Presence Of Red Colour Signs Research Articles

CT-derived quantitative liver volumetric parameters for prediction of severe esophageal varices and the risk of first variceal hemorrhage

PurposeTo assess whether CT (computed tomography)-derived quantitative parameters of liver lobe volume can predict severe esophageal varices (EV) and the risk of first varicealhemorrhage (FVH) in patients with liver cirrhosis. MethodsA total of 217 endoscopically confirmed EV patients were included in this retrospective study and were divided into a low-risk EV group (mild-to-moderate EV, n = 83) and a high-risk EV group (severe EV, n = 134), a FVH group (n = 17) and a non-FVH group (n = 27), patients’ clinical findings were recorded. The left, right, caudate lobe, total liver volume and the corresponding functional volume were measured respectively, and the ratio of caudate volume/total volume (CV/TV), caudate functional volume/total functional volume (CFV/TFV) were calculated. Univariate and multivariate logistic analysis were used to determine the independent factors and the receiver operating characteristic (ROC) curves were performed to evaluate the diagnostic performance. ResultsCV, CFV, CV/TV, CFV/TFV were significantly different in the EV severity study and FVH study (p < 0.05). Multivariate analysis indicated that CV/TV and ascites were independent predictive factors for severe EV, a predictive model combing those two factors revealed a satisfactory diagnostic performance (area under the curve (AUC), 0.853, 95 %CI 0.797–0.905). Furthermore, CV/TV and the presence of red color sign under endoscopy were found to be independent predictive factors for FVH, and the former showed a better discriminative performance than the latter (AUC, 0.851 vs 0.779). ConclusionsCT-derived quantitative parameters of CV, CFV, CV/TV, CFV/TFV may be used as an alternative to endoscopy in predicting severe varices and the risk of bleeding.

Quantitative Liver Volumetric Parameters on Computed Tomography May Be Used for Identifying Severe Esophageal Varices and the Risk of First Variceal Hemorrhage

Background: To assess whether the quantitative parameters of liver lobe volume (LLV) based on computed tomography (CT) can identify severity of esophageal varices (EV) and the risk of first variceal hemorrhage (FVH) in patients with liver cirrhosis. Methods: A total of 217 endoscopically confirmed EV patients were enrolled in this study and were divided into a non-conspicuous EV group (mild-to-moderate EV, n=83) and a conspicuous EV group (severe EV, n=134), a FVH group(n=17) and a non-FVH group (n=27), patients’ clinical finding were recorded. The left, right, caudate lobe volume and the corresponding functional volume (LV, RV, CV, LFV, RFV, CFV), total liver volume and the functional volume (TV, TFV) were measured respectively, and the ratio of CV/TV, CFV/TFV were calculated. Univariate and multivariate logistic analysis were used to determine the independent factors and the receiver operating characteristic(ROC) curves were performed to evaluate the diagnostic performance. Results: CV, CFV, CV/TV and CFV/TFV were significantly different in the conspicuous EV study and the FVH study (p <0.05). Multivariate analysis indicated that CV/TV and ascites were independent predictive factors for severe EV. A nomogram combing CV/TV and presence of ascites revealed a satisfactory diagnostic performance for severe EV(area under the curve (AUC)=0.853, 95%CI 0.797, 0.905). Furthermore, CV/TV and the presence of red color sign (RC) were found to be independent predictive factors for the risk of FVH, CV/TV showed a superior discriminative performance (AUC=0.851,95%CI 0.714-0.987) when compared with RC sign under endoscopy (AUC=0.779, 95%CI 0.649-0.91). Conclusions: Quantitative parameters of LLV have great potential be used as an alternative to identify EV severity and the risk of FVH. Funding Information: Not applicable. Declaration of Interests: The authors declare that they have no competing interests. Ethics Approval Statement: This study had approval from the Institutional Review Board of West China Hospital, and informed consent requirement was waved.

Predictors of Bleeding from Esophageal Varices: The Role of Factor VII and von Willebrand Factor (vWF)

