three studies had NOS quality scores &lt; 5, 6 had a score of 5–7, and 7 studies had quality scores &gt;7. Overall, the cohorts were representative and included patients with various etiologies of cirrhosis, though most were retrospective in design and lacked a control group. Detailed data on patient-level factors impacting bleeding complications (including degree of liver dysfunction and coagulopathy) were inconsistently reported and limited across studies. CONCLUSION: There is a low risk of bleeding complications in cirrhosis patients following TEE, suggesting TEE is safe and risk stratification with upper endoscopy may not be necessary.

Non-endoscopic predictors of esophageal varices in children with chronic liver disease and their utility in resource-constrained countries.

Although endoscopy is the standard diagnostic screening test to identify esophageal varices in patients with chronic liver disease (CLD), selective endoscopy in patients who are at higher risk of having varices may be cost-effective in a resource-constrained country. The aim of this prospective study was to identify non-endoscopic parameters that may predict the presence of varices, especially high-risk esophageal varices in children with CLD. From January 2016 through March 2018, consecutive children with CLD without a history of variceal bleeding were prospectively included. Esophagogastroduodenoscopy was done in all the children to detect and to grade esophageal varices. Both univariate and multivariate logistic regression analyses were done using SPSS version 22 to identify factors associated with esophageal varices. The mean age of 84 children was 9.7 ± 3.2years (male 44). Esophageal varices were present in 71.4% of children and 55% of them had large varices. On univariate analysis, low platelet count (< 100,000/mm3) and splenomegaly were found to be associated with the presence of esophageal varices (p = 0.006 and 0.001, respectively) and large varices (p = 0.03 and 0.01, respectively). On multivariate analysis, both low platelet count and splenomegaly were independent predictors for the presence of esophageal varices (respectively, OR 11.21, 95% CI 1.2-96.9; and OR 11.39, 95% CI 3.19-40.59). Splenomegaly and low platelet count independently predict the presence of any grade of esophageal varices and can be used as screening tests to select children for endoscopy. This strategy may help in relieving medical, social, and economic costs in resource-constrained countries.

Percentage of small platelets on peripheral blood smear and Child-Turcott-Pugh class can predict the presence of oesophageal varices in newly diagnosed patients with cirrhosis: development of a prediction model for resource limited settings

BackgroundIn cirrhosis upper-gastrointestinal-endoscopy (UGIE) identifies oesophageal varices (OV). UGIE is unavailable in most resource-limited settings. Therefore, we assessed prediction of presence of OV using hematological parameters (HP) and Child-Turcott-Pugh (CTP) class.MethodsA prospective study was carried out on consecutive, consenting, newly-diagnosed patients with cirrhosis, in the University Medical Unit, Colombo North Teaching Hospital, Ragama, Sri Lanka from April 2014–April 2016. All patients had UGIE to evaluate presence and degree of OV, prior to appropriate therapy. HP (full blood count with indices using automated analyzer and peripheral blood smear using Leishmann stain) and CTP class were assessed on admission. Linear logistic regression model was developed to predict OV using HP and CTP class.Results54-patients with cirrhosis were included [14(26%), 24(44%) and 16(30%) belonged to CTP class A, B and C respectively]. 37 had varices [CTP-A 4/14(26.6%), CTP-B 19/24(79.2%), CTP-C 14/16(87.5%)] on UGIE. Generalized linear model fitting showed decreasing percentage of small platelets (%SP) (P = 0.002), CTP-B (P = 0.003) and CTP-C (P = 0.003) compared to CTP-A had higher probability of having OV. The model predicts the log odds for having OV = − 0.189 – (0.046*%SP) + 2.9 [if CTP-B] + 3.7 [if CTP-C]. Based on receiver operating characteristic (ROC) analysis, a model value > − 0.19 was selected as the cutoff point to predict OV with 89%-sensitivity, 76%-specificity, 89%-positive predictive value and 76%-negative predictive value.ConclusionsWe constructed a model using %SP on peripheral blood smear and CTP class. This model may be used to predict the presence of OV, in newly diagnosed patients with cirrhosis, with acceptable sensitivity and specificity, to prioritize the patients who deserve early UGIE in limited resource settings.

