Size Of Varices Research Articles

Noninvasive assessment of the presence and size of esophageal varices

Background/Aim. A significant number of patients with liver cirrhosis who underwent screening endoscopy do not have esophageal varices (EVs) or have EVs that do not require prophylactic therapy. Given the invasiveness of the procedure, the need to develop nonendoscopic methods in predicting the presence of EVs is reasonable. The aim of the study was to determine the significance of clinical, biochemical, and ultrasonic parameters in the prediction of EVs. Methods. The study included 59 patients with cirrhosis of the liver, 39 (66.1%) patients with EVs, and 20 (33.9%) patients without EVs. In the group of patients with EVs, 22 (56.4%) patients had small EVs, and 17 (46.3%) had large EVs. Clinical parameters that included Child-Pugh (CP) score, ascites, and splenomegaly were evaluated. In all participants, complete blood count, liver function tests, abdominal ultrasound, and gastroscopy were performed, and a platelet count/spleen diameter (PC/SD) ratio was calculated. Results. Univariate logistic regression analysis showed that in-dependent risk factors for the occurrence of EVs were the following: CP B class [odds ratio (OR) 6.67; p = 0.003] and CP C class (OR 23.33; p = 0.005) relative to class A, ascites (OR 7.78; p = 0.001), spleen size (OR 1.035; p = 0.016), bilirubin (OR 1.065; p = 0.007), albumin (OR 0.794; p = 0.001), prothrombin time (OR 0.912; p < 0.001), international normalized ratio-INR (OR 231.364; p < 0.001), platelet count (OR 0.989; p = 0.023), and PC/SD ratio (OR 0.999; p = 0.034). In a multivariate model, it was shown that a decreased platelet count was a statistically significant risk factor for the presence of EVs (OR 0.983; p = 0.023). Leukopenia and the size of the right liver lobe were found to be statistically significant factors for the occurrence of large EVs. Based on the receiver operating characteristic (ROC) curve for the PC/SD ratio, the cutoff value of the test was obtained at 907 (907.11), with a negative predictive value of 76.4% for large EVs. Conclusion. The cutoff value of PC/SD ratio < 907 has a predictive value for the occurrence of large EVs.

АССОЦИАЦИЯ ВАРИКОЗНО РАСШИРЕННЫХ ВЕН ПИЩЕВОДА И ЖЕЛУДКА С ДРУГИМИ ФЕНОТИПИЧЕСКИМИ СТИГМАМИ ЦИРРОЗА ПЕЧЕНИ

Background. Portal hypertension resulted from the increased pressure in the portal system is one of the leading syndromes of liver cirrhosis. A frequent and often fatal manifestation of portal hypertension is upper gastrointestinal bleeding mainly due to varicose veins of the esophagus and the stomach. Objective. To study the prevalence of esophageal and gastric varices and their association with other phenotypic stigmas of cirrhosis. Material and methods. A total of 108 patients with cirrhosis, including 46 (42.59%) men and 62 (57.41%) women, were included in the study. Results. Varicose veins were detected in 77 (71,3%) of 108 examined patients. All varices were localized in the esophagus. Of all patients examined, 36 patients (33.33%) were Child-Pugh class A, 58 patients (53.70%) were class B, and 14 patients (12.96%) were class C. Among Class A patients, 9 patients (11.7%) had grade I varicose veins, 9 patients (11.7%) had grade II, 8 patients (10.4%) had grade III, while 13 patients (16.9%), 24 patients (31.2%) and 3 patients (3.9%) had grade B varicose veins, respectively. All patients classified as class C had large varicose veins. The size of varices was associated with the severity of liver cirrhosis (τ=0.2, 95% CI: p˂0.05). Grade II-III varices were seen in 55 patients (50.9%), 9 of whom (16.4%) had a history of gastrointestinal bleeding. Such complication was not observed in any patient with class A cirrhosis, but occurred in all patients with Child-Pugh class C cirrhosis. Conclusions. Patients with liver cirrhosis should undergo follow-up upper GI endoscopy for early detection of varices and, if necessary, for prescription of prophylactic therapy to reduce the risk of bleeding and associated high mortality.

