Screening For Esophageal Varices Research Articles

M1003 Use of a Patient Registry Database to Improve Hepatocellular Carcinoma Screening, Vaccination Rates, and Esophageal Varices Screening in Patients with Cirrhosis

presents a preliminary analysis of data abstracted to date. Methods: Records from all patients discharged from 4 teaching hospitals in Cleveland from 1992-2005 were searched to identify patients with a primary diagnosis of AH (ICD-9 571.1): the Cleveland Clinic (n = 85), the Cleveland VAMC (n = 138), Metrohealth Medical Center (n = 273), and University Hospitals (n=793). Patient records were then reviewed. Results: A total of 890 charts have been reviewed to date. Demographics of the cohort are shown in Table 1. The number of those with an elevated Maddrey discriminant score (MDF ≥ 32) or MELD score > 18 and their treatments are listed in Table 2. Discussion: Multiple clinical trials have suggested a decrease in mortality in patients with severe AH treated with prednisone. However, physicians remain reluctant to prescribe them: only 25% of patients with an MDF ≥ 32 (the usual treatment threshold) were given steroids. Px was used in 28.7% of the cohort. Almost 40% went untreated, despite severe disease. Further research is needed regarding the determinants of physician prescribing, and to define the optimal medical treatments in AH. Table 1

Sensitivity of PillCam ESO for Detection of Esophageal Varices; A Meta Analysis

Introduction: Current guidelines recommend screening for esophageal varices at diagnosis of cirrhosis and depending on the findings, treatment and subsequent surveillance is indicated. Esophago-gastro-duodenoscopy (EGD) is the current gold standard for evaluation of esophageal varices. Recently numerous studies have evaluated the role of esophageal capsule endoscopy (ECE) as an alternative to EGD for screening of varices. Aim: To perform a Meta analysis to evaluate the overall pooled sensitivity and specificity of ECE in detecting esophageal varices when compared to traditional EGD.

Non-invasive assessment of liver fibrosis in chronic liver diseases: implementation in clinical practice and decisional algorithms.

Chronic hepatitis B and C together with alcoholic and non-alcoholic fatty liver diseases represent the major causes of progressive liver disease that can eventually evolve into cirrhosis and its end-stage complications, including decompensation, bleeding and liver cancer. Formation and accumulation of fibrosis in the liver is the common pathway that leads to an evolutive liver disease. Precise definition of liver fibrosis stage is essential for management of the patient in clinical practice since the presence of bridging fibrosis represents a strong indication for antiviral therapy for chronic viral hepatitis, while cirrhosis requires a specific follow-up including screening for esophageal varices and hepatocellular carcinoma. Liver biopsy has always represented the standard of reference for assessment of hepatic fibrosis but it has some limitations being invasive, costly and prone to sampling errors. Recently, blood markers and instrumental methods have been proposed for the non-invasive assessment of liver fibrosis. However, there are still some doubts as to their implementation in clinical practice and a real consensus on how and when to use them is not still available. This is due to an unsatisfactory accuracy for some of them, and to an incomplete validation for others. Some studies suggest that performance of non-invasive methods for liver fibrosis assessment may increase when they are combined. Combination algorithms of non-invasive methods for assessing liver fibrosis may represent a rational and reliable approach to implement non-invasive assessment of liver fibrosis in clinical practice and to reduce rather than abolish liver biopsies.

Capsule endoscopy: Technique and indications

Since it was introduced in 2000, capsule endoscopy has become the gold standard for endoscopic examination of the small bowel in several clinical situations such as obscure gastrointestinal bleeding, suspicion of Crohn's disease, and surveillance of polyposis syndromes. In this technique a miniaturised endoscope, embedded in a swallowable capsule, is propelled through the gut by peristalsis and reaches the right colon in 5-8h. Images captured by the capsule are recorded on a hard drive in a belt worn by the patient. In addition to the extensive literature currently available on small bowel CE, new capsule devices are currently under evaluation for the examination of the colon with the purpose of screening for colorectal cancer, and of the oesophagus for screening for oesophageal varices and Barrett's oesophagus. These latter indications currently remain under evaluation. This review considers the technical aspects of capsule endoscopy and discusses the indications. Issues of safety and tolerance are also discussed.

