Varices In Cirrhosis Patients Research Articles

Platelet counts to spleen diameter ratio: A promising noninvasive tool for predicting esophageal varices in cirrhosis patients

BACKGROUND Liver cirrhosis is the end stage of progressive liver fibrosis as a consequence of chronic liver inflammation, wherein the standard hepatic architecture is replaced by regenerative hepatic nodules, which eventually lead to liver failure. Cirrhosis without any symptoms is referred to as compensated cirrhosis. Complications such as ascites, variceal bleeding, and hepatic encephalopathy indicate the onset of decompensated cirrhosis. Gastroesophageal varices are the hallmark of clinically significant portal hypertension. AIM To determine the accuracy of the platelet count-to-spleen diameter (PC/SD) ratio to evaluate esophageal varices (EV) in patients with cirrhosis. METHODS This retrospective observational study was conducted at Tikur Anbessa Specialized Hospital and Adera Medical Center from January 1, 2019, to December 30, 2023. Data were collected via chart review and direct patient interviews using structured questionnaires. The data were exported to the SPSS software version 26 for analysis and clearance. A receiver operating characteristic curve was plotted for splenic diameter, platelet count, and PC/SD ratio to obtain sensitivity, specificity, positive predictive value, negative predictive value, positive likelihood ratio, and negative likelihood ratio. RESULTS Of the 140 participants, 67% were men. Hepatitis B (38%) was the most common cause of cirrhosis, followed by cryptogenic cirrhosis (28%) and hepatitis C (16%). Approximately 83.6% of the participants had endoscopic evidence of EV, whereas 51.1% had gastric varices. Decompensated cirrhosis and PC were associated with the presence of EV with adjusted odds ratios of 12.63 (95%CI: 3.16-67.58, P = 0.001) and 0.14 (95%CI: 0.037-0.52, P = 0.004), respectively. A PC/SD ratio < 1119 had a sensitivity of 86.32% and specificity of 70% with area under the curve of 0.835 (95%CI: 0.736-0.934, P < 0.001). CONCLUSION A PC/SD ratio < 1119 predicts EV in patients with cirrhosis. It is a valuable, noninvasive tool for EV risk assessment in resource-limited settings.

Spleen Thickness Plus Platelets Can Effectively and Safely Screen for High-Risk Varices in Cirrhosis Patients.

Currently, most primary hospitals cannot routinely perform liver stiffness measurements (LSMs) and spleen stiffness measurements (SSMs), which are recommended by guidelines to exclude high-risk varices (HRVs). We tried to find more convenient indicators for HRV screening. We enrolled 213 cirrhosis patients as the training cohort (TC) and 65 primary biliary cirrhosis patients as the validation cohort (VC). We included indicators such as SSM by two-dimensional shear wave elastography, LSM by transient elastography, and other imaging and laboratory tests. Variable analysis revealed SSM, platelets (PLT), and spleen thickness (ST) as independent risk indicators for HRV. In TC, ST+PLT (ST < 42.2 mm and PLT > 113.5 × 109/L) could avoid 35.7% of the esophagogastroduodenoscopies (EGDs), with a 2.4% missed HRV rate. Although the proportion of EGDs spared by ST+PLT was less than SSM+PLT (SSM < 29.89 kPa + PLT > 113.5 × 109/L) (35.7% vs. 44.1%), it was higher than that of the Baveno VI criteria (B6) (35.7% vs. 28.2%). We did not validate SSM+PLT in VC considering our aims. ST+PLT safely spared 24.6% of EGDs in VC, identical to B6. Conclusions: The ability of ST+PLT to exclude HRVs was superior to B6 but slightly inferior to SSM+PLT. When SSM cannot be routinely performed, ST+PLT provides an extra option for patients to exclude HRVs as a more convenient model.