ATYPICAL CAUSE OF A NECROTIZING LUNG LESION: CONCERN FOR A BRONCHOTRANSJUGULAR INTRAHEPATIC PORTOSYSTEMIC SHUNT FISTULA

ATYPICAL CAUSE OF A NECROTIZING LUNG LESION: CONCERN FOR A BRONCHOTRANSJUGULAR INTRAHEPATIC PORTOSYSTEMIC SHUNT FISTULA

S1476 Efficacy and Clinical Outcomes of Endoscopic Variceal Ligation With N-butyl-2-cyanoacrylate in Pediatric Patients in a Tertiary Care Center—A Retrospective Study

Introduction: Acute variceal bleeding (AVB) from gastroesophageal varices is a life-threatening complication in patients with portal hypertension. Bleeding from gastric varices is less common and treatment options are not standardized. Endoscopic variceal obliteration (EVO) with N-butyl-2-cyanoacrylate glue or balloon-occluded retrograde transvenous obliteration (BRTO) are the 2 most common treatment modalities and information on these are limited to adult series. There is paucity of information about gastric varices and its treatment in children. Methods: We conducted a retrospective cohort study among pediatric patients (1-18 years) who presented to our center with AVB from gastric varices. Between 2011-2021, we identified 538 among 4539 cases (12%) of portal hypertension with bleeding from gastric varices. Of these only 14 cases (2.6%) had a diagnosis of gastric variceal bleeding in children. Details of 13 patients were extracted with non-availability of records of 1 patient. Cyanoacrylate glue in 0.5-1 ml were injected in to the gastric varices. Patients were evaluated for efficacy, safety and complications associated with the treatment. Endoscopy was repeated after 3 weeks for assessment of variceal size and need for repeat glue injection. Results: The mean age of the patients was 13.3±5.2, with males (54%) and females (46%). The mean age at first presentation to hospital with gastrointestinal bleeding was 8.7±3.6, with hematemesis (62%) being the most common presentation. On endoscopy, 8 patients had type 1 gastro-esophageal varices and 3 patients had type 2 gastroesophageal varices. All 13 patients had stigmata of recent gastric variceal bleeding. The most common cause of portal hypertension was extra hepatic portal venous obstruction (EHPVO) (54%). The mean age at glue therapy treatment was 11.3±5.3. While immediate hemostasis was achieved in all 13 patients (100%) with gastric variceal bleeding, re-bleeding was seen among 3 patients, which occurred after 1 month of glue therapy. 1-3 sessions were required for obliteration of gastric varices. There was one case of death among the 13 children: a patient with decompensated Wilson’s disease. We did not encounter complications like anaphylactic shock, treatment-associated infection, gastric perforation, and distant emboli. Conclusion: The experience from our series suggests that endoscopic vascular obliteration using cyanoacrylate glue injection is safe and effective in children with gastric variceal bleeding.

P1020: SCREENING FOR PORTAL HYPERTENSION IN PATIENTS WITH PHILADELPHIA NEGATIVE MYELOPROLIFERATIVE NEOPLASMS

Background: Portal hypertension (PH) is a well-recognized complication of BCR-ABL negative myeloproliferative neoplasms (MPNs) and is associated with significant morbidity and mortality. However, the prevalence of PH and its associated risk factors have not been studied systematically in this patient population. Screening by esophagogastroduodenoscopy (EGD) can facilitate early diagnosis of PH and opportunity for intervention to prevent complications. Aims: To investigate the prevalence of PH and its patient and disease-related risk factors. Methods: From May 2013 to March 2019, MPN patients ≥ 18 years old with spleen >5 cm below the costal margin in myelofibrosis (MF) or any size in Polycythemia Vera (PV) or Essential Thrombocythemia (ET) were enrolled prospectively (NCT01816256). Patients with a known history of portal or hepatic vein thrombosis, liver cirrhosis, and esophageal varices were excluded. Screening for PH was done by EGD to evaluate for esophageal varices (EV) or gastric varices (GV), and portal hypertensive gastropathy (PHG). Abdominal Doppler ultrasonography (USG) was performed to evaluate for portal vein thrombosis and spleen size. PH severity was based on the size of varices or severity of PHG. For sample-size calculation, a precision approach was used, considering scenarios where PH prevalence ranged from 5 to 10% and an upper limit for sample size of 100. At a prevalence estimate of 8%, the 90% confidence interval (CI) was 4-14%, with an acceptable lower limit for moving forward with a screening program. Prevalence of PH was calculated as a proportion and CI are exact using Clopper-Pearson method. Results: Among 102 enrolled patients, EGD and USG were completed in 85 and 84, respectively. Primary and Post-PV/ET MF comprised the majority of the study population (93% [79/85]). Evidence of PH was found in 32 patients (38%, [90% CI 29-47]) of whom 12 (14% [90% CI 9-22]) had moderate to severe PH. EV, GV, and PHG were found in 81% (26/32), 13% (4/32), and 31% (10/32) of patients, respectively. The prevalence of PH among MF and PV/ET patients was 35% (28/79) and 67% (4/6), respectively. In MF patients, PH was moderate-to-severe in 13% (90% CI 8-20). No cases of portal vein thrombosis were identified on USG. Apart from a palpable liver observed more frequently in non-PH patients, there were no other significant differences in baseline characteristics among patients with and without PH. The frequency of JAK2, MPL and CALR mutations among PH patients was 78% (25/32),13% (4/32), and 6% (2/32). There was a trend towards more JAK2 mutations in PH patients (78% [25/32] vs 64% [34/53], p=0.23), but no difference in DIPSS risk or frequency of high molecular-risk mutations. Overall survival was similar in both groups. PH-directed interventions were initiated in 59% (19/32); 28% (9/32) were started on beta blocker (BB) prophylaxis, 16% (5/32) were treated with BB and variceal banding, and 16% (5/32) continued on surveillance EGDs alone. Three patients with moderate PH at baseline developed variceal bleeding (2) and ascites (1). All 3 patients were on BB prophylaxis, and 1 had prior prophylactic banding. There were no adverse events related to study procedures EGD or USG. Image:Summary/Conclusion: Given the study population, our results are generalizable to MF patients. Our study shows that clinically significant PH is common in MF patients, and led to additional clinical interventions in significant number of patients. These data support the inclusion of asymptomatic PH screening in the work up of MF patients.