External Validation of the Platelet Count/Spleen Diameter Ratio for the Diagnosis of Esophageal Varices in Hepatitis C Virus-Related Cirrhosis

Screening for esophageal varices (EV) is an important part of the diagnostic workup of cirrhotic patients. To independently validate the use of the platelet count/spleen diameter ratio for the non-invasive diagnosis of EV in patients with HCV-related cirrhosis and in a sub-group of patients with compensated disease. A platelet count/spleen diameter ratio cut-off value of 909 was evaluated for the diagnosis of EV in the whole population (n = 311) and in patients with compensated disease alone (n = 114). Compensated disease was defined as the absence of ascites as detected by abdominal ultrasound in patients who are not on diuretics and absence of hepatic encephalopathy. In the whole cohort (EV prevalence 49.5%), the platelet count/spleen diameter ratio 909 cut-off value had 96.9% positive predictive value, 100% negative predictive value, and 98.4% efficiency for EV diagnosis. In compensated cirrhotics (EV prevalence 26.3%), the platelet count/spleen diameter ratio 909 cut-off showed an excellent negative predictive value (100%) and a positive predictive value of 93.8%. for the diagnosis of EV. In patients with HCV-related cirrhosis, the platelet count/spleen diameter may be proposed as a non-invasive tool for EV diagnosis, especially in financially deprived developing countries.

Screening for esophageal varices: Endoscopy, other tools, or endoscopy and other tools?

Screening for esophageal varices: Endoscopy, other tools, or endoscopy and other tools?

Screening for Esophageal Varices in End Stage Liver Disease: Utility of Esophageal Capsule Endoscopy

Background: Esophageal varices are a major complication of liver cirrhosis. 50% of patients with esophageal varices will eventually bleed and this is associated with 20% mortality at about 6 weeks. Current AASLD guidelines recommend screening for esophageal varices in patients with cirrhosis. This should be done yearly and every 2-3 years in patients with and without varices respectively. Esophagogastroduodenoscopy (EGD) has been the standard tool used for this evaluation. We describe our experience with the esophageal capsule endoscope (ECE). Methods: A prospective observational study was conducted on 217 consecutive patients in an outpatient hepatology/liver transplantation setting. The Pillcam Eso esophageal capsule was used on all the patients. This device acquires 14 images/second (7 frames/second/end). All patients fasted prior to the procedure and data was collected on all 217 patients. The video capsule images were evaluated by a trained investigator. Results: The average age was 57.1 and 50.2 % of the patients were male. Esophageal varices were seen in 38% (83/217). Other findings include gastric varices 1.3% (3/217), portal hypertensive gastropathy 11% (24/217). Barrett's esophagus and esophageal erosion was seen 2 and 1 patient respectively. The mean esophageal transit time was 3.8 ± 3.7 minutes. Stigmata of recent bleed were seen in 8.8% (19/217). Esophageal ring was seen in 3 patients and in 10 patients the capsule did not reach the stomach during the 20 minutes of study. Gastric visualization was obscured in 5 patients with retained food in the stomach. Conclusion: Our study shows that ECE is a valuable screening tool for esophageal varices in cirrhotic patients. Other findings in this study suggest it may also be useful for diagnosis of other co-existent esophageal and gastric pathologies. Failure rate was very low as the capsule failed to reach the stomach within the study period in only 10 patients. Studies have estimated the sensitivity and specificity of the esophageal capsule endoscopy to be 92-97% and 95-100% respectively. The overall concordance between ECE and EGD for diagnosis esophageal varices has been estimated to be 96.9%. Relative ease of swallow and convenience may make this a more attractive alternative for patients In future.

