Screening For Varices Research Articles

Extending and validating the Baveno VI criteria for the exclusion of high-risk varices.

The updated Baveno VI guidelines recommend that screening for high-risk varices (HRV) by esophago-gastro-duodenoscopy (EGD) can be avoided in patients with compensated advanced chronic liver disease (cACLD) who have liver stiffness LSM<20 kPa and platelet count PLT>150,000/L. The aims of this study were to validate extended Baveno VI criteria in patients with chronic liver disease and to establish cut-off values for our cohort. This retrospective study included 839 patients with liver cirrhosis evaluated by Transient Elastography (TE), biological tests, and upper endos-copy, all within one year. The Baveno VI criteria were validated on a sub-group of 728 patients (Cohort 1, randomly selected from the study sample) and tailored cut-off points were determined. The remaining 111 patients comprised the validating set (Cohort 2) for these specific cut-off values. In Cohort 1, Baveno VI criteria had 86.2% accuracy. The calculated cut-offs to rule-in HRV were PLT<150,000/mm3 and LSM >35.3 kPa; while to rule-out HRV they were PLT >150.000/mm3 and LSM <19.6 kPa. In patients in the "grey-zone", by multivariate analysis, albumin was independently associated with HRV at a cut-off of ˂3.4 g/dl. In the validation cohort, the calculated rule out cut-offs had 100% accuracy. The Baveno VI criteria had a good accuracy for exclusion of HRV in this large cohort of cirrhotic patients. Adding an albumin-related threshold increased performance and broadened applicability. Using the calculated rule-out criteria for HRV, all unnecessary EGD could be excluded.

Two-dimensional shear wave elastography for screening varices in Asian patients with primary biliary cholangitis

ABSTRACT Objectives: The presence of varices affects the survival of patients with primary biliary cholangitis (PBC). The aim of this study is to assess the criteria based on liver stiffness (LS) measured by two-dimensional shear wave elastography (2D-SWE) and platelet count (PLT), and recently published noninvasive models for triaging PBC patients. Methods: 231 patients with PBC who underwent EGD and 2D-SWE examination were enrolled. Areas under the receiver-operating characteristic curve (AUROC) were used to assess the performance of 2D-SWE for predicting all-size varices and high-risk varices. All-size varices and high-risk varices miss rate < 10% and <5%, respectively, were acceptable for screening varices. Results: The AUROCs of LS for predicting all-size varices and high-risk varices were 0.87 (95%CI: 0.82–0.91) and 0.84 (95%CI: 0.74–0.86), respectively. LS <25 kPa and PLT >110 × 109/L spared 46.3% EGD screening, with 3.7% high-risk varices miss rate and 8.4% all-size varices miss rate. One hundred and sixteen (50.2%) patients met the Newcastle varices in PBC score (cutoff, 0.5), with 4.3% high-risk varices miss rate and 11.2% all-size varices miss rate. Conclusion: The criteria based on LS and PLT are useful for triaging PBC patients. LS <25 kPa and PLT >110 × 109/L could be the optimal criteria for screening varices.

Variceal bleeding is aggravated by portal venous invasion of hepatocellular carcinoma: a matched nested case-control study

