Presence Of Red Signs Research Articles

The Predictors Of Re-Bleeding In Chronic Liver Disease Patients After Endoscopic Variceal Band Ligation.

Variceal bleeding is a key and most fatal complication observed in chronic liver disease patients with portal hypertension and is a major contributor to the high morbidity and mortality seen in these patients. Exploring the predictors of rebleeding in chronic liver disease patients is of paramount importance to alter disease course and impact on morbidity and mortality. About 50 patients with chronic liver disease who previously had evidence of varices on upper GI endoscopy and had at least one episode of rebleeding after EVBL were included in this study. Patients were assessed for the possible contributors to rebleeding through complete history, clinical examination, coagulation profile and platelet count, ultrasound features (splenic size and portal pressure), and upper GI endoscopic findings (site and grade of varices, red sign). Sample selection was done using non-probability purposive sampling technique and sample size calculated using the standard WHO formula. Data was entered and analyzed using SPSS version 20. In this study, mean age of the patients was 51.34±6.34 years with male predominance (64%). Rebleeding was significantly associated with grade of varices, presence of red sign on upper GI endoscopy, site of varices, splenic size and coagulopathy. Rebleeding in chronic liver disease patients following EVBL is predicted by grade, extent and site of varices, red sign on upper GI endoscopy, splenic size and coagulation disturbances.

Predictive Values of Platelets Count and Spleen Diameter in the Diagnosis of Esophageal Varices in Black African Cirrhotic Patients

Background: Gastrointestinal hemorrhage from ruptured esophageal varices is of concern in Africa where gastrointestinal fibroscopy for diagnosis is lacking. Purpose: To determine the performance of the length of the spleen, of the platelet count in the diagnosis of esophageal varices (OVs) by specifying the diagnostic thresholds in order to facilitate the prophylaxis of varicose hemorrhages in black African cirrhotic patients. Material and Method: This was a prospective study with a descriptive and analytical aim on cirrhotic patients hospitalized at the university hospital of Bouake (Ivory Coast) from 2017 to 2019. The patients included in the study were the cirrhotic of black race hospitalized having carried out an abdominal ultrasound with measurement of the spleen diameter (SD), an eso-gastro-duodenal endoscopy, and a blood count with platelet count (PC). The first primary endpoint was the diagnosis of esophageal varices in cirrhosis. Cirrhosis was retained by the combination of clinical, biological, ultrasound and endoscopic arguments. The OVs were distributed according to size and the presence of red signs. The platelet count, and the measurement of the spleen to calculate the PC/SD ratio were the second endpoint. The secondary endpoints studied were, the viral and ethyl etiologies of the cirrhosis, the Chlid-Pugh prognostic score. Performance was assessed using the ROC curve. The difference was significant for p less than 0.05. Results: The study included 101 patients; they were 79 men (78.2%) and 22 women (21.8%). The mean age of the cirrhotic patients was 48 ± 14. Esophageal varices were present in (n = 93; 92%) of cases. The different etiologies were hepatitis B virus (HBV) (n = 65; 78.3%), hepatitis C virus (HCV) (n = 21; 25, 3%), and alcohol (n = 6; 7.2%). Platelet count (PC) 130 mm) and PC/SD ratio 102 mm predicted 75% of OVs (AUROC = 0.797). CP with a cutoff 129 mm predicted large OVs. Conclusion: Platelet count, spleen diamater, and PC/SD ratio were all performant for the diagnosis of OVs in our setting with better diagnostic performance for PC/SD. This report could help initiate prophylactic treatment for OVs rupture in cirrhotic patients in health centers where gastrointestinal endoscopy is lacking.