472 Randomized Controlled Trial of Esophageal Capsule Endoscopy Versus Standard Endoscopy for Screening in Patients Pre-Liver Transplantation. Assessment of Inter-Observer Variability and Patient Preferences

Introduction: Patients awaiting liver transplantation (OLT) are recommended to undergo endoscopic screening (EGD) for the presence of varices. The esophageal capsule (PillCam ESO capsule, ECE) has shown accuracy for detection of varices (Endoscopy 2006). The aim of this randomized controlled trial was to determine the utility of ECE in a pre-transplant population. Secondary aims were to define inter-observer variability between ECE readers, patient preferences, and the prevalence of extraesophageal findings. Methods: We invited patients scheduled for EGD pre-OLT. Patients received ECE prior to EGD. An expert hepatologist performed the EGDs. Two blinded independent faculty experts interpreted ECE images. Varices were graded as F1=small straight varices; F2= enlarged tortuous varices < 1/3 of the lumen; and F3= large coil-shaped varices ≥ 1/3 lumen. Portal HTN gastropathy was rated as mild=no erosions; moderate=erosions/heme spots; and severe=active bleeding. We used the kappa statistic to determine inter-observer variability. Results: We invited 39 patients to participate. 24 (62%) patients (mean age 52±8.4 (range 36-70) years, 14 (58%) men, 17 (71%) Child's B, and 19 (79%) HCV) were enrolled. Esophageal varices were detected in 12 (50%) by EGD and in 11 (46%) by ECE. The varices were significant (grade F2-F3) in 8 (33%) by both ECE and EGD. ECE visualization was deemed adequate in 11/ 24 (46%). The mean esophageal transit time was 260±336 seconds (range 2-840 seconds). All patients had portal HTN gastropathy. Portal HTN jejunopathy was present in the 9 patients with transit to the duodenum, with a mean GE time of 9.7±5.5 (range 2.4-18.3) minutes. 61% of patients preferred ECE, 9% EGD, and 33% had no preference. Patients reported less discomfort (p=0.03), greater satisfaction (p=0.03), and less fatigue (p<0.001)with ECE. Kappa coefficients for inter-observer variability are shown in the table. For the presence of varices, the sensitivity was 75% with a specificity of 92% for reader 1 and 75% and 83% for reader 2. There was perfect (100%) agreement between ECE readers and EGD findings for combined grades F0/F1 and 88% agreement for combined grades F2/ F3. Conclusions: In patients pre-OLT undergoing screening for esophageal varices, ECE appears to be sensitive, specific, and preferred by patients. There was good agreement between ECE experts. Visualization of portal HTN enteropathy occurred in approximately 1/3 of the patients. Inter-Observer Variability

M1109 The Clinical Impact of Esophageal Capsule Endoscopy for Screening of Esophageal Varices in Cirrhotic Patients

M1109 The Clinical Impact of Esophageal Capsule Endoscopy for Screening of Esophageal Varices in Cirrhotic Patients

The budget impact of endoscopic screening for esophageal varices in cirrhosis

The cost-effectiveness of screening for esophageal varices in cirrhosis remains uncertain. Previous analyses found that screening with upper endoscopy (EGD) may not be cost effective versus empiric beta-blocker (BB) therapy. However, these models were conducted before advances in variceal screening, including capsule endoscopy (CE), and they did not measure the budget impact (vs cost-effectiveness) of variceal screening. To compare the managed care budget impact of variceal screening strategies. Budget impact model. Hypothetical managed care organization with 1 million covered lives. Patients with compensated cirrhosis. Compared 5 strategies: (1) empiric BB, (2) screening EGD followed by BB if varices present (EGD --> BB), (3) EGD followed by endoscopic band ligation if varices present (EGD --> EBL), (4) CE followed by BB if varices present (CE --> BB), and (5) CE followed by EBL if varices present (CE --> EBL). Per-member per-month cost. BB was the least expensive, and CE --> EBL was the most expensive. Substituting CE --> BB in lieu of BB cost each member an additional $0.20 per month to subsidize. Compared with CE --> BB, both EGD-based strategies were more expensive. However, CE was not viable in managed care organizations capable of reducing the cost of endoscopy below $410, unless the cost of CE was reduced in lockstep. Data on CE remain limited. Screening for varices may have an acceptable budget impact but is highly sensitive to local costs of EGD and CE. In managed care organizations willing to subsidize EBL for variceal prophylaxis, it is inefficient to screen with CE compared with EGD.