BackgroundWe hypothesized that portal vein tumor thrombosis (PVTT) in hepatocellular carcinoma (HCC) increases portal pressure and causes esophageal varices and variceal bleedings. We examined the incidence of high-risk varices and variceal bleeding and determined the indications for variceal screening and prophylaxis.MethodsThis study included 1709 asymptomatic patients without any prior history of variceal hemorrhage or endoscopic prophylaxis who underwent upper endoscopy within 30 days before or after initial anti-HCC treatment. Of these patients, 206 had PVTT, and after 1:2 individual matching, 161 of them were matched with 309 patients without PVTT. High-risk varices were defined as large/medium varices or small varices with red-color signs and variceal bleeding. Bleeding rates from the varices were compared between matched pairs. Risk factors for variceal bleeding in the entire set of patients with PVTT were also explored.ResultsIn the matched-pair analysis, the proportion of high-risk varices at screening (23.0% vs. 13.3%; P = 0.003) and the cumulative rate of variceal bleeding (4.5% vs. 0.4% at 1 year; P = 0.009) were significantly greater in the PVTT group. Prolonged prothrombin time, lower platelet count, presence of extrahepatic metastasis, and Vp4 PVTT were independent risk factors related to high-risk varices in the total set of 206 patients with PVTT (Adjusted odds ratios [95% CIs], 1.662 [1.151–2.401]; 0.985 [0.978–0.993]; 4.240 [1.783–10.084]; and 3.345 [1.457–7.680], respectively; Ps < 0.05). During a median follow-up of 43.2 months, 10 patients with PVTT experienced variceal bleeding episodes, 9 of whom (90%) had high-risk varices. Presence of high-risk varices and sorafenib use for HCC treatment were significant predictors of variceal bleeding in the complete set of patients with PVTT (Adjusted hazard ratios [95% CIs], 26.432 [3.230–216.289]; and 5.676 [1.273–25.300], respectively; Ps < 0.05).ConclusionsPVTT in HCC appears to increase the likelihood of high-risk varices and variceal bleeding. In HCC patients with PVTT, endoscopic prevention could be considered, at least in high-risk variceal carriers taking sorafenib.

Liver Stiffness-Based Model Predicts Hepatic Venous Pressure Gradient in Patients Undergoing Hepatectomy and Liver Transplantation

Background: Invasive hepatic venous pressure gradient (HVPG) measurement is the gold standard test to assess portal hypertension. The aim was to develop a model predictive of clinically significant portal hypertension (HVPG≥10mmHg) using pre-operative noninvasive makers. Methods: 161 patients [66% men, median age of 63 years] who have been planned for liver resection/transplantation were enrolled prospectively and preoperative liver stiffness measurement (LSM), liver function test, and intraoperative HVPG were performed. Results: Median LSM, and HVPG were 9.5kPa, and 5mmHg respectively. No underlying liver disease (F0/1), chronic liver disease (F2/3), and cirrhosis (F4) were found in 32.9%, 32.9% and 34.2% patients respectively. The study cohort was randomly divided into training [n=106] and validation [n=55] sets. Independent predictors of HVPG≥10mmHg in the training set, LSM [p< 0.01, OR=1.1], total bilirubin [p=0.04, OR=0.9], alkaline phosphatase [p=0.02, OR=1], and international normalized ratio [p< 0.01, OR=41.4], were used to develop a probability score model called HVPG10score. Area under receiver operating curve in the training and internal validation sets were 0.91 [95%CI:0.83-0.98] and 0.93 [95%CI:0.86-0.99] respectively with a cutoff of 0.15. HVPG10score was calculated by multiplying the probability by 100. In the overall cohort, HVPG10score of 15 would predict the individual risk of HVPG≥10mmHg with 83% accuracy, 90% sensitivity, 81% specificity and 96% negative predictive value. Conclusions: HVPG10score is an easy-to-use noninvasive continuous scale tool to predict HVPG≥10mmHg. A score < 15 would accurately rule out the need for esophageal varices screening and risk of decompensation in >95% chronic liver disease patients.

Screening varices in patients with HBV-related cirrhosis on antiviral therapy: Platelet alone or together with LSM.