Insulin resistance is not a risk factor for oesophageal varices development in hepatitis C.

Chronic hepatitis C (HCV) patients commonly have insulin resistance which is a risk factor for disease progression. Oesophageal varices may bleed with high mortality. We aimed to assess the relationship between insulin resistance and oesophageal varices. HCV-related compensated liver cirrhosis patients (n = 146) underwent gastroscopy and homeostasis model assessment (HOMA)-IR, HOMA-β and HOMA-S calculations. Their average age was 54.98 years; most (84.9%) patients were men and non-diabetic (60.3%). Patients with oesophageal varices had higher median Model for End-Stage Liver Disease (MELD) scores and comparable Child-Pugh class. Patients with and without oesophageal varices had comparable (P > 0.05) HOMA scores and insulin resistance percentage of 82.9% versus 85.5%. We therefore conclude that insulin resistance is unrelated to the presence of oesophageal varices.

Band ligation versus no intervention for primary prevention of upper gastrointestinal bleeding in adults with cirrhosis and oesophageal varices.

The presence of oesophageal varices is associated with the risk of upper gastrointestinal bleeding. Endoscopic variceal ligation is used to prevent this occurrence but the ligation procedure may be associated with complications. To assess the beneficial and harmful effects of band ligation versus no intervention for primary prevention of upper gastrointestinal bleeding in adults with cirrhosis and oesophageal varices. We combined searches in the Cochrane Hepato-Biliary Group Controlled Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, LILACS, and Science Citation Index with manual searches. The last search update was 9 February 2019. We included randomised clinical trials comparing band ligation verus no intervention regardless of publication status, blinding, or language in the analyses of benefits and harms, and observational studies in the assessment of harms. Included participants had cirrhosis and oesophageal varices with no previous history of variceal bleeding. Three review authors extracted data independently. The primary outcome measures were all-cause mortality, upper gastrointestinal bleeding, and serious adverse events. We undertook meta-analyses and presented results using risk ratios (RRs) with 95% confidence intervals (CIs) and I2 values as a marker of heterogeneity. In addition, we calculated the number needed to treat to benefit (NNTTB) for the primary outcomes . We assessed bias control using the Cochrane Hepato-Biliary domains; determined the certainty of the evidence using GRADE; and conducted sensitivity analyses including Trial Sequential Analysis. Six randomised clinical trials involving 637 participants fulfilled our inclusion criteria. One of the trials included an additional small number of participants (< 10% of the total) with non-cirrhotic portal hypertension/portal vein block. We classified one trial as at low risk of bias for the outcome, mortality and high risk of bias for the remaining outcomes; the five remaining trials were at high risk of bias for all outcomes. We downgraded the evidence to moderate certainty due to the bias risk. We gathered data on all primary outcomes from all trials. Seventy-one of 320 participants allocated to band ligation compared to 129 of 317 participants allocated to no intervention died (RR 0.55, 95% CI 0.43 to 0.70; I2 = 0%; NNTTB = 6 persons). In addition, band ligation was associated with reduced risks of upper gastrointestinal bleeding (RR 0.44, 95% CI 0.28 to 0.72; 6 trials, 637 participants; I2 = 61%; NNTTB = 5 persons), serious adverse events (RR 0.55, 95% CI 0.43 to 0.70; 6 trials, 637 participants; I2 = 44%; NNTTB = 4 persons), and variceal bleeding (RR 0.43, 95% CI 0.27 to 0.69; 6 trials, 637 participants; I² = 56%; NNTTB = 5 persons). The non-serious adverse events reported in association with band ligation included oesophageal ulceration, dysphagia, odynophagia, retrosternal and throat pain, heartburn, and fever, and in the one trial involving participants with either small or large varices, the incidence of non-serious side effects in the banding group was much higher in those with small varices, namely ulcers: small versus large varices 30.5% versus 8.7%; heartburn 39.2% versus 17.4%. No trials reported on health-related quality of life.Two trials did not receive support from pharmaceutical companies; the remaining four trials did not provide information on this issue. This review found moderate-certainty evidence that, in patients with cirrhosis, band ligation of oesophageal varices reduces mortality, upper gastrointestinal bleeding, variceal bleeding, and serious adverse events compared to no intervention. It is unlikely that further trials of band ligation versus no intervention would be considered ethical.