Esophageal capsule endoscopy in patients refusing conventional endoscopy for the study of suspected esophageal pathology

Esophageal capsule endoscopy is a well tolerated procedure that does not require sedation and has proved its value for the study of the esophagus. The aim of our study was to assess the feasibility, accuracy, safety and acceptability of esophageal capsule endoscopy for the study of gastroesophageal reflux disease and esophageal varices in patients who refused conventional upper gastrointestinal endoscopy. Thirty consecutive examinations performed in 28 patients (15 men/13 women; mean age: 58.5+/-12.4 years; range: 23-87 years) were reviewed. Twenty-five examinations were performed in 23 patients presenting with chronic gastroesophageal reflux disease symptoms and the remaining five were carried out in patients with cirrhosis for screening of esophageal varices. The procedures were done with the new PillCam ESO that harbors two viewing cupules and takes a total of 14 frames/s. Technical data (total recording time, esophageal transit time and Z-line visualization), clinical findings (Savary-Miller grade; presence and characteristics of esophageal varices or portal hypertension gastropathy), and patient's opinion (quality and comfort questionnaire) were analyzed. All the patients ingested and excreted the capsule without complications. Two examinations in the gastroesophageal reflux disease group were repeated; one was issued as a follow-up and the other because no images were recorded in the first capsule endoscopy. From the former, only the satisfaction questionnaire was analyzed. Mean total recording time and esophageal transit time were 1224 and 243.79 s, respectively (range: 2-1192 s). Complete study of the Z-line was possible in 23 examinations (23/29; 79.3%). Esophageal erosions were seen in 58.33% (14/24) of the examinations carried out in patients with gastroesophageal reflux disease. Nine out of 14 patients (64.29%) presented with grade I esophagitis and the other five (35.71%) with grade II esophagitis. Among the five patients with cirrhosis, small varices were visualized in one (1/5; 20%), while large varices with red spots were evidenced in the remaining three (3/5; 60%). All four patients showing esophageal varices were found to have portal hypertension gastropathy. In most examinations, patients found the capsule easy to swallow (28/30; 93.33%), asymptomatic (29/30; 96.66%), evaluated the procedure as comfortable (29/30; 96.66%), and would repeat it if necessary (30/30; 100%). Esophageal capsule endoscopy is an adequate alternative diagnostic method for the study of gastroesophageal reflux disease and for the screening of esophageal varices in patients refusing to undergo conventional upper gastrointestinal endoscopy.

Liver stiffness measurement selects patients with cirrhosis at risk of bearing large oesophageal varices

Periodic endoscopic screening for oesophageal varices is recommended in patients with cirrhosis, but might be limited to a subgroup of patients if a simple non-invasive test was available to select those at risk of bleeding. We studied in 165 patients with cirrhosis the relation between the presence of oesophageal varices assessed by endoscopy, and liver stiffness measurement by Fibroscan, a non-invasive parameter related to liver fibrosis. The results were compared to those of other parameters reflecting portal hypertension, splenic size, platelet count, and platelet count/spleen size ratio. Liver stiffness measurement was correlated to the grade of oesophageal varices (r = 0.6, p < 0.0001). AUROC values of liver stiffness measurement were 0.84 (95% CI: 0.78-0.90) for the presence of oesophageal varices and 0.83 (0.76-0.89) for varices grade > or = II. Liver stiffness measurement value < 19 kPa was highly predictive of the absence of oesophageal varices grade > or = II (Se: 84%, PPV: 47%, NPV: 93%). Liver stiffness measurement allows to predict the presence of large oesophageal varices in patients with cirrhosis, and may help to select patients for endoscopic screening.