Non-invasive assessment criteria to rule out high-risk varices (HRV) in compensated hepatitis B virus (HBV) cirrhosis on antiviral therapy remains unclear. HBV-related compensated cirrhotic patients who underwent screening endoscopy during antiviral therapy were enrolled and randomly divided into the derivation and validation sets. HRV were defined as medium to large varices or small varices with red signs. Univariate and multivariate logistic analysis were used to determine the parameters associated with HRV. A total of 436 HBV-related compensated cirrhotic patients screened for varices were enrolled, the median duration of antiviral therapy was 4years (IQR: 2.5-5.5years). In the derivation set (N=290, 17.2% with HRV), only platelet (PLT) count (OR=0.972, 95% CI 0.961-0.984, P<.05) was independently associated with HRV, whereas liver stiffness measurement was not associated with the presence of HRV. With a PLT count cut-off value of 105×109 /L, unnecessary endoscopies could be spared in 56.9% patients, with a 3.6%. risk of missing HRV. In the validation cohort (N=146, 16.4% with HRV), the proportion of patients that could safely spare endoscopies (61.0%) identified by this PLT count cut-off value was higher than that obtained by using Baveno VI criteria (34.9%), with an acceptable risk of missing HRV (3.4%). Compared with the 'Baveno VI criteria or beyond' criteria, PLT count higher than 105×109 /L could safely spare more screening endoscopies without increasing the risk of missing HRV in patients with HBV-related compensated cirrhosis on antiviral therapy.

Noninvasive scores for the prediction of esophageal varices and risk stratification in patients with cirrhosis.

The primary purpose of variceal screening in patients with cirrhosis is to detect gastroesophageal varices at high risk of hemorrhage and implement preventative intervention(s). It was previously recommended that all patients with cirrhosis undergo initial and periodic longitudinal variceal screening via upper endoscopy. However, there has been growing interest and methods to identify patients with cirrhosis who may not have clinically significant portal hypertension and therefore be unlikely to have varices requiring intervention or benefit from upper endoscopy. Because the population of patients with compensated advanced chronic liver disease continues to grow, it is neither beneficial nor cost-effective to perform endoscopic variceal screening in all patients. Therefore, there is ongoing research into the development of methods to non-invasively risk stratify patients with cirrhosis for the presence of high-risk esophageal varices and effectively limit the population that undergoes endoscopic variceal screening. This is particularly important and timely in light of increasing healthcare reform and barriers to healthcare. In this review, we discuss and compare, with respect to test characteristics and clinical applicability, the available methods used to non-invasively predict the presence of esophageal varices.

Variceal band ligation and its outcome: A single tertiary care centre study.

Objectives: To determine the frequency of complications after esophageal variceal band ligation in patients of decompensated chronic liver disease. Study Design: Descriptive Case study Setting: Department of Gastroenterology Lahore General Hospital, Lahore. Period: June 2015 to June 2016. Material &amp; Methods: In the present study, the cases of both genders and age more than 20 years having esophageal variceal of any grade on variceal screening esophagogastroduodenoscopy and duration of decompensated liver cirrhosis of at least 6 months or more were included. Esophageal variceal band ligation was performed using a multiband ligation device (Six-shooter, Wilson-Cook Inc., Winston-Salem, NC) and up to 6 bands were placed per session and next session was performed at 2 week intervals until esophageal varices were eradicated, which was defined as a complete disappearance of varices and/or the presence of a varix being too small to be ligated. All patients were followed every month regarding complications in terms of ulcer bleed and esophageal strictures. Results: In this study there were total 720 cases out of which 450 (62.5%) were males and 270 (37.5%) females. The mean age of the subjects was 33.504±4.00 years, mean duration of cirrhosis was 9.086±2.54 months and mean weight was 72.44±13.78Kg. Ulcer bleed was seen in 6.9% patients and esophageal strictures was seen in 2.5% patients. Conclusion: Complications of esophageal variceal band ligation are not that common and amongst them ulcer bleed is the salient one. Both ulcer bleed and esophageal stricture are significantly associated with varices more than 2.