Difference between type 2 gastroesophageal varices and isolated fundic varices in clinical profiles and portosystemic collaterals.

BACKGROUNDThere is significant heterogeneity between gastroesophageal varices (GOV2) and isolated gastric varices (IGV1). The data on the difference between GOV2 and IGV1 are limited.AIMTo determine the etiology, clinical profiles, endoscopic findings, imaging signs, portosystemic collaterals in patients with GOV2 and IGV1. METHODS Medical records of 252 patients with gastric fundal varices were retrospectively collected, and computed tomography images were analyzed.RESULTSSignificant differences in routine blood examination, Child–Pugh classification and MELD scores were found between GOV2 and IGV1. The incidence of peptic ulcers in patients with IGV1 (26.55%) was higher than that of GOV2 (11.01%), while portal hypertensive gastropathy was more commonly found in patients with GOV2 (22.02%) than in those with IGV1 (3.54%). Typical radiological signs of cirrhotic liver were more commonly observed in patients with GOV2 than in those with IGV1. In patients with GOV2, the main afferent vessels were via the left gastric vein (LGV) (97.94%) and short gastric vein (SGV) (39.18%). In patients with IGV1, the main afferent vessels were via the LGV (75.61%), SGV (63.41%) and posterior gastric vein (PGV) (43.90%). In IGV1 patients with pancreatic diseases, spleno-gastromental-superior mesenteric shunt (48.15%) was a major collateral vessel. In patients with fundic varices, the sizes of gastric/esophageal varices were positively correlated with afferent vessels (LGVs and PGVs) and efferent vessels (gastrorenal shunts). The size of the esophageal varices was negatively correlated with gastrorenal shunts in GOV2 patients. CONCLUSIONSignificant heterogeneity in the etiology and vascular changes between GOV2 and IGV1 is useful in making therapeutic decisions.

Evaluation and management of esophageal varices by through-the-scope endoscopic Doppler probe method.

Objective assessments of esophageal varices (EVs) are inadequate. The recurrence of variceal bleeding after endoscopic variceal ligation (EVL) is associated with residual blood flow underlying EVL or incomplete treatment of a perforating vein by EVL. We aimed to assess our novel through-the-scope endoscopic Doppler probe method (DOP) for the evaluation and management of EVs. This study included 20 patients (54 varices) with a history of esophageal variceal rupture from June 2019 to May 2021 who underwent DOP at a tertiary hospital. Variceal velocities were compared based on the size and endoscopic variceal findings. Additionally, we performed EVL assisted by DOP (EVL + DOP) in nine patients. Doppler imaging of EVs was observed in all 20 patients. The velocity of varices was significantly higher in EVs with a larger size, greater form, blue color, and red color sign positive. Perforating veins connecting to the EVs were identified in six out of nine patients who underwent EVL + DOP. Eight out of nine patients underwent repeat EVL. Repeat EVL was performed until the variceal velocity reached absent. No recurrence of variceal bleeding occurred during the follow-up period (mean 8.7 ± 3.2 months). No adverse events associated with DOP were observed. The evaluation of EVs using DOP is feasible and accurate. EV velocities are related to the variceal size, form, blue color, and red color sign. EVL + DOP may be a more reliable treatment for EVs. Further large-scale, long-term comparative studies are warranted.