Role of Plasma Von Willebrand Factor-Antigen in predicting the presence of Esophageal Varices and occurrence of its bleeding in cirrhotic patients

Background and study aim: Baveno VI consensus recommended the use of non- invasive predictors of EV to avoid unnecessary endoscopies. Von Willbrand factor (VWF) and VITRO score, (VWF/ platelet count), are both correlated to liver cirrhosis and fibrosis. The aim of this study was to evaluate the role of VWF and VITRO score as predictors of esophageal varices and their bleeding. Patients and Methods: Seventy seven patients were included in this study. They were randomly selected from cirrhotic patients admitted to endoscopy unit for the first time. They were allocated into two groups;group I:patients who have esophageal varices,group II:patients with no esophageal varices. Results: VWF Ag and VITRO score were significantly higher in the varices group (group I). VWF Ag level was 169.3±20.2 in group I vs 146.8±35.5 µg/dL in group II p<0.001. VITRO score was 2.2±1.1 in group I vs 1.6±0.7 µg/108 platelet p=0.05. We found that at cut off value of 153% VWF can predict the presence of EV with sensitivity 88.1% and specificity of 61.1% and AUC= 0.66 p=0.04. VITRO score can predict the presence of varices with sensitivity of 69.5% and specificity of 50% at a cut off value 1.5 AUC=0.065 P=0.05. Conclusion: VWF and VITRO score rise significantly in patients with esophageal varices. Both markers can be reliable in prediction of the presence of EV’s. VWF Ag can be reliable marker in prediction of risky and bleeding varices.

ESOPHAGEAL VARICES;

Objectives: To determine the correlation between serum albumin levels and the grades of esophageal varices in patients of liver cirrhosis due to hepatitis B and C. Study Design: Cross-sectional descriptive study. Place and Duration of Study: Unit I, Department of Medicine, Allied Hospital, Faisalabad from 29th June, 2014 to 28th December, 2014. Methodology: 95 patients of either sex between 20-70 years of age, with the diagnosis of liver cirrhosis due to hepatitis B and C were selected using non - probability consecutive sampling. The presence of esophageal varices was confirmed by endoscopy. Results: Out of a total of 95 patients, 59 (62.11%) were between the age group of 20-50 years while 36 (37.89%) were between 51-70 years of age. Mean+SD was calculated as 48.37+11.75 years. Gender distribution showed that 51 (53.68%) patients were males and 44 (46.32%) were females. Correlation between serum albumin level and the grade of esophageal varices in patients of liver cirrhosis due to hepatitis B &amp; C showed that out of 26 cases with serum albumin level &lt;2.8, 10 had Grade I and 16 had Grade II while out of 69 cases with ≥2.8 serum albumin level, 40 had grade I and 29 had grade II EV. r value was recorded to be -0.697 whereas p-value was calculated as 0.000. Conclusion: There is a significant negative correlation between serum albumin level and grade of esophageal varices in patients of liver cirrhosis due to hepatitis B and C.

Diagnostic Accuracy of Multidetector Computed Tomography in Detection of Esophageal Varices.

ObjectiveTo determine the diagnostic accuracy of multidetector computed tomography (MDCT) in the detection of esophageal varices by taking endoscopy as the reference standard.Materials and methodsThis was a cross-sectional prospective study conducted at the Department of Radiology, Aga Khan University Hospital, (AKUH) Karachi, for the duration of 12 months from August 1, 2014 to July 31, 2015. One hundred ninety-six patients with a suspicion of chronic liver disease/cirrhosis undergoing 64 slice MDCT were enrolled in our study and underwent computed tomography (CT) scanning in the Department of Radiology at AKUH. Biphasic CT was performed with images obtained during the hepatic arterial phase (30-second delay) and the portal venous phase (65-second delay) after the intravenous (IV) injection of 120 mL of nonionic contrast material at a rate of 3.5 mL/s. The presence of esophageal varices was evaluated on MDCT with endoscopy as gold standard. The sensitivity, specificity, negative predictive value and positive predictive value, and accuracy of MDCT were assessed against the gold standard.ResultsOur results yielded an MDCT sensitivity of 98.96%, specificity of 100%, positive predictive value (PPV) of 100%, negative predictive value (NPV) of 66.67%, and diagnostic accuracy of 98.97% for esophageal varices in chronic liver disease (CLD) patients.ConclusionThe rate of detection of esophageal varices in patients with chronic liver disease on MDCT in our country is comparable to the international data and we advocate that MDCT should be used as a screening tool in patients with chronic liver disease to exclude esophageal varices.