Predicting variceal bleeding in patients with biliary atresia

Background/aims: Variceal bleeding is the main cause of morbidity and mortality in children with portal hypertension and biliary atresia. The aim of this study is to predict high-risk varices by analyzing various clinical factors, thus improve prognosis of patients with biliary atresia.Methods: A total of 157 patients with biliary atresia who underwent Kasai portoentrostomy were enrolled in a single center. Clinical data including laboratory values, endoscopic findings and values of transient elastography (FibroScan®) were analyzed retrospectively.Results: The bleeding group and the non-bleeding group showed statistically significant differences in several variables; The FibroScan® value (HR 1.05, 95% CI (1.03–1.07), p < .01) was higher in the bleeding group. The bleeding group had values of lower albumin after 3 months of operation (HR 0.28, 95% CI (0.11–0.73), p = .01), higher bilirubin after 3 months of operation (total bilirubin: HR 1.18, 95% CI (1.04–1.33), p = .01), (direct bilirubin: HR 1.21, 95% CI (1.05–1.41), p = .01). Gastric varix (HR 4.10, 95% CI (1.62–10.36), p < .01) was more frequent in the bleeding group. And the presence of red sign was also predictive of bleeding. The FibroScan® cut-off value with the predictive power of bleeding was 31.5 kPa (HR 7.7, 95% CI (3.36–17.73), p < .01).Conclusions: Several clinical factors including high value of transient elastography (FibroScan®), gastric varix or red sign of endoscopy, and low albumin or high bilirubin values after 3 months of Kasai operation can be useful in predicting variceal bleeding in patients with biliary atresia.

Oesophageal varices in patients with liver cirrhosis

About one third of cirrhotic patients with oesophageal varices (OV) develops an episode of oesophageal hemorrhage, and subsequently has high morbidity and mortality. Early detection and prevention of OV in these patients are crucial to minimizing complications. This study was carried out to determine the prevalence of OV among the cirrhotic patients at our institution. Fifty six patients with liver cirrhosis who had upper gastrointestinal endoscopy done were recruited into the study. The study was carried out at the Ekiti State University Teaching Hospital, Ado –Ekiti, between January 2010 and December 2011. Liver cirrhosis was diagnosed on the basis of liver biopsy, clinical and ultrasound findings. At the point of recruitment, a full medical history was taken. The severity of liver disease was assessed according to Child's classification. All the patients underwent upper gastrointestinal (GIT) endoscopy. The diagnosis of variceal bleeding was confirmed if an actively bleeding varix or a varix with adherent clot was seen. The following endoscopic features were recorded during the procedure: size, colour, and location of varices (oesophageal, fundal or portal gastropathy) and the presence of red signs. Ethical approval for the study was obtained from hospital’s Ethics Committee and all the patients gave their individual signed consent. SPSS version 15.0 (SPSS, Inc., Chicago, Illinois, USA) was deployed for statistical analysis using the t-test for quantitative variables and χ2 test for qualitative variables. Differences were considered to be statistically significant if P value was less than 0.05. Fifty six cirrhotic patients comprising of 37 males and 19 females were recruited into the study. The Male: Female ratio was 1.9:1. The mean age for males was 51.6±10.2, while that of the females was 55.4±10.6. Oesophageal varices were found in 30 of the 56 patients giving an overall prevalence rate of 53.6%. All the varices were oesophageal in location; 73.3% (22/30) were males while 26.7% (8/30) were females. A large proportion (64.3%) of the patients were in Child’s grade A, while 28.5% were in Child’s Grade B and only 7.1% were in Child’s Grade C. Endoscopically, 13 of the varices were small (F1), 10 were medium sized (F2) while 7 were of large size (F3). The statistically significant risk factors for oesophageal varices found in this study were hepatitis B virus infection and tattoo marks. The prevalence of oesophageal varices in cirrhotic patients in this study was 53.6%. Upper gastrointestinal endoscopy is therefore recommended in the cirrhotic patients to ameliorate the risk of bleeding and the related high mortality.

Management of Gastric Varices

According to their location, gastric varices (GV) are classified as gastroesophageal varices and isolated gastric varices. This review will mainly focus on those GV located in the fundus of the stomach (isolated gastric varices 1 and gastroesophageal varices 2). The 1-year risk of GV bleeding has been reported to be around 10%-16%. Size of GV, presence of red signs, and the degree of liver dysfunction are independent predictors of bleeding. Limited data suggest that tissue adhesives, mainly cyanoacrylate (CA), may be effective and better than propranolol in preventing bleeding from GV. General management of acute GV bleeding must be similar to that of esophageal variceal bleeding, including prophylactic antibiotics, a careful replacement of volemia, and early administration of vasoactive drugs. Small sample-sized randomized controlled trials have shown that tissue adhesives are the therapy of choice for acute GV bleeding. In treatment failures, transjugular intrahepatic portosystemic shunt (TIPS) is considered the treatment of choice. After initial hemostasis, repeated sessions with CA injections along with nonselective beta-blockers are recommended as secondary prophylaxis; whether CA is superior to TIPS in this scenario is not completely clear. Balloon-occluded retrograde transvenous obliteration (BRTO) has been introduced as a new method to treat GV. BRTO is also effective and has the potential benefit of increasing portal hepatic blood flow and therefore may be an alternative for patients who may not tolerate TIPS. However, BRTO obliterates spontaneous portosystemic shunts, potentially aggravating portal hypertension and its related complications. The role of BRTO in the management of acute GV bleeding is promising but merits further evaluation.