A Dynamic Nomogram Predicting Portal Vein Thrombosis in Cirrhotic Patients During Primary Prophylaxis for Variceal Hemorrhage.

BackgroundPortal vein thrombosis (PVT) would exert a further increase in resistance to portal blood flow, resulting in worsening portal hypertension and poor outcome. This study aimed to identify risk factors and develop an clinically applicable dynamic nomogram predicting the occurrence of PVT in cirrhotic patients during primary prophylaxis for variveal hemorrhage (VH).MethodsThe multi-center retrospective study enrolled cirrhotic patients with high-risk varices, which were further divided into training and validation cohorts for 3 years follow-up. A dynamic nomogram based on the Cox proportional hazard regression model was developed with the cutoff value calculated by X-title analysis. The performance of the nomogram was evaluated with Harrell’s concordance index (C-index), calibration curve and decision curve analysis.Results91 (34.0%) of the whole cohort were diagnosed with PVT during 3-year follow-up. Variables including carvedilol (P < 0.001), low portal vein velocity (P < 0.001), increased size of esophageal varices (P = 0.005), and high HbA1c (P < 0.001) and procalcitonin (P = 0.015) were identified to be independently associated with PVT, which were further incorporated into the dynamic nomogram with optimal cutoff (8.8 and 14.6) for risk-stratification. The C-indexes (0.894 of internal validation and 0.892 of external validation) and calibration curves demonstrated ideal discrimination and calibration. The thresholds for more reasonable application of the nomogram were 0–0.27, 0–0.66, and 0.04–1.00 at 1, 2, and 3-year, respectively.ConclusionThe dynamic nomogram could be accurately and reliably used for clinical risk-stratification of PVT in cirrhotic patients during primary prophylaxis for VH.

Risk Factors of Esophageal Bleeding in Children with Various Etiologies of Liver Cirrhosis – A Single-Center Report from Iran

Abstract Esophageal bleeding is a common complication in patients with liver cirrhosis. In thee present study, our aim was to divulge major factors predicting esophageal bleeding in Iranian children with liver cirrhosis. This was a cross-sectional study including 101 children &lt; 18 years old referred to the Pediatric Endoscopy Unit of Nemazee Teaching Hospital of Shiraz from 2014 until 2016. Children with esophageal varices were included. The patients were divided into two groups including those with and without history of esophageal bleeding. Statistical methods were performed in SPSS 16 software. There were 49 boys and 52 girls. The mean age was 7.74±5.26 years old. A history of esophageal bleeding was observed in 53 (52.4%). In univariate analyses, significant relationships were found between esophageal bleeding and varices size (P=0.001), Child-Pugh score (P=0.01), age of bleeding initiation (P&lt;0.001), serum creatinine (P=0.01), and serum sodium (P=0.002). There was no statistically significant difference in the mean of PELD/MELD score among children with (12.34±12) and without (14.61±17.51) history of esophageal bleeding (P=0.5). Among various etiologies of cirrhosis, a significant association was observed between autoimmune hepatitis and the history of esophageal bleeding (P=0.01). Regarding the clinical importance of esophageal bleedings in children with liver cirrhosis, it is recommended to further divulge the risk factors pre-disposing to this event.

Correlation of Ultrasonographically Measured Splenic Size with Endoscopic Grading of Esophageal Varices in Cirrhosis of Liver

Background: Cirrhosis is the end stage of chronic liver disease, resulting in formation of fibrous tissue, derangement of liver architecture and ultimately results in portal hypertension and its complication. Objective: To find out the correlation between splenic size and endoscopic grading of esophageal varices in diagnosed cases of cirrhosis of liver. Methods: This prospective observational cross-sectional study was carried out in the Department of Radiology and Imaging in collaboration with GHPD, BIRDEM, Dhaka. 110 liver cirrhosis patients with or without esophageal varices diagnosed by endoscopy of UGIT referred to the department of Radiology and Imaging were included in this study on the basis of selection criteria. Result: The following observations and results were obtained in this study the mean age was 44.81 (±14.42) years, minimum age was 18 years and maximum age was 65 years. Majority 69% were male and 31% were female. Esophageal variceal grading of the study population majority 47(42.73%) were grade I, 24(21.82%) were grade II, 16(14.55%) were grade III, 12(10.91%) were grade IV and 11(10%) were no varices. Splenic size by ultrasonography, majority 66(60%) were 12-14.9 cm, 37(33.64%) were ≥15 cm and 07(6.36%) were &lt; 12 cm. In splenic size ≤ 15 cm, grading of esophageal varices, 15.07% had no varices, 60.27% had grade I, 20.55% had grade II, 2.74% had grade III and 1.37% had grade IV. In splenic size ≥ 15 cm grading of esophageal varices, 8.11% had grade I, 24.32% had grade II, 37.84% had grade III and 29.73% had grade IV. That means there is a positive correlation between ultrasonographically measured splenic size and endoscopic grading of esophageal varices in liver cirrhosis patients. Conclusion: Positive correlation was found between ultrasonographically measured splenic size with endoscopic grading of esophageal varices. Bangladesh Crit Care J March 2022; 10 (1): 57-61