Anticoagulation Therapy in Patients with Liver Cirrhosis is Associated With an Increased Risk of Variceal Hemorrhage

ObjectiveThe belief that cirrhotic patients are “auto-anticoagulated” often results in anticoagulation therapy being withheld in these patients. We aimed to understand patterns of use of anticoagulation and to determine the risk of bleeding complications in cirrhotic patients. MethodsWe retrospectively analyzed 320 cirrhotic patients treated with anticoagulation therapy from July 15, 2014 to January 30, 2018. We performed bivariate and multivariate analyses to identify risk factors for clinically relevant bleeding. We conducted a separate analysis using propensity score matching to compare bleeding rates of a noncirrhotic cohort group on anticoagulation to anticoagulated patients with cirrhosis. ResultsNonalcoholic steatohepatitis (47%) was the most common cause of cirrhosis, and 49% were classified as Child-Pugh class B, a mean model for end-stage liver disease score of 14 and Charlson comorbidity index of 7. Anticoagulation was initiated for atrial fibrillation/atrial flutter in 56% of patients; warfarin was used in 57% of patients and concomitant use of antiplatelet therapy in 25%. Bleeding occurred in 18%, with upper gastrointestinal bleeding (53%) being the most common source. In the propensity-matched cohort, bleeding rates were higher in cirrhotics than in control patients who were matched for baseline characteristics. In multivariate analysis of the cirrhotic patients, the presence of esophageal varices was associated with higher odds of clinically relevant bleeding. ConclusionAnticoagulated cirrhotic patients who have esophageal varices are at an increased risk of bleeding. We recommend that patients with cirrhosis and esophageal varices who require anticoagulation have their varices managed carefully prior to initiation of anticoagulation.

Outcome of Esophageal Variceal Ligation in Cirrhotic Patients: Experience in a Tertiary Care Hospital in Dhaka

Background: Bleeding from esophageal varices in cirrhosis is an emergency condition. Esophageal varices band ligation has shown better results in terms of variceal obliteration as well as having fewer side effects like ulceration, perforation and stricture formation.&#x0D; Methods: This observational study was conducted at the gastroenterology department of BIRDEM general hospital, from September 2014 to March 2015. Subjects were eligible if they had a diagnosis of cirrhosis based on history, physical examination, biochemical parameters and presence of esophageal varices in upper gastrointestinal endoscopy. All patients were tested to determine the cause of liver cirrhosis. All patients under-went upper gastrointestinal endoscopy after consent. Esophageal variceal ligation was done at appropriate situation and patients were followed up later on. SPSS 23 was used for statistical analysis.&#x0D; Results: The sample size was 69. The cumulative mean age was 55.58±14.462 years (range: 20-90), with gender-based mean age of 54.76±15.704 years for males and 57.22±11.739 years for female. Mild portal hypertensive gastropathy (PHG) was found 31 (44.9%) patient and severe PHG 36 (52.2%). Patients were followed up for mean period of 8.52±3.6 months. Variceal obliteration was achieved in 25 (36.2%) patients, while 06 (8.7%) cases developed re-bleeding during the study period and this type of patients were managed by other modalities or combination therapies. Recurrence of varices occurred in 13 (18.8%). 25 (36.2%) patients reduction of varix size occured after esophageal variceal ligation (EVL), 32 (46.4%) required second session and 12 (17.4%) required more than second session (Table-2). Thirty nine (56.5%) patients experienced minor adverse events like GI discomfort (retrosternal pain or dysphagia), while severe adverse events were noticed in 13 (18.8%) patients. Fundal varix was found among 8 (11.6%) patient on follow up endoscopy and GAVE found in 6 (8.69%) patients. All patient developed PHG during follow up endoscopy.&#x0D; Conclusion: Band ligation eradicates esophageal varices with less complications and a lower re-bleeding rate, but at the same time eradication is associated with more frequent development of PHG and fundal varices.&#x0D; Birdem Med J 2019; 9(1): 63-69