Accuracy and Degree of Interobserver Agreement of Small-Caliber Endoscope in Screening for Esophageal Varices

Accuracy and Degree of Interobserver Agreement of Small-Caliber Endoscope in Screening for Esophageal Varices

The Budget Impact of Screening for Esophageal Varices (EV) with Capsule Endoscopy

Background: The cost-effectiveness of screening for EV in cirrhosis remains uncertain. Previous data indicate that screening with upper endoscopy (EGD) may not be cost-effective vs empiric beta-blocker (BB) therapy (Spiegel et al Hepatology 2004). However, recent data indicate that capsule endoscopy (CAP) may be an accurate method to screen for EV, and it may therefore compete favorably with EGD and BB. We performed an economic analysis to compare the potential managed care budget impact of CAP in EV screening. Methods: We developed a comprehensive (77 variable) budget impact model to calculate the per-member per-month (PMPM) cost of 5 strategies for primary EV bleed prophylaxis in managed care patients with compensated cirrhosis: (1) empiric BB, (2) screening EGD followed by BB if EV present (EGD→BB), (3) EGD followed by endoscopic band ligation if EV present (EGD→EBL), (4) CAP followed by BB if EV present (CAP→BB), and (5) CAP followed by EBL if EV present (CAP→EBL). We derived probability estimates with a systematic review and cost estimates from Medicare, and varied each in sensitivity analysis. Key estimates: underlying EV in cirrhosis = 35%; Sens/Spec of EGD = 100%/98% and CAP = 100%/89%; significant complication of EGD + sedation = 0.1%; GI consult fee = $160; EGD procedure fee = $231; EGD facility fee = $433; CAP = $750. PMPM calculations were based on a managed care population of 1 million covered lives with a 1% prevalence of cirrhosis, and were amortized over a 10-year horizon. Results: BB was least expensive and CAP→EBL most expensive (Table 1). Substituting CAP→BB in lieu of BB cost each member $0.38 per month to subsidize. Compared to CAP→BB, both EGD-based strategies were more expensive. The PMPM cost of CAP→BB depended on the prevalence of cirrhosis in the managed care population (e.g. $0.19 PMPM if 0.5%, $1.91 if 5%), and the cost of CAP (e.g. $0.25 PMPM if $400, $0.50 if $1000). Conclusions: Screening for EV with CAP may have an acceptable budget impact vs empiric BB therapy when CAP is used to direct medical therapy, and may be the least expensive of the endoscopic screening strategies. However, in managed care organizations willing to subsidize EBL for primary prophylaxis, it is inefficient to screen for EV with CAP compared to EGD. Table 1Projected budget impact in managed care organization of 1 mil. covered lives and 1% cirrhosis prevalence Strategy 10-Year Total Cost per Cirrhotic PMPM vs. BB BB \$38,313 -- CAP→BB \$42,892 \$0.38 EGD→BB \$43,825 \$0.46 EGD→EBL \$44,802 \$0.54 CAP→EBL \$46,114 \$0.65 Open table in a new tab

Management of digestive bleeding related to portal hypertension in cirrhotic patients: A French multicenter cross-sectional practice survey

To investigate the conformity of management practices of gastrointestinal hemorrhage in cirrhotic patients with relevant guidelines. A questionnaire on the management of digestive bleeding was completed for all consecutive cirrhotic patients admitted to 31 French hospitals. One hundred and twenty-six bleeding events were recorded. It was the first bleeding episode in 79 patients (63%), of whom 40 (51%) had a prior diagnosis of cirrhosis and 25 (32%) had previously undergone an endoscopy. The bleeding episode was a recurrence in 46 patients (37%). The median time between onset and admission was 4 h, but exceeded 12 h in 42% of cases. There was an agreement between centers for early vasoactive drug administration (87% of cases), association with ligation (42%) more often than sclerosis (21%) at initial endoscopy, and antibiotic prophylaxis (64%). By contrast, prescription of beta-blockade alone or in combination (0 to 100%, P = 0.003) for secondary prophylaxis and lactulose (26% to 86%, P = 0.04), differed among centers. In French hospitals, management of bleeding related to portal hypertension in cirrhotic patients is generally in keeping with the consensus. Broad variability still remains concerning beta-blockade use for secondary prophylaxis. Screening for esophageal varices, the use of antibiotic prophylaxis and patients information need to be improved.