Combined Pharmacological and Endoscopic Treatment for Worsening Gastroesophageal Varices in Patients with Cirrhosis.

BackgroundAt the present time, in patients with liver cirrhosis and gastroesophageal varices, primary prophylaxis of variceal bleeding made with combination therapy with non-selective β-blockers (NSBBs) and endoscopic band ligation (EBL) is not recommended. The aim of this study was to evaluate if patients with worsening varices while on NSBBs regimen benefit, in terms of bleeding and survival, from adding treatment with EBL.MethodsPatients with cirrhosis and endoscopic finding of gastroesophageal varices with high risk feature (increased variceal size and/or development of red signs) during primary prophylaxis with NSBBs, followed at the Unit of Internal Medicine and Hepatology, University and General Hospital of Padova, Italy, from 2012 to 2019, were retrospectively evaluated. When an increased bleeding risk of the varices was confirmed, patients maintained the pharmacological therapy alone or underwent also EBL. The primary endpoint of the study was the rate of variceal bleeding, the secondary endpoint was mortality at 30 months.ResultsCompared to patients treated only with NSBBs (n=56), in patients treated also with EBL (n=45), the 30‐month probability of variceal bleeding (29.1% vs 5.1%; P =0.036) was significantly reduced, while the probability of survival was similar (59.6% vs 65.7%; P=0.61). On multivariate analysis, treatment with EBL was found to be a weak protective factor for mortality (HR 0.47, P=0.044).ConclusionIn patients with liver cirrhosis, when varices show endoscopic feature of increased haemorrhagic risk, adding EBL to NSBBs is effective in reducing the probability of first bleeding.

Influence of esophageal flap valve on esophageal variceal bleeding

Background and Aim: Increased exposure to gastric acid in patients with abnormal gastroesophageal flap valve (GEFV) may lead to increase esophageal variceal bleeding. We aimed to investigate the relationship between GEFV and esophageal variceal bleeding episodes. Methods: It is an interim analysis of a cross-sectional study involving 109 patients with esophageal varices and flap valve of any grade. Patients are divided into two groups on basis of Hill’s grade of flap valve (Hill’s grade 1,2-normal and Hill’s grade 3,4-abnormal). They are assessed with esophagogastroduodenoscopy and incidence of variceal bleeding and size of varices (Two groups: large{>5mm} and small {<5 mm} varices) are compared with Hill’s Grade of flap valve. Results: This study included 109 patients out of which 72 had normal and 37 had abnormal flap valve. Number of bleeding episodes was significantly higher in patients with esophageal varices who had abnormal flap valve compared to whom having normal flap valve (Mean number of bleeding episodes- 2.5 vs 1.1, p<0.001). Predominantly, patients with abnormal flap valve had larger varices while patients with normal flap valve had smaller varices (94.6% vs 73.6%, p<0.001). Conclusions: Abnormal GEFV is independent risk factor for esophageal variceal bleeding.

Prophylactic cyanoacrylate injection for gastric extension of esophageal varices: a randomized controlled trial

Aim of the studyGastric variceal bleeding is more severe and fatal than esophageal bleeding. Injection of cyanoacrylate into bleeding gastric varices is recommended, but prophylactic injection is debatable. Aim of this study is to evaluate prophylactic cyanoacrylate injection into gastric extension of esophageal varices type 2 (GOV2).Material and methodsThis randomized controlled trial included 75 patients (3 groups) with risky or bleeding esophageal varices and non-bleeding GOV2. Group A received a cyanoacrylate GOV2 injection, esophageal variceal band ligation (EBL), and β-blocker (BB); group B received EBL and BB; and group C received EBL. Follow-up for ≥ 24 weeks to check for bleeding or death was performed.ResultsBaseline variables were comparable among the 3 groups. During follow-up (median, 37.5 weeks), increasing gastric extension and or bleeding risk signs were significantly lower in group A (0%) than B (12%) and C (32%) (p < 0.001). Bleeding occurred more in groups B (24%) and C (24%) than in A (8%) (p = 0.2). Gastric extension size was an independent predictor of bleeding (p = 0.03). Portal hypertensive gastropathy (PHG) decreased in groups A (24%) and B (24%) more than in C (8%) (p = 0.5). Mortality rates were 0.0% in group A, 8% in B, and 4% in C (p = 0.2).ConclusionsProphylactic cyanoacrylate injection into GOV2 before EBL significantly decreased the varix size and risk signs for bleeding with a statistically insignificant tendency to decrease the bleeding rate. A large gastric extension was an independent predictor of bleeding. Adding β-blockers can potentially decrease PHG and bleeding risk. An independent study with a larger sample size is recommended to confirm the rate of bleeding and test the mortality difference.