Risk and causes of gastroesophageal bleeding in patients with liver cirrhosis

Variceal bleeding is the most life-threating complication in liver cirrhosis. The aim of this study was to analyze the sources of gastroesophageal bleeding in patients with liver cirrhosis and to ascertain the risk factors of bleeding from esophageal varices. This prospective study included 52 patients with liver cirrhosis and portal hypertension. Severity of liver dysfunction according to Child's classification, coagulation parameters, and endoscopic findings were analyzed. In patients with varices we analyzed the size, color, location of varices, and the presence of red signs. The varices were classified as small, medium and large. Esophageal varices were found in 76.9% of the patients. Isolated varices were present in 36.6%, and associated with other findings in 40.3%. Small varices were present in 10%, medium in 25% and large in 65% patients. Of them 55% had variceal bleeding. Variceal bleeding was present in 50% of the patients with medium and in 65.38% of the patients with large varices. There was no bleeding in the patients with small varices. Endoscopy revealed red signs before bleeding in 85% of the patients with large varices. There was a higher incidence of variceal bleeding in the Child's group B. There were no significant differences (p > 0.05) in the coagulation parameters in patients with and without variceal bleeding. Rebleeding was present in 86.36% of the patients. Most of them (52.63%) were rebleeding between 7 weeks and 12 months after the first episode of variceal bleeding. In the patients with the most severe hepatocellular dysfunction (Child's group C) the period between the first bleeding and rebleeding was the shortest (mean, 20.8 days). Our study revealed that esophageal varices are the most frequent sources of bleeding in the patients with liver cirrhosis. There is the association between the first bleeding and large varices and the red signs. Coagulation disorders and hepatic dysfunction were not related to the initial episode of variceal bleeding. The risk of early rebleeding was higher in the patients with severe hepatic dysfunction (Child's class C).

INDICATION OF TREATMENT FOR ESOPHAGEAL VARICES: WHO AND WHEN?

Variceal bleeding is a major cause of death in patients with liver cirrhosis. However, indication (to whom) and timing (when) of the treatment for patients who have never had previous variceal bleeing is not completely established. Given the poor outcome associated with variceal bleeding, the identification of those at high risk and the prevention of a first bleeding episode are critical objectives. Clinical factors associated with an increased risk of a first variceal bleeding include continued alcohol use and poor liver function. Endoscopic predictive factors for the risk of bleeding are large size of varices and presence of red signs on the varices. Current recommendations for primary prophylaxis pertain only to cirrhotics with large varices. However, more patients with small varices will bleed than those with large ones. Non‐selective beta‐blockers are the prophylactic therapy of choice in patients with medium‐sized/large varices, irrespective of the severity of liver dysfunction. Beta‐blockers should be continued life long. Endoscopic variceal band ligation should be contemplated in high‐risk patients who have contraindications or side effects of beta‐blockers. It is salutary to remember that prophylactic sclerotherapy caused harm and its use was abandoned. The use of venodilators (nitrates) alone should be discouraged because there is as yet no proof of their efficacy and evidence suggests that they could worsen the already altered circulatory state of the cirrhotic patient. In patients with small varices, follow‐up endoscopy should be performed every 1–2 years because the risk of bleeding is so small.