Objectives: Bleeding from gastroesophageal varices is the most serious and life-threatening complication of cirrhosis and accounts for 10% of all cases of bleeding from the upper GI tract. It is essential to identify and treat those patients at the highest risk because each episode of variceal hemorrhage carries a 20 percent to 30 percent risk of death, and up to 70 percent of patients who do not receive treatment die within one year of the initial bleeding episode. The aim of this study is to determine the clinical predictors of bleeding esophageal varices and study the role of F VII (factor VII) and vWF (von willebrand factor) in predicting bleeding in patients with eosphogeal varices. Methods: A case control study was done on all patients with esophageal varices admitted at Sohag and Qena faculty of medicine hospitals from January 2012 to August 2013. Various clinical, laboratory and endoscopic variables were tested to determine the predictors of esophageal bleeding. Results: Among 300 patients with esophageal varices, 80 percent was due to hepatitis C virus (HCV), 18 percent was due to hepatitis B virus (HBV), and 2 percent had both HCV and HBV. As an etiologic factor for their liver disease, hemoglobin was 10.12 ± 2.26 g/l, platelet count 135.55 ± 65.94 × l09/l, prothrombin time 14.1 ± 0.92 second, albumin 2.88 ± 0.71 g/dl, ALT 48.25 ± 24.15 u/l, total bilirubin 1.92 ± 1.36 mg/dl. Factor VII was 27.4 ± 8.92 percent and vWF was 188.33 ± 13.66 IU/dl. Splenomegaly was reported 79.6 percent, 90.3 percent had ascites. 35 percent had grade III esophageal varices, 29 percent had four-column esophageal varices on endoscopy, 13.7 percent had concomitant gastric varices and 38.3 percent had portal hypertensive gastropathy. Platelet count, presence of red color sign, the number of columns of esophageal varices, presence of portal gastropathy on eosphagogastroduodenoscopy (EGD) showed a significant positive correlation with bleeding. There is a significant decrease of FVII and a significant increase of vWF in bleeding group in comparison with non bleeding group. Conclusion: Thrombocytopenia, presence of encephalopathy and endoscopic findings of large varices, presence of red color sign, and portal hypertensive gastropathy were found to be predictors of esophageal variceal bleeding. Increase of vWF and decrease of FVII are laboratory predictors of esophageal variceal bleeding.

Measurement of Variceal Pressure with a Computerized Endoscopic Manometry: Validation and Effect of Propranolol Therapy in Cirrhotic Patients

Background and PurposeRecently, we invented a computerized endoscopic balloon manometry (CEBM) to measure variceal pressure (VP) in cirrhotic patient. The purpose of this study was to evaluate the reliability and feasibility of this method, and whether this technique provided further information to pharmacological therapy.Patients and MethodsVP measurements were performed in 83 cirrhotic patients and compared with HVPG as well as endoscopic bleeding risk parameters. Furthermore, VP was assessed before and during propranolol therapy in 30 patients without previous bleeding.ResultsVP measurements were successful in 96% (83/86) of all patients. Of the 83 patients, the VP correlated closely with the HVPG (P<0.001). The presence of red colour signs and the size of varices were strongly associated with VP. Patients with previous bleeding had higher VP than those who had not yet experienced bleeding. In univariate analysis, the level of VP, the size of varices, and red color signs predicted a higher risk of bleeding. The multiple logistic regression model revealed that VP was the major risk factor for bleeding. In 30 patients receiving propranolol, VP significantly decreased from 21.1±3.5 mmHg before therapy to 18.1±3.3 mmHg after 3 months and to 16.3±4.0 mmHg after 6 months. Comparing the mean decrease in VP with that in hepatic venous pressure gradient (HVPG), the decrease in VP was more obvious than HVPG response to propranolol.ConclusionsThis study showed that CEBM is safe and practical to assess VP in cirrhotic patient. It has the potential to be used as a clinical method to assess the risk of variceal bleeding and the effects of pharmacological therapy.Trial registrationEffect of vasoactive drugs on esophageal variceal hemodynamics in patients with portal hypertension. Chinese Clinical Trial Registry –TRC-08000252.

Experiences with Endoscopic Interventions for Variceal Bleeding in Children with Portal Hypertension: A Single Center Study

PurposeThe aim of this study was to compare the efficacy and safety of band ligation and injection sclerotherapy in the endoscopic treatment of children with variceal bleeding.MethodsThe study population included 55 children, all of whom were treated at the time of endoscopic diagnosis of esophageal varices at Asan Medical Center, Seoul, Korea, between January 1994 and January 2011. The primary outcomes included initial success rates and duration of hemostasis after endoscopic management (band ligation vs. injectionsclerotherapy).ResultsThe mean age was 6.7±5.2 years and the mean follow-up time was 5.4±3.7 years. The most common cause of esophageal varices was biliary atresia. Of 55 children with acute variceal bleeding, 39 had band ligation and 16 had injection sclerotherapy. No differences between groups were observed in terms of the size, location, and presence of red color sign. The success rates of band ligation and sclerotherapy in the control of acute bleeding episodes were 89.7% and 87.5%. The mean duration of hemostasis after endoscopic intervention was 13.2±25.1 months. After one year, 19 of 39 patients (48.7%) treated with band ligation and 7 of 16 patients (43.8%) with injection sclerotherapy had experienced rebleeding episodes. Complications after the procedures were observed in 10.3% and 18.8% of children treated with band ligation and injection sclerotherapy.ConclusionThe results of our current study suggest that band ligation and injection sclerotherapy are equally efficient treatments for the control of acute variceal bleeding and prevention of rebleeding.