CORRELATION OF THROMBOCYTOPENIA WITH GRADING OF ESOPHAGEAL VARICES IN PATIENTS WITH CIRRHOSIS

Abstract&#x0D; Objective: To determine the relationship of severity of thrombocytopenia with various grades of esophageal varices in patients with cirrhosis.&#x0D; Study design: A cross sectional observational study.&#x0D; Place and duration of study: Medicine department of Pakistan Railway General Hospital from 1st September, 2018 to 31st August, 2020.&#x0D; Material and Methods: The record of 100 patients with cirrhosis having concomitant thrombocytopenia and esophageal varices was retrospectively analyzed. The information about clinical, hematological, biochemical, ultrasound and endoscopic findings was retrieved from medical record. On the basis of platelet count, four groups were made. Group I consisted of patients with a platelet count ≤ 20,000/ µl, group II 21,000-49,000/ µl, group III 50,000-99,000/ µl, and group IV 100,000- 149,000/ µl. Esophageal varices were reclassified as small and large varices group depending on the size. Correlation of thrombocytopenia with grading of esophageal varices was calculated using spearman’s correlation.&#x0D; Results: Out of 100 patients, 76% had large varices and 24% had small varices. Thrombocytopenia was more severe in patients with large varices group when compared with small varices group. There was significant negative correlation between thrombocytopenia and grading of esophageal varices (r= -.691; P &lt; 0.001).&#x0D; Conclusion: The severity of thrombocytopenia increased with increase in the size of esophageal varices. Low platelet count can strongly predict large varices in patients with cirrhosis.

VP20.06: Fetal intra‐abdominal umbilical vein varix: retrospective study and review of literature

To investigate the ultrasound characteristics, associations and obstetric outcome in pregnancies with intra-abdominal umbilical vein varix of the fetus. It was a retrospective cohort study conducted over two years i.e., from March 2019- February 2021. Data was collected from ultrasound records, antenatal and intra- partum records. For the neonatal outcome patients and respective consultants were followed up by telephonic calls. The data collected was demographic characteristics, varix characteristics (gestational age at diagnosis, size, progression, turbulence, thrombus formation, associated malformations and genetic), obstetric complications (fetal growth restriction/ IUFD) and neonatal outcome. Descriptive statistics (means, standard deviations, and percentages [%]) were calculated using SPSS, version 21.0 (SPSS Inc, Chicago, USA). Over the period of 2 years six cases of FIUVV were diagnosed making the incidence of FIUVV of 5/10000 pregnancies. Incidence of isolated FIUVV was 4.4/10000 cases. The mean gestational age at diagnosis was 25 weeks 3days with earliest diagnosis at 19w1d. Aneuploidy screening was done in five of cases with low risk for trisomy 21, 18 & 13 as outcome. The mean varix size was 11.85mm±2.28 mm (range 8.9mm-14.8 mm). No incidence of turbulence or thrombus formation within the varix was seen in the current study. One case had absent DV with anomalous connection of umbilical vein with IVC. One Perinatal death after planned LSCS at term & sudden IUFD at 33 weeks were noted in this study. Detailed anatomical scan and counselling should be done after FIUVV diagnosis. The fetal surveillance should be increased to look for major dilatation thombus or FGR. Longer analysis on the large population is needed to study the association of controls with the outcome. Also, long term studies are needed to for any delayed consequences affecting the adult life of these fetuses.