Diagnostic Accuracy of Non-invasive Laboratory-Based Fibrosis Scores in Predicting the Presence of Esophageal Varices in Liver Cirrhosis

Introduction: Non-invasive assessment of esophageal varices (EVs) may reduce endoscopic burden and cost. This study aimed to evaluate the diagnostic accuracy of non-invasive fibrosis scores (AAR, APRI, FIB-4, King and Lok scores) for the prediction of varices in liver cirrhosis.&#x0D; Methods: This prospective study included 100 liver cirrhosis patients who underwent screening endoscopy for EVs. AAR, APRI, FIB-4, King and Lok scores were assessed. The receiver operating characteristic curves (ROC) were plotted to measure and compare the performance of each score for predicting EVs and to obtain the corresponding optimal prediction value.&#x0D; Results: Of the 100 patients, 70 were males and 30 were females with a mean age of 54.05±11.58 years. Esophageal varices were found in 77 patients out of which 58.44% were high-risk varices. Platelet count and non-invasive fibrosis scores APRI, FIB-4, Lok and King were able to discriminate patients with and without varices. Using area under receiver operating characteristic curve (AUROC), these scores were found to have low to moderate diagnostic accuracy for the presence of EVs and high-risk EVs, where the APRI score had the highest AUROC (0.77 and 0.70) respectively. At a cutoff value &gt; 1.4, APRI score had 90.9% sensitivity, 60.9% specificity and 84 % diagnostic accuracy in predicting the presence of varices, while it had 84.4% sensitivity, 45.5% specificity and 63% diagnostic accuracy in predicting the presence of highrisk varices, at a cutoff value &gt; 2.02.&#x0D; Conclusion: APRI, AAR, FIB-4, King, and Lok scores had low to moderate diagnostic accuracy in predicting the presence of varices in liver cirrhosis. The APRI score can help select a patient for the endoscopy but cannot replace endoscopy for esophageal varices screening.

Accuracy of Fibrosis-4 Index in Identification of Patients with Cirrhosis Who Could Potentially Avoid Variceal Screening Endoscopy.

A potential restriction of the Baveno VI consensus, which helps to avoid unnecessary endoscopies, is the limited availability of FibroScan. We aimed to identify serum fibrosis indices that might aid in ruling out the presence of high-risk varices in cirrhotic patients. This retrospective study included 541 consecutive patients with cirrhosis who underwent endoscopy and had data available for nine serum fibrosis indices, including platelet count, hyaluronic acid, 7S fragment of type 4 collagen, procollagen type III N-terminal peptide, tissue inhibitor of metalloproteinases 1, Mac-2 binding protein glycosylation isomer, fibrosis index based on four factors (FIB-4), aspartate transaminase/platelet ratio index and enhanced liver fibrosis score. Optimal index cutoffs for predicting high-risk varices were calculated in an estimation cohort (n = 127) and evaluated in a validation cohort (n = 351). The diagnostic performance of the indices was assessed by receiver operating characteristic curve analysis. In the estimation cohort, a FIB-4 cutoff of 2.78 provided the greatest diagnostic accuracy in predicting both all-grade and high-risk varices. FIB-4 had a negative predictive value of 1.00 for high-risk varices in both cohorts, and 21.3% (27/127) and 14.8% (52/351) of the estimation and validation cohorts, respectively, avoided esophagogastroduodenoscopy; no high-risk varices were missed in either cohort. FIB-4 correctly identifies the absence of high-risk varices in patients with cirrhosis. Therefore, those with a FIB-4 of ≥2.78 should undergo esophagogastroduodenoscopy, and FIB-4 determination should be recommended every 6–12 months concurrently with the other blood tests until the index value reaches 2.78 in those with a FIB-4 of <2.78.

S1157 Avoiding Invasive Variceal Screening: Does the Baveno VI Consensus Criteria Apply in a Local Cohort?