Does gastroesophageal reflux have an influence on bleeding from esophageal varices?

Mucosal breaks induced by gastroesophageal reflux of gastric contents were more frequently found on the right anterior wall of the lower esophagus. Bleeding from esophageal varices may be also derived from gastroesophageal reflux. The circumferential location of the ruptured esophageal varices was evaluated to elucidate the relationship between gastroesophageal reflux and variceal rupture. Between January 2004 and December 2006, 26 patients who had primary bleeding from esophageal varices and 74 patients without evidence of bleeding with positive red color signs on varices were enrolled in this study retrospectively. Locations of bleeding spots and nonbleeding red color signs of esophageal varices were retrospectively evaluated by endoscopic photographs, and the relationship between the location of red color signs and the risk of bleeding was evaluated. Other possible predictors for bleeding were also investigated by multivariate regression analysis. Red color signs were frequently found in the right posterior wall of the lower esophagus. However, bleeding spots of esophageal varices were more frequently seen in the right anterior side (64.0%) than in others. The positive predictor for bleeding from esophageal varices was the presence of red color sign in the right anterior wall of the esophagus, and the administration of proton pomp inhibitor was the negative predictor. Gastroesophageal acid reflex may be a risk factor of bleeding from esophageal varices. Attention should be paid to the circumferential location of red color signs in endoscopic screening of patients with esophageal varices to predict future bleeding.

Noninvasive endoscopic determination of intravariceal pressure in patients with portal hypertension: clinical experience with a new balloon technique.

Recently, details of a noninvasive balloon manometry technique for endoscopic measurement of variceal pressure (VP) have been published. However, to date, only few data exist on its feasibility and virtually none on its relation to endoscopic or clinical variables of portal hypertension. We investigated a total of 64 patients with esophageal varices using a scaled transparent balloon and a calibrated pressure manometer. Averaged from both fivefold balloon insufflation (variceal collapse) or desufflation (variceal appearance), we took measurements of the VP (mmHg) using the two techniques. These measurements were correlated between two investigators as well as to both clinical and endoscopic signs of portal hypertension. Furthermore, pressures were assessed prospectively before and during propranolol application. Measurements were successful in > 95% of all sessions without side effects. The intraobserver variance was 11.0 +/- 13.1%. Measurements correlated significantly between two observers (r = 0.80, insufflation technique, p < 0.01/r = 0.81, desufflation technique, p < 0.01). Pressures correlated positively to variceal sizes (p < 0.05). The presence of fundic varices was strongly associated with higher pressures (p < 0.02). In patients without medical decompressive therapy we found a significant relationship between VP and the presence of red colour signs or previous bleeding episodes. Clinical parameters did not correlate with VP (p > 0.05). As assessed by this technique, 8/11 patients receiving propranolol showed a decrease in VP (18.6 +/- 19.5% after 1.5 months and 33.3 +/- 11.9% after 3 months). This noninvasive balloon technique is a safe and practical method for estimating VP in patients with portal hypertension. As found by invasive methods, patients with large varices and concomitant fundic varices have higher VP. A drop in intravariceal pressure after propranolol therapy appears to be assessable.

Measurement of variceal pressure with an endoscopic pressure sensitive gauge: validation and effect of propranolol therapy in chronic conditions

Aim/Methods: Variceal pressure was measured at endoscopy in 98 patients with a non-invasive, pressure-sensitive gauge technique. Results: In nine patients undergoing sclerotherapy, the values obtained correlated closely with those determined by fine-needle puncture of the varices ( r=0.95, p<0.001). In 15 patients receiving placebo as part of a double-blind, placebo-controlled prospective evaluation of prophylactic treatment with propranolol, variceal pressure did not change significantly over a 1-year period: 16.5±3.2 mmHg at onset: 16.7±3.4 after 3 months and 15.9±3.5 after 12 months. In contrast, propranolol therapy given to 15 patients decreased the pressure from 16.2±3.0 mmHg before therapy to 13.5±2.0 after 3 months ( p<0.001) and to 13.1±4.1 after 12 months ( p<0.05). Patients with a recent bleeding episode had higher pressures than those who had not yet experienced any haemorrhage (19.3±3.5 mmHg, n=17 vs 13.9±3.3, n=62) ( p<0.001). This was confirmed in a prospective study: the last variceal pressure in bleeders and non-bleeders was respectively 17.2±1.7 mmHg ( n=4) and 14.8±4.1 mmHg ( n=26) ( p<0.01). Overall, variceal pressure measurements correlated with the size of varices, the presence of red colour signs and with the North Italian Endoscopic Club score. Conclusions: This study has shown that the non-invasive pressure gauge Varipress® represents a reproducible method to regularly assess variceal pressure, an important parameter related to the risk of bleeding,and to assess the effects of pharmacological therapy with propranolol.