Noninvasive diagnosis of cirrhosis in chronic hepatitis C based on standard laboratory tests

Noninvasive assessment of hepatic fibrosis is gaining popularity.1, 2 Several noninvasive tests have been proposed, including indirect markers of liver fibrosis composed of routine laboratory parameters. We read with great interest the article by Lok et al.3 on the use of the regression formula log odds = −5.56 − 0.0089 × platelet (×109/L) + 1.26 × AST/ALT ratio + 5.27 × INR (“model 3”) for prediction or exclusion of cirrhosis (Ishak fibrosis score F5–F6) in patients with chronic hepatitis C (CHC). Although this model was developed in a cohort of nonresponders to previous antiviral treatment that comprised patients with more advanced stages of fibrosis (Ishak fibrosis score F3–F6), it was also applied to 265 treatment-naïve CHC patients previously studied,4 confirming its diagnostic accuracy across a broad range of fibrosis (Ishak fibrosis score F0–F6). We recently evaluated several noninvasive tests based on standard laboratory parameters, including the aspartate aminotransferase to platelet ratio index (APRI) and platelet count per se, in a cohort of 194 treatment-naïve CHC patients.5 For external validation, we applied model 3 in our CHC study cohort and compared its diagnostic accuracy for prediction/exclusion of cirrhosis (Ishak fibrosis score F5–F6) with that of platelet count and APRI. Ishak fibrosis score correlated moderately with platelet count, APRI, and model 3 (Spearman's R −0.50, 0.62, and 0.53, respectively). Evaluation of the overall diagnostic accuracies for the prediction of cirrhosis by receiver-operating characteristic analysis revealed comparable results: areas under the receiver-operating characteristic curves for platelet count, APRI, and model 3 were 0.89, 0.90, and 0.90, respectively. Our findings on the diagnostic accuracy of model 3 for prediction/exclusion of cirrhosis are very similar to the results reported by Lok et al. (Table 1). Each of the noninvasive tests evaluated was more suited for exclusion of cirrhosis than for its prediction. Using the reported cutoff values of ≥150 × 109/L (platelet count), <1.0 (APRI), and <0.2 (model 3), each of the tests reliably excluded cirrhosis with a negative predictive value of 95% or more in 78%, 59%, and 49% of patients, respectively. Conversely, prediction of cirrhosis using a cutoff value of <150 × 109/L (platelet count), ≥2.0 (APRI), and ≥0.5 (model 3) was much less reliable (positive predictive value 56%, 59%, and 58%, respectively). Our data confirm the excellent diagnostic accuracy of model 3 for the exclusion of cirrhosis; however, we would like to point out that the platelet count per se allows the exclusion of cirrhosis with a fair degree of accuracy without the need for a calculator or computer. Exclusion of cirrhosis in patients with CHC is important, because costly diagnostic workup may be avoided, including (1) endoscopic screening for esophageal varices and (2) surveillance for hepatocellular carcinoma via regular ultrasound and α-fetoprotein examinations. In treatment-naïve patients with CHC typically seen in a referral center, cirrhosis can be reliably excluded in a considerable number of patients using simple noninvasive fibrosis tests based on routine laboratory parameters. Carolin Lackner*, Gerd Struber*, Csilla Bankuti , Bernd Bauer , Rudolf E. Stauber , * Department of Pathology, Medical University Graz, Graz, Austria, Department of Internal Medicine, Medical University Graz, Graz, Austria, Department of Internal Medicine, Landeskrankenhaus Hoergas, Gratwein, Austria.