INTRODUCTION: Variceal bleeding is a complication of portal hypertension and its practice to request variceal screening for patients with a new diagnosis of cirrhosis. OGD is generally considered safe but not without complications.The Baveno VI consensus states that in patients with a Fibroscan(transient elastrography, TE) reading of < 20kPA and a platelet count of >150, screening endoscopy can be safely deferred. We aim to demonstrate that these can be validated in our local trust population. METHODS: We extracted data from the trust’s fibroscan clinic logbook, and electronic database. We compared TE results, platelet count and endoscopic findings with the intention of validating the Baveno VI criteria in this group. RESULTS: Two hundred fourteen patients had a fibroscan reading in 2018. There was a female predominance (n = 121). The modal indication was for assessment of non-alcoholic fatty liver (41.6%), followed by alcohol related pathology (20.4%). Other indications included autoimmune, metabolic, viral or idiopathic liver disease. Of all patients who underwent fibroscan, 111 had endoscopy results available. Within this group, 33 patients were at-risk on the basis of having a TE > 20 kPa and/or platelet count < 150. 78 patients were deemed not to be at risk according to the Baveno VI criteria. In the at-risk group, 10 patients were found to have oesophageal varices (OV) at endoscopy. Two patients from the at-risk group were found to have gastric varices and two patients were found to have portal hypertensive gastropathy (PHG). In the patients who were deemed not to be in need of variceal screening, one had grade I OV, 1 gastric varices and 2 had PHG. Six patients were identified in need of variceal screening but had not undergone upper GI endoscopy. Two patients in the cohort underwent OGD for a suspected acute upper GI bleed—one had PHG and another grade II varices with red signs which were banded. CONCLUSION: These findings demonstrate that the Baveno VI criteria have a negative predictive value of 98.7% (95% CI) in the assessment of OV. For gastric varices, the criteria have a negative predictive value of 79.2% (95% CI). This retrospective analysis of a local cohort demonstrate that the TE and platelet count can be used as a non-invasive method to stratify patients with liver disease according to their risk of having oesophageal varices. We would advocate for greater use of TE in patients with liver disease in the hope of minimising the costs and risks associated with unnecessary endoscopic screening.

WHEN CATHETERIZATIONS GO "DOWNHILL"

SESSION TITLE: Medical Student/Resident Signs and Symptoms of Chest Disease Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Downhill esophageal varices (DEV) are a rare cause of upper gastrointestinal bleeding secondary to superior vena cava (SVC) obstruction. While uphill varices from portal hypertension are commonly seen in practice, there are no current guidelines on the screening and management of downhill varices due to their unique pathophysiology. Here we present an underreported case of DEV from SVC obstruction after long-standing catheter placement. CASE PRESENTATION: A 65-year-old male patient presented to clinic with dysphagia. On upper endoscopy, an isolated upper esophageal varix was noted without varices in the lower esophagus. Chest CT revealed SVC stenosis close to the RA junction. Systemic collaterals were noted via branching to the intercostal and inferior phrenic vein. No significant stenosis of the SVC was present post-ballooning. Patient history indicated a long-term right-sided Port-A-Cath that had been removed a couple months prior due to a thrombus. DISCUSSION: DEV are found in the upper 2/3 of the esophagus as a result of SVC obstruction, from causes like thrombus, thyroid tumors, etc. Central venous catheters, typically in patients with end-stage renal disease, are an accepted cause of DEV from SVC obstruction. Mechanistically, SVC obstruction follows turbulent blood flow, endothelial injury, and thrombosis. This produces varices via dilation of venous drainage, specifically the azygous and hemiazygous systems. Obstruction precedes retrograde blood flow through collateral channels to the IVC. Varices form in the upper third of the esophagus if the stenosis is above the azygous vein and form in the entire esophagus if the stenosis is below or involves the azygous vein. Treatment focuses on the underlying cause of the SVC narrowing. Depending on the specific anatomy of the DEV, options include stenting, thrombolysis, angioplasty, tumor resection, variceal band ligation, or open surgery. In our case, a diagnosis of DEV rather than uphill varices was supported by the isolated upper varices without any lower varix presentation found on endoscopy. Further chest CT displayed SVC stenosis and systemic collaterals. Diagnosis of DEV was confirmed given the patient’s recent history of long-term right sided Port-A-Cath use. CONCLUSIONS: In patients with long-standing catheterizations, clinicians should be cognizant of potential DEV given risk of rupture and progression to hematemesis or hemoptysis. Due to the commonality of dilated collaterals on imaging, prior patient history indicative of SVC obstruction is critical in supporting diagnosis of DEV. The diverse pathophysiology & anatomy involved necessitates DEV treatment focus on the underlying source of the SVC obstruction. Reference #1: Chakinala, R. C., … Aronow, W. S. (2018). Downhill esophageal varices: a therapeutic dilemma. Annals of translational medicine, 6(23), 463. doi:10.21037/atm.2018.11.13 Reference #2: Berkowitz, J. C., Bhusal, S., Desai, D., Cerulli, M. A., & Inamdar, S. (2016). Downhill Esophageal Varices Associated With Central Venous Catheter-Related Thrombosis Managed With Endoscopic and Surgical Therapy. ACG case reports journal, 3(4), e102. doi:10.14309/crj.2016.75 Reference #3: Harwani, Y. P., Kumar, A., Chaudhary, A., Kumar, M., Choudeswari, P. R., Kankanala, V. V., … Tripathi, A. (2014). Combined uphill and downhill varices as a consequence of rheumatic heart disease: a unique presentation. Journal of clinical and experimental hepatology, 4(1), 63–65. doi:10.1016/j.jceh.2013.10.003 DISCLOSURES: No relevant relationships by jayanth keshavamurthy, source=Web Response No relevant relationships by Rohit Munagala, source=Web Response No relevant relationships by Moonkyung Schubert, source=Web Response