Farbkodierte Dopplersonographie: ein verlässliches Verfahren zur Erkennung des Risikos von Ösophagusvarizen-Blutung bei Patienten mit Leberzirrhose

The aim of the study was to examine the role of Doppler ultrasonography of the portal vein in predicting esophageal variceal bleeding in patients with liver cirrhosis and portal hypertension by comparing the ultrasound data to the endoscopic findings. 99 patients with liver cirrhosis and esophageal varices underwent color Doppler ultrasonography and esophagogastroduodenoscopy. The following portal hemodynamic parameters were analyzed: diameter and cross-sectional area, mean blood flow velocity, blood flow volume, perfusion pressure gradient, congestion index, and platelet count-to-spleen diameter ratio. Variceal characteristics, the size and the presence of red signs, were determined by endoscopic examination. Patients with variceal red signs had significantly higher values of portal diameter (1.538 +/- 0.246 vs. 1.243 +/- 0.167), cross-sectional area (1.286 +/- 0.448 vs. 0.945 +/- 0.256), blood flow volume (965.520 +/- 432.728 vs. 625.117 +/- 320.999) and congestion index (0.165 +/- 0.068 vs. 0.126 +/- 0.051) than patients without red signs, while the perfusion pressure gradient (0.260 +/- 0.087 vs. 0.447 +/- 0.271) and the platelet-to-spleen ratio (522.424 +/- 222.823 vs. 708.921 +/- 230.769) were lower. The same pattern of differences between the ultrasound parameters was found in patients with large varices comparing ones with red signs to the ones without them (diameter, 1.567 +/- 0.234 vs. 1.258 +/- 0.175; cross-section, 1.313 +/- 0.455 vs. 1.061 +/- 0.264; flow volume, 988.195 +/- 443.353 vs. 739.423 +/- 414.281; congestion index, 0.171 +/- 0.067 vs. 0.130 +/- 0.058; perfusion pressure gradient 0.247 +/- 0.078 vs. 0.501 +/- 0.379 and platelet-to-spleen ratio 479.930 +/- 184.302 vs. 699.094 +/- 316.171). Differences in values of ultrasonographic parameters were less obvious among groups of patients with different variceal sizes: only the diameter, cross-sectional area and blood flow volume were significantly different. The mean blood flow velocity did not depend on the variceal size or on the presence of red signs. The sensitivities and specificities of the analyzed parameters were 60-80% and 48.6-78.4%, respectively. Results suggest that color Doppler ultrasonography is a useful noninvasive method for evaluating the risk of esophageal variceal bleeding in patients with liver cirrhosis.

Glue for gastric varices: some sticky issues

Glue for gastric varices: some sticky issues

3896 Eus doppler-guided manometry of esophageal varices.

Background and Aims: Variceal size and the presence of red signs on esophageal varices (EV) are considered to be the most important endoscopic factors to predict the risk of variceal rupture. However, endoscopic parameters alone cannot reliably anticipate the eminence of variceal bleeding. Variceal pressure (VP) is a major determinant of the risk of variceal bleeding and has been assessed by direct needle puncture of EV. This method, however, is invasive and may cause bleeding requiring immediate sclerotherapy. Reliability of non-invasive techniques to assess VP remains controversial. The endoscopic balloon technique is strongly observer-dependant : the ideal time for pressure reading is often difficult to decide, resulting in inter- and intra-observer variances. In this study we assessed the feasibility and accuracy of a new method based on EUS power doppler for monitoring EV blood flow during balloon manometry. Methods: Experimental assessment of this technique was performed with an in vitro model consisting of a plastic tube containing artificial latex varices, perfused with water and connected to a manometer. A linear array echoendoscope featuring power doppler was used to assess flow within the varices. A specially designed balloon for EV manometry was attached to the tip of the echoendoscope. Insufflation of this balloon resulted in compression of the varices until flow ceased on EUS power doppler. At this time, pressure readings were made. This procedure was then performed in 12 patients with portal hypertension and EV. Patients were sedated with midazolam and esophageal peristalsis was minimized with iv hyoscine butylbromide. Results: In vitro studies showed a good correlation between the measured pressure and the actual pressure (r=0.92). Determination of VP was technically successful in all patients. VP was 26.2 ± 6.8 mm Hg. Conclusions: Our preliminary results indicate that EUS doppler-guided manometry of EV is feasible and accurate. This technique may become a more reliable method for VP measurement and warrants further investigation. This research was funded in part by the Portuguese Health Ministry Committee for Investigation in Health Care.