Non-Invasive Predictors of Esophageal Varices in Patients with Cirrhosis of Liver- A Prospective Study

Background: Liver disease particularly chronic liver disease is one of the major public health problem, accounting for significant morbidity and mortality worldwide. Among the different complications, gastro-esophageal variceal bleeding is the deadliest complications of advanced liver disease and have been described in 50% of patients with liver cirrhosis. Aim: To identify the non-invasive predictors of esophageal varices in patients with cirrhosis of liver, so as to reduce number of unnecessary endoscopies. Methods: Ninety two patients with cirrhosis of liver irrespective of etiology were analysed prospectively from October 2019 to March 2020. Appropriate clinical, biochemical and ultrasonographic parameters were selected as variables to compare with esophageal varices. The data were assessed by univariate and multivariate analysis. Results: Univariate analysis of the studied parameters showed that decreased platelet count, albumin levels and platelet count/splenic diameter ratio and increased bilirubin levels, prothrombin time, splenic size, portal vein size were significantly associated with the presence of esophageal varices and their values correlated with increasing size of varices. On multivariate analysis of variables, the independent predictors for the presence of varices were platelet count/splenic size &lt;1433.1, splenic size&gt;115.75 mm. Conclusion: Platelet count/splenic size&lt;1433.1, Splenic size&gt;115.75 mm are independent noninvasive predictors of esophageal varices in patients with cirrhosis of liver

Predictors of early rebleeding after endoscopic therapy of first variceal bleeding in liver cirrhosis

BackgroundDespite the great advancement in therapeutic modalities for esophageal varices, early variceal rebleeding still occurs at high rates leading to an exaggeration of the morbidity and mortality for cirrhotic patients, so meticulous follow-up with optimum prediction and proper preventive measures for early variceal rebleeding are mandatory for increasing survival of those patients. In this respect, we evaluated the clinical, laboratory, abdominal ultrasound, and endoscopic criteria of variceal cirrhotic patients as possible risk predictors of early variceal rebleeding after endoscopic control of first variceal bleeding. All included patients were followed up blindly for 12 weeks after endoscopic control of bleeding for ascertainment of first variceal rebleeding. The demographic, clinical, laboratory, abdominal ultrasound, and upper gastrointestinal endoscopic criteria were evaluated for all patients at first admission.ResultsBy univariate regression analysis, the statistically significant predictors for early variceal rebleeding were serum albumin, serum bilirubin, prothrombin concentration, Child-Pugh score, platelet count, spleen diameter, ascites, portal vein diameter and velocity, variceal size, variceal location, and red color sign. By using multivariate regression analysis, the most independent significant predictors were Child-Pugh score (sig: 0.001 and OR: 1.661), platelets count (sig: 0.000 and OR: 0.956), portal vein velocity (sig: 0.000 and OR: 0.664), variceal grading (sig: 0.000 and OR: 3.964), and variceal red color sign (sig: 0.000 and OR: 4.964). We used the multivariate regression coefficients for the significant predictors to build up early variceal rebleeding risk (EVRR) score with a significant discriminatory performance (AUC: 0.965 and sig: 0.000).ConclusionChild-Pugh score, platelet count, portal vein velocity, variceal grading, and variceal red color sign are independent risk predictors for early variceal rebleeding after successful control of first variceal bleeding in cirrhotic patients. Our proposed EVRR score could be helpful for the prediction of early variceal rebleeding in cirrhotic patients after endoscopic control of acute variceal bleeding; however, it should be externally validated in large prospective studies.

СЕЛЕКТИВНАЯ ДЕВАСКУЛЯРИЗАЦИЯ ДНА ЖЕЛУДКА У ПАЦИЕНТОВ С ХРОНИЧЕСКИМ ПАНКРЕАТИТОМ И ПОДПЕЧЁНОЧНОЙ ПОРТАЛЬНОЙ ГИПЕРТЕНЗИЕЙ. Предварительное сообщение о серии случаев

Background. Making treatment / prevention decisions in bleeding from gastroesophageal varices in patients with subhepatic portal hypertension remains challenging and thus requires further research. Objective. To perform a preliminary analysis of the outcomes of selective devascularization of the gastric fundus in patients with chronic pancreatitis and subhepatic portal hypertension. Material and methods. Selective devascularization of the gastric fundus was performed in five patients (3 men and 2 women) aged 23 to 54 with chronic recurrent pancreatitis and subhepatic portal hypertension. In 2 patients, Roux-en-Y cystojejunostomy for pancreatic pseudocyst was performed as the main treatment, and in 3 patients - Frey's surgery. Selective devascularization of the gastric fundus was adjuvant to a draining surgery or a resection-draining one. Results. All patients underwent surgery successfully. The duration of the operation (Me [min; max]) was 205 [190; 255] min. The time spent in the Department of anesthesiology, resuscitation and intensive care comprised 1 [1; 2] days. Postoperative follow-up of these patients over the period of 17 - 58 months detected no recurrence of bleeding from gastric varices. Endoscopy performed a year after revealed a decrease in the size of esophageal varices in all patients. Conclusions. The proposed technique of selective devascularization of the gastric fundus is substantiated by numerous studies of the variant anatomy of venous outflow from the spleen in extrahepatic portal hypertension. This technique is regarded as adjuvant to a draining surgery or a resection-draining one in patients with chronic pancreatitis and subhepatic portal hypertension performed to prevent bleeding from gastric fundus varices. There should be noted the reproducibility of this surgical intervention, its effectiveness and safety. Further research on the efficiency of the technique using randomized controlled trials is required.