S0442 Natural History of Barrett’s Esophagus in Cirrhotic Patients Undergoing Liver Transplantation

INTRODUCTION: Barrett’s esophagus (BE) is incidentally diagnosed in patients with liver cirrhosis who undergo upper endoscopy for esophageal variceal screening and surveillance. The management of BE in this context is poorly described and higher rates of progression have been reported. A prevailing concern is the use of immunosuppression in cirrhotic patients with BE undergoing transplantation, with reported accelerated progression to esophageal adenocarcinoma (EAC). We aimed to assess the natural history of BE in patients undergoing liver transplantation (LT) to better understand whether immunosuppression affects progression in BE. METHODS: Patients were identified from an academic medical center according to ICD-10 codes. Only patients with confirmed liver cirrhosis and both endoscopic and histologic confirmation of BE were included in the study. Review of the EMR was conducted to abstract clinical variables. Prevalent dysplasia was defined as dysplasia diagnosed at index endoscopy and incident dysplasia as dysplasia diagnosed during endoscopic surveillance. RESULTS: A total of 40 patients met inclusion criteria. Of these, BE was diagnosed pre-LT in 27 (67.5%) and post-LT in 13 (32.5%). Median follow up after LT and BE diagnosis was 8.2 and 7.9 years, respectively. Post-LT BE was diagnosed at a median of 7 years after LT. Clinical characteristics are presented in Table 1. BE-related and demographic characteristics did not significantly differ between those diagnosed with BE before or after LT. Dysplasia was found in 5 patients (12.5%), of which it was prevalent in 3 and incident in 2. Progression to high-grade dysplasia (HGD) or EAC only occurred in 3 patients. A fourth patient experienced progression from non-dysplastic BE to low-grade dysplasia. Both post-LT progressors were found to have intramucosal EAC and underwent endoscopic resection. All other patients with dysplasia were treated endoscopically and achieved complete eradication of dysplasia and intestinal metaplasia. CONCLUSION: BE-related neoplasia occurs in cirrhotic patients with similar frequency to historical data for non-cirrhotics. In this cohort of patients undergoing LT with long-term follow up, the risk of progression to HGD/EAC does not appear to be increased by iatrogenic immunosuppression. No cases of invasive or metastatic EAC were encountered and all patients were safely and effectively managed with endoscopic therapy. These data support the application of current BE management guidelines to cirrhotic patients undergoing LT.Table 1.: Clinical characteristics in the study population