Computed tomography evaluation of patent paraumbilical vein and its aneurysm in relation to other portosystemic collateral channels in patients with liver cirrhosis and portal hypertension

PurposeThe aim of the study was to evaluate the relationship between the diameter and aneurysmal dilatation of the paraumbilical vein (PUV) and the presence of portosystemic collateral shunts and their relationship with age and portal vein diameter.Material and methodsThe retrospective analysis, performed in the II Department of Radiology, Medical University Hospital in Warsaw, included 126 patients (77 males and 49 females) with patent umbilical vein and signs of portal hypertension due to liver cirrhosis. All patients underwent contrast enhanced abdominal CT. The average age was 54.7 ±12.98. We analysed the number and type of portosystemic collateral channels in respect of age, sex, presence of oesophageal varices, and the diameter of the paraumbilical vein and the portal vein.ResultsOur results disclosed statistically significant negative correlation between patient age and diameter of paraumbilical vein, number of portosystemic collateral channels and diameter of portal vein and positive correlation between diameter of paraumbilical vein and diameter of portal vein. A statistically significant difference in diameter of portal vein and number of collateral channels was found in groups with and without oesophageal varices. No significant difference in age and portal vein diameter was found in these groups.ConclusionsOur study showed that younger patients with liver cirrhosis are characterised by wider paraumbilical veins and higher number of portosystemic collateral channels. The presence of oesophageal varices does not correlate with age, sex, diameter of paraumbilical vein, and number of collateral portosystemic channels.

Sclerosis of Fundic Varices. Experience in a Reference Center in the South West of Colombia, 2011-2017

Abstract: Treatment of variceal bleeding in the esophagus and fundus is a clinic challenge which sometimes leads to seeking alternative management for this type of patients. This study was carried out to make known the demographic characteristics of patients with gastric varices with or without the presence of esophageal varices that were taken to cyanocrylate sclerotherapy (CYP). Endoscopic findings, outcomes and complications are described. Data used to evaluate the safety and efficacy of the procedure in the management of patients with or without active variceal bleeding. This observational descriptive retrospective cross-sectional study included patients with manifest portal hypertension with esophageal and fundic varices, a total of 132 sclerotherapy procedures with cyanoacrylate mixed with lipiodol. We included 132 records of sclerotherapy with CYA, with equal gender distribution. Esophageal varices were found in 90.2% (119 records). In 31 procedures the indication was emergency bleeding (23.5%), of these 7 had CP-A, 12 CP-B, 0 CP-C and 12 without data. Out of the 101 elective interventions, 34 had CP-A, 24 CP-B, 6 CP-C and 37 without data, with no significant differences between groups (p value = 0.1). Homeostasis was achieved in 100% of patients with active bleeding. Varice sclerosis was successful with a single puncture in 81.1%, two punctures in 13.6% and three or more in 5.3% of the procedures. There were no complications in any of the patients, nor damage in the equipment used. In conclusion Endoscopic obliteration of fundic varices with CYP was safe and effective in the treatment of upper gastric variceal bleeding, without clinical complications in the procedure or damage to the endoscopic equipment used.