4579 Eus doppler-guided manometry of esophageal varices.

`Background and Aims: Variceal size and the presence of red signs on esophageal varices (EV) are considered to be the most important endoscopic factors to predict the risk of variceal rupture. However, endoscopic parameters alone cannot reliably anticipate the eminence of variceal bleeding. Variceal pressure (VP) is a major determinant of the risk of variceal bleeding and has been assessed by direct needle puncture of EV. This method, however, is invasive and may cause bleeding requiring immediate sclerotherapy. Reliability of non-invasive techniques to assess VP remains controversial. The endoscopic balloon technique is strongly observer-dependent: the ideal time for pressure reading is often difficult to decide, resulting in inter- and intra-observer variances. In this study we assessed the feasibility and accuracy of a new method based on EUS power doppler for monitoring EV blood flow during balloon manometry. Methods: Experimental assessment of this technique was performed with an in vitro model consisting of a plastic tube containing artificial latex varices, perfused with water and connected to a manometer. A linear array echoendoscope featuring power doppler was used to assess flow within the varices.A specially designed balloon for EV manometry was attached to the tip of the echoendoscope. Insufflation of this balloon resulted in compression of the varices until flow ceased on EUS power doppler. At this time, pressure readings were made. This procedure was then performed in 12 patients with portal hypertension and EV. Patients were sedated with midazolam and esophageal peristalsis was minimized with iv hyoscine butylbromide. Results: In vitro studies showed a good correlation between the measured pressure and the actual pressure (r=0.92). Determination of VP was technically successful in all patients. VP was 26.2 ± 6.8 mm Hg. Conclusions: Our preliminary results indicate that EUS dopplerguided manometry of EV is feasible and accurate. This technique may become a more reliable method for VP measurement and warrants further investigation. This research was funded in part by the Portuguese Health Ministry Committee for Investigation in Health Care.

Endoscopic Diagnosis and Classification of Varices

Several studies have shown that some endoscopic features of esophageal varices, such as large size and the presence of red signs on their surface, are associated with the risk of variceal hemorrhage. A prognostic index that uses these endoscopic signs in association with an index of liver function, such as the Child’s classification, has been shown to be useful in predicting the risk of bleeding in individual patients. Gastric varices are much more difficult to evaluate and classify than esophageal varices. For this reason, a precise relationship between the endoscopic appearances of gastric varices and the risk of bleeding has not yet been established.

Gastroesophageal endoscopic features in cirrhosis: Observer variability, interassociations, and relationship to hepatic dysfunction

Nowadays, gastroesophageal endoscopic features of portal hypertension are the recognized predictive factors for bleeding and consequently allow the selection of patients for prophylactic therapies. The aim of this prospective study was to investigate the interobserver agreement, the interassociations between these features, and the relationship between these signs and the degree of hepatic dysfunction. In 100 consecutive cirrhotic patients (84% with alcoholism) without history of digestive bleeding, gastroesophageal endoscopic examination was performed and recorded using a videoendoscope. Four independent observers evaluated the following endoscopic features: the size, extent, color, and red signs of esophageal varices, the mosaic pattern, congestive gastropathy, fundic varices, and associated lesions of the stomach. Agreement was assessed using kappa statistics (κ) and a quantitative score. The size of esophageal varices was significantly associated with their extent and the presence of red signs, whereas no relation was found either between gastropathy or mosaic pattern and fundic varices, or between esophageal and gastric features. Agreement between observers was good for the size of esophageal varices (κ = 0.59), the presence of red signs (κ = 0.60), and of gastric-associated lesions (κ = 0.68) and gastropathy (κ = 0.50), while it was poor for the extent (κ = 0.37) and the color (κ = 0.28) of esophageal varices as well as for the mosaic pattern (κ = 0.38). The Child-Pugh score significantly increased along with the presence or the size of esophageal varices as well as with the presence of red signs; no relationship could be shown between this score and the presence of gastric features. We conclude that (1) interobserver agreement was good for the main endoscopic features, especially for the size and the red signs of esophageal varices; (2) esophageal patterns were significantly associated between themselves and related to hepatic dysfunction; and (3) gastric patterns were related neither to esophageal features nor to hepatic dysfunction and were not associated between themselves.