Current situation of screening, prevention and treatment of bleeding esophageal varices in cirrhotic portal hypertension in Tibet region: a multicenter study

Objective: To investigate and analyze the current situation, screening, clinical characteristics, prevention and treatment of bleeding esophageal varices in cirrhotic patients with portal hypertension in Tibet region. Methods: Clinical data of cirrhotic patients with portal hypertension through March 2017 to February 2020 from Tibet region were collected and analyzed retrospectively. Results: 511 cases with liver cirrhosis were included in the study, of which 185 cases (36.20%) had compensated cirrhosis and 326 cases (63.80%) had decompensated cirrhosis. Further analysis of the etiological data of liver cirrhosis showed that 306 cases (59.88%) were of chronic hepatitis B, 113 cases (22.11%) of alcoholic liver disease, and 68 cases (13.31%) of chronic hepatitis B combined with alcoholic liver disease. Among patients with compensated liver cirrhosis, 48 cases (25.95%) underwent endoscopic examination of which 33 diagnosed as high-risk variceal bleeding. However, none of these 33 cases had received non-selective β-blocker therapy, and only four patients had received endoscopic variceal banding therapy. Among patients with decompensated liver cirrhosis, 83 cases (25.46%) had a history of upper gastrointestinal bleeding, 297 cases (91.10%) had ascites, 23 cases (7.05%) had hepatic encephalopathy, and 3 cases (0.92%) had hepatorenal syndrome. Among the patients with a history of upper gastrointestinal bleeding, 42 cases (50.60%) had received secondary preventive treatment for bleeding esophageal varices, including 39 cases of endoscopic treatment, 1 case of endoscopic combined drug treatment, 3 cases of interventional treatment, and 2 cases of surgical treatment. Conclusion: Chronic hepatitis B and alcoholic liver diseases are the main causes of liver cirrhosis in Tibet region. Moreover, this region lacks screening, prevention and treatment for bleeding esophageal varices in cirrhotic patients with portal hypertension. Therefore, it is necessary to increase the screening of high-risk groups to prevent and improve the first-time bleeding, and promote multidisciplinary team to prevent and treat re-bleeding.

Identifying Quality Gaps in Preventive Care for Outpatients With Cirrhosis Within a Large, Academic Health Care System.

We sought to identify specific gaps in preventive care provided to outpatients with cirrhosis and to determine factors associated with high quality of care (QOC), to guide quality improvement efforts. Outpatients with cirrhosis who received care at a large, academic tertiary health care system in the United States were included. Twelve quality indicators (QIs), including preventive care processes for ascites, esophageal varices, hepatic encephalopathy, hepatocellular carcinoma (HCC), and general cirrhosis care, were measured. QI pass rates were calculated as the proportion of patients eligible for a QI who received that QI during the study period. We performed logistic regression to determine predictors of high QOC (≥ 75% of eligible QIs) and receipt of HCC surveillance. Of the 439 patients, the median age was 63years, 59% were male, and 19% were Hispanic. The median Model for End-Stage Liver Disease-Sodium score was 11, 64% were compensated, and 32% had hepatitis C virus. QI pass rates varied by individual QIs, but were overall low. For example, 24% received appropriate HCC surveillance, 32% received an index endoscopy for varices screening, and 21% received secondary prophylaxis for spontaneous bacterial peritonitis. In multivariable analyses, Asian race (odds ratio [OR]: 3.7, 95% confidence interval [CI]: 1.3-10.2) was associated with higher QOC, and both Asian race (OR: 3.3, 95% CI: 1.2-9.0) and decompensated status (OR: 2.1, 95% CI: 1.1-4.2) were associated with receipt of HCC surveillance. A greater number of specialty care visits was not associated with higher QOC. Conclusion: Receipt of outpatient preventive cirrhosis QIs was variable and overall low in a diverse cohort of patients with cirrhosis. Variation in care by race/ethnicity and illness trajectory should prompt further inquiry into identifying modifiable factors to standardize care delivery and to improve QOC.