Safety and efficacy of EUS-guided coil and glue injection for the primary prophylaxis of gastric variceal hemorrhage

Gastric variceal bleeding (GVB) is associated with high morbidity and mortality. EUS-guided coil and cyanoacrylate (CYA) injection (EUS-CCI) has been shown to be an effective therapy in acute bleeding and secondary prophylaxis; however, there is a paucity of data on primary prophylaxis. In this single-center observational study, adult patients with high-risk gastric varices (GV; size >10mm or cherry red spot) without prior bleeding underwent EUS-CCI for the primary prophylaxis of GVB between June 2009 and December 2019. The primary outcome was post-treatment GVB. Eighty patients with a mean variceal size of 22.5 ± 9.4mm and a mean length of follow-up of 3.0 ± 2.4 years were included. The etiology of portal hypertension was cirrhosis in 71 patients (88.7%) and noncirrhotic in 9 (11.3). The mean model for end-stage liver disease score was 12.3 ± 3.7 in patients with cirrhosis. The mean coil number was 1.5 (range, 1-3) and mean glue volume injected 2 mL (range, .5-5). Technical success was achieved in 100%, 96.7% had EUS confirmation of GV obliteration, and 67.7% were obliterated with 1 treatment session. Post-treatment GVB occurred in 2 patients (2.5%) and adverse events in 4 (4.9%). No deaths related to GVB occurred, and emergent transjugular intrahepatic shunts were not needed during the follow-up period. In patients with high-risk GV, EUS-CCI for primary prophylaxis is highly effective at preventing GVB with a low rate of adverse events. Primary prophylaxis of high-risk GV with coil and CYA glue injection should be considered in centers with the appropriate expertise.

Proprotein convertase subtilisin/kexin type 9 (PCSK9) levels are not associated with severity of liver disease and are inversely related to cholesterol in a cohort of thirty eight patients with liver cirrhosis

BackgroundProprotein convertase subtilisin/kexin type 9 (PCSK9) is of particular importance in cholesterol metabolism with high levels contributing to hypercholesterolemia. Cholesterol and sphingolipids are low in patients with liver cirrhosis. Purpose of this study was to find associations of plasma PCSK9 with circulating cholesterol and sphingolipid species and measures of liver disease severity in patients with liver cirrhosis.MethodsPCSK9 protein levels were determined by ELISA in systemic vein (SVP), hepatic vein (HVP) and portal vein plasma of patients with mostly alcoholic liver cirrhosis. PCSK9 and LDL-receptor protein expression were analysed in cirrhotic and non-cirrhotic liver tissues.ResultsSerum PCSK9 was reduced in patients with liver cirrhosis in comparison to non-cirrhotic patients. In liver cirrhosis, plasma PCSK9 was not correlated with Child-Pugh score, Model for End-Stage Liver Disease score, bilirubin or aminotransferases. A negative association of SVP PCSK9 with albumin existed. PCSK9 protein in the liver did not change with fibrosis stage and was even positively correlated with LDL-receptor protein levels. Ascites volume and variceal size were not related to PCSK9 levels. Along the same line, transjugular intrahepatic shunt to lower portal pressure did not affect PCSK9 concentrations in the three blood compartments. Serum cholesterol, sphingomyelin and ceramide levels did not correlate with PCSK9. Stratifying patients by high versus low PCSK9 levels using the median as cut-off, several cholesteryl ester species were even low in the subgroup with high PCSK9 levels. A few sphingomyelin species were also reduced in the patients with PCSK9 levels above the median. PCSK9 is highly expressed in the liver but systemic, portal and hepatic vein levels were similar. PCSK9 was not correlated with the inflammatory proteins C-reactive protein, IL-6, galectin-3, resistin or pentraxin 3. Of note, HVP PCSK9 was positively associated with HVP chemerin and negatively with HVP adiponectin levels.ConclusionsIn the cohort of patients with liver cirrhosis mostly secondary to alcohol consumption high PCSK9 was associated with low levels of certain cholesteryl ester and sphingomyelin species. Positive correlations of PCSK9 and LDL-receptor protein in the liver of patients with chronic liver injury are consistent with these findings.