Application of the platelet count/spleen diameter ratio to rule out the presence of oesophageal varices in patients with cirrhosis: A validation study based on follow-up

Background. Screening for oesophageal varices represents an important part of the diagnostic work-up of cirrhotic patients. We have previously shown that the platelet count/spleen diameter ratio is a parameter that can rule out the presence of oesophageal varices safely and in a cost-effective fashion. Aim. To evaluate the prognostic and diagnostic accuracy of the platelet count/spleen diameter ratio for ruling out the presence of oesophageal varices in the follow-up of a cohort of cirrhotic patients without oesophageal varices at inclusion. Methods. After initial endoscopy, the 106 cirrhotic patients without oesophageal varices who participated in our previous study were followed-up with annual or biannual surveillance endoscopy. Patients were censored at the time of diagnosis of oesophageal varices or at their last visit, and at that time platelet count and spleen diameter were recorded. Sixty-eight patients made up the study cohort after excluding patients who were lost to follow-up or died before undergoing control endoscopy. Results. During the follow-up, 27 patients (40%) developed oesophageal varices. Patients with higher baseline platelet count/spleen diameter ratios ( p < 0.0001) as well as a ratio above 909 were less likely to develop oesophageal varices ( p < 0.0005). At follow-up, a platelet count/spleen diameter ratio ≤909 had 100% negative predictive value and 84% efficiency in identifying the presence of oesophageal varices. Conclusions. The use of the platelet count/spleen diameter ratio proved to be an effective means for ruling out the presence of oesophageal varices even in the longitudinal follow-up of patients.

Long-term Management of Alcoholic Liver Disease

Despite the epidemics of viral hepatitis C and nonalcoholic fatty liver disease, alcohol remains one of the major causes of liver disease. Commonly, hepatitis C and other liver diseases are found in association with alcohol consumption. This association in many instances is noted to accelerate the progression of liver disease. In many respects, the long-term management of alcoholic liver disease is not dissimilar from the long-term management of patients with cirrhosis from other etiologies. One major element is the abstinence of alcohol use. The ability to maintain sobriety has a major impact on the outcome of patients with alcoholic cirrhosis because maintaining abstinence can lead to significant regression of fibrosis and possibly early cirrhosis. Similarities in managing patients with cirrhosis due to alcohol or cirrhosis from other causes include vaccination to prevent superimposed viral hepatitis and screening for esophageal varices and hepatocellular carcinoma with subsequent appropriate therapy.

Incidental esophageal varices

Incidental esophageal varices

Prevalence and predictors of esophageal varices in patients with primary sclerosing cholangitis.

Patients with primary sclerosing cholangitis (PSC) may develop and bleed from esophageal varices. However, the exact prevalence of esophageal varices in patients with PSC remains unknown and potential predictors of esophageal varices in this population have not been identified. Our aim was to determine the prevalence of esophageal varices in patients with PSC and the variables that predict their presence. Data were collected on 283 patients with PSC treated for the first time at the Mayo Clinic (Rochester, MN) during 8 consecutive years. Thirty-six percent (102 of 283) of patients had esophageal varices including 56% (57 of 102) with moderate/large varices. After excluding 28 patients with a history of variceal bleeding, data on 183 patients were analyzed to identify independent predictors of esophageal varices and of moderate/large size varices. Platelet count, albumin level, and advanced histologic disease were independent predictors of esophageal varices (area under the receiver operator characteristic [ROC] curve = 0.88). After controlling for the presence of advanced histologic stage and albumin levels, the odds ratios (OR) of platelet count less than 150 x 10(3)/dL for the presence of esophageal varices was 6.3 (95% CI: 2.6-15.8). The diagnostic accuracy of these results was corroborated by cross-validation of the data in an independent set of 72 patients with PSC (area under the ROC = 0.90). In conclusion, in patients with PSC, noninvasive markers of portal hypertension and of advanced liver disease predict the presence of esophageal varices. Our results suggest a clinically applicable and useful approach to identify patients with PSC who are more likely to benefit from endoscopic screening for esophageal varices.