Portal vein thrombosis in cirrhotic patients awaiting liver transplantation

Introduction: The development of portal vein thrombosis (PVT) in cirrhotic patients awaiting liver transplantation is unclear. PVT not only aggravates liver function but also challenges liver transplantation techniques. We aimed to investigate possible predictive factors relating with PVT and the outcome after liver transplantation (LT). Method: From January 2013 to December 2015, a total of 349 cirrhotic patients who were awaiting liver transplantation were included. PVT is defined by radiology-revealed filling defect in portal vein (PV) in all patients. Of the patients had liver transplantation, PV was confirmed with a PV thrombus during operation. We have assessed the correlation of the development of portal vein thrombosis (PVT, n=48) and the opposite group (non-PVT, n=301) with clinicopathologic features by Pearson’s chi-squared test. Univariate and multivariate analyses were carried out to identify independent risk factors, followed by survival analysis. Result: Forty-eight (13.8%) among all patients had PVT. The average MELD score was 16.4±7.5. Presence of esophageal varices (EV), a positive EV bleeding history, INR prolongation, thrombocytopenia and relative deficiency of protein C and protein S level were observed for patients with PVT. Eighteen of forty-eight patients and 145 of 301 patients received liver transplantation in PVT and non-PVT group, respectively. Multivariate analysis demonstrated low protein S level (P= 0.017, HR= 2.46, 95% CI=1.17-5.46) as the only independent risk factor for PVT development. Protein S deficiency demonstrated prognostic value on short-term survival, not only for cirrhotic patient awaiting LT (1-year OS: 69.9 v.s 84.1%, p=0.012), but also for whom after LT (1-year OS: 70.4 v.s 84.8%, p=0.047). Conclusion: In cirrhotic patients awaiting LT, PVT development cause lots of clinical complexity and surgical challenges. Protein S deficiency not only correlates with PVT but also acts as an indicative prognostic factor independently. We suggest early LT for certain cases for a better Result.

Association between Serum-Ascites Albumin Gradient and Esophageal Varices in Patients of Cirrhotic Ascites

Background: Serum-Ascitic Albumin Gradient (SAAG) can identify ascites related to portal hypertension. Esophageal varix (EV) is another feature of portal hypertension in cirrhosis. This study was done to find out the relation between SAAG and esophageal varices.Materials and methods: It was a cross- sectional descriptive study of 50 cases of cirrhotic ascites. SAAG was measured and upper gastrointestinal endoscopy was done for esophageal varices.Results: Among 50 cases, mean SAAG value 1.77 (±0.45 SD). Esophageal varices were found in 43(86%) cases. All cases with SAAG value &gt;2.0gm/dl had EV. A significant statistical association was found between level of SAAG and the presence of esophageal varices (p=0.01).Conclusion: In patients of cirrhosis, the level of SAAG has positive association with the esophageal varices. This finding may permit us to use SAAG as a preliminary parameter of esophageal varices (EV) especially where endoscopy facilities are not available.TAJ 2014; 27(2): 36-38

Transient Elastography- a Non-invasive Alternative to Upper Endoscopy for Detection of Gastric and Esophageal Varices in HBV and HCV Cirrhosis

Introduction: Esophageal and gastric varices are one of the most important complications of liver cirrhosis leading to Upper GI Bleed with a significant mortality and morbidity. Upper endoscopy is the currently recommended method for variceal screening and treatment to prevent upper GI bleed. However this method is invasive and carries a small but definitive risk of complications as well as an incremental expense. Non invasive methods to detect patients with large esophageal varices at high risk for bleeding are desirable. In this respect, several clinical, biological, ultrasonographic and elastrographic (transient elastography-TE) methods have been proposed Some of these have been validated as non-invasive alternatives to endoscopy Our study was done with the objective of studying the validity of liver stiffness measurement by fibroscan to predict the presence of esophageal and gastric varices in cirrhotic patients due to hepatitis C and B infection Methods: A retrospective analysis of medical records of 75 patients who underwent fibro scan and then screening endoscopy was carried out. This data was then analyzed to correlate the fibroscan findings with the presence of esophageal and gastric varices. Patients aged 18 to 80 years with HCV and HBV related chronic liver disease were included in this study. Patients with Hepatocellular carcinoma and cirrhosis due to non- HBV/ HCV related liver disease were excluded. Results: The results produced from this data shows that there is a significant association between liver stiffness measured during transient elastography and the presence of esophageal varices. .The results also show that fibro scan score is a better predictor of esophageal varices then gastric varices. There is no strong association between gastric varices and fibro scan score. So fibro scan can be used as screening for only esophageal varices and not for gastric varices Conclusion: The results produced from this data shows that there is a significant association between fibro scan score and esophageal varices. This shows that a non invasive modality like fibroscan score can be used as a screening tool for presence and degree of esophageal varices in patients with chronic hepatitis B and C. The results also show that fibro scan score is a better predictor of esophageal varices then gastric varices.