AS107 - Assessment of Baveno VI and expanded Baveno VI criteria for screening and follow-up of all-size esophageal varices in patients with compensated viral cirrhosis (ANRS/CO12 CirVir cohort)

AS107 - Assessment of Baveno VI and expanded Baveno VI criteria for screening and follow-up of all-size esophageal varices in patients with compensated viral cirrhosis (ANRS/CO12 CirVir cohort)

The variscreen algorithm using successively platelets, liver stiffness and INR improves and secures the screening of esophageal varices needing treatment

The variscreen algorithm using successively platelets, liver stiffness and INR improves and secures the screening of esophageal varices needing treatment

A comparison of non-invasive methods for the screening of gastroesophageal varices in patients with compensated cirrhosis

A comparison of non-invasive methods for the screening of gastroesophageal varices in patients with compensated cirrhosis

LBP23 - CHESS criteria for the screening of varices in patients with compensated advanced chronic liver disease: a multicenter study

LBP23 - CHESS criteria for the screening of varices in patients with compensated advanced chronic liver disease: a multicenter study

Screening endoscopy in patients with cirrhosis: screening of varices and gastrointestinal neoplasia.

Screening endoscopy in patients with cirrhosis: screening of varices and gastrointestinal neoplasia.

Including Ratio of Platelets to Liver Stiffness Improves Accuracy of Screening for Esophageal Varices That Require Treatment

Based on platelets and liver stiffness measurements, the Baveno VI criteria (B6C), the expanded B6C (EB6C), and the ANTICIPATE score can be used to rule out varices needing treatment (VNT) in patients with compensated chronic liver disease. We aimed to improve these tests by including data on the ratio of platelets to liver stiffness. In a retrospective analysis of data from 10 study populations, collected from 2004 through 2018, we randomly assigned data from 2368 patients with chronic liver disease of different etiologies to a derivation population (n= 1579; 15.1% with VNT, 50.2% with viral hepatitis, 28.9% with nonalcoholic fatty liver disease, 20.8% with alcohol-associated liver disease, with model for end-stage liver disease scores of 9.5 ± 3.0, and 93.0% with liver stiffness measurements ≥10 kPa) or a validation population (n= 789). Test results were compared with results from a sequential algorithm (VariScreen). VariScreen incorporated data on platelets or liver stiffness measurements and then the ratio of platelets to liver stiffness measurement, adjusted for etiology, patient sex, and international normalized ratio. In the derivation population, endoscopies were spared for 23.9% of patients using the B6C (VNT missed in 2.9%), 24.3% of patients using the ANTICIPATE score (VNT missed in 4.6%), 34.5% of patients using VariScreen (VNT missed in 2.9%), and 41.9% of patients using the EB6C (VNT missed in 10.9%). Differences in spared endoscopy rates were significant (P ≤ .001), except for B6C vs ANTICIPATE and in missed VNT only for EB6C vs the others (P ≤ .009). VariScreen was the only safe test regardless of sex or etiology (missed VNT ≤5%). Moreover, VariScreen secured screening without missed VNT in patients with model for end-stage liver disease scores higher than 10. This overall strategy performed better than a selective strategy restricted to patients with compensated liver disease. Test performance and safety did not differ significantly among populations. In a retrospective study of data from 2368 patients with chronic liver disease, we found that the B6C are safe whereas the EB6C are unsafe, based on missed VNT. The VariScreen algorithm performed well in patients with chronic liver disease of any etiology or severity. It is the only test that safely rules out VNT and can be used in clinical practice.