Spleen stiffness determined by spleen-dedicated device accurately predicted esophageal varices in cirrhosis patients

Background: The advantages of spleen stiffness in prediction of high-risk varices (HRV) in cirrhosis patients have been confirmed. Recently, a new device utilizing a 100 Hz probe dedicated to spleen stiffness measurement (SSM) was developed. Objectives: To validate the clinical applicability of SSM@100 Hz in predicting HRV by comparing it with other non-invasive tests (NITs). Design: A prospective cohort study. Methods: A total of 171 cirrhosis patients who underwent esophagogastroduodenoscopy (EGD) examination were included in this study. SSM using a 100 Hz probe and liver stiffness measurement using a 50 Hz probe were performed. Additionally, 22 healthy controls underwent spleen stiffness evaluation using the 100 Hz probe. Results: The failure rates of spleen stiffness examination in patients with cirrhosis and in healthy controls were 2.9% and 4.5%, respectively. The means of SSM values were 56.4 ± 21.6 and 13.8 ± 6.7 kPa in cirrhosis and controls. SSM increased proportionally with the severity of esophageal varices. The area under receiver operating characteristic (ROC) for spleen stiffness in predicting HRV was 0.881 (95% confidence interval 0.829–0.934), with a cutoff value of 43.4 kPa. The accuracy, false negative rate and EGD spare rate were 86.5%, 2.5% and 24.3%, respectively. For HRV prediction, SSM was comparable to expanded Baveno VI and VII and superior to other NITs. As to viral versus non-viral cirrhosis and compensated versus decompensated cirrhosis, the cut-off and performance of SSM were different. Conclusion: SSM@100 Hz demonstrates high accuracy in predicting HRV with a low missed HRV rate. Our findings suggest that SSM@100 Hz can be used independently due to its simplicity and effectiveness. However, further studies are needed to determine appropriate cutoff values based on the cause of cirrhosis and liver function. Trail Registration: ChiCTR2300070270.

Nomogram for predicting the risk of gastroesophageal varices after primary endoscopic prophylaxis for variceal hemorrhage in patients with cirrhosis.

The aim of this study was to identify predictors of non-high-risk gastroesophageal varices and evaluate the probability of the residual high-risk varices in cirrhosis patients after the primary endoscopic treatment. Medical records of the patients with cirrhosis admitted for primary endoscopic prophylaxis gastroesophageal varices hemorrhage were retrospectively analyzed. The patients were divided into high-risk varices and non-high-risk varices groups according to the endoscopy. A nomogram was developed based on the results of multivariate Cox analyses. Accuracy of this model was validated by the concordance index (Harrell's c-index) and calibration curve. Altogether 117 patients were enrolled between March 2014 and April 2018. The multivariate Cox analyses identified spleen length <140 mm [odds ratio (OR) = 2.715; P = 0.037), small or medium size of esophageal varices (OR = 4.412; P = 0.017), unaccompanied with gastric varices (OR = 7.025; P = 0.003) and frequency of endoscopic variceal ligation ≥one time per 4 months (OR = 3.834; P = 0.034) as independent factors of non-high-risk varices. All significant predictors were incorporated into a nomogram to predict the residual high-risk varices, which showed a notable accuracy with the concordance index (0.833). The nomogram-based prediction of residual high-risk varices can be used for risk stratification in cirrhosis patients with gastroesophageal varices.

2D shear wave liver elastography by Aixplorer to detect portal hypertension in cirrhosis: An individual patient data meta-analysis.

Liver stiffness measured with 2-dimensional shear wave elastography by Supersonic Imagine (2DSWE-SSI) is well-established for fibrosis diagnostics, but non-conclusive for portal hypertension. We performed an individual patient data meta-analysis of 2DSWE-SSI to identify clinically significant portal hypertension (CSPH), severe portal hypertension and large varices in cirrhosis patients, using hepatic venous pressure gradient and upper endoscopy as reference. We used meta-analytical integration of diagnostic accuracies with optimized rule-out (sensitivity-90%) and rule-in (specificity-90%) cut-offs. Five studies from seven centres shared data on 519 patients. After exclusion, we included 328 patients. Eighty-nine (27%) were compensated and 286 (87%) had CSPH. 2DSWE-SSI<14kPa ruled out CSPH with a summary AUROC (sROC), sensitivity and specificity of 0.88, 91% and 37%, and correctly classified 85% of patients, with minimal between-study heterogeneity. The false negative rate was 60%, of which decompensated patients accounted for 78%. 2DSWE-SSI≥32kPa ruled in CSPH with sROC, sensitivity, specificity and correct classifications of 0.83, 47%, 89% and 55%. In a subgroup analysis, the 14kPa cut-off showed consistent sensitivity and higher specificity for patients with compensated cirrhosis, without ascites, viral aetiology or BMI<25kg/m2 . 2DSWE-SSI ruled out severe portal hypertension and large varices with fewer correctly classified and lower sROC, and with minimal benefit for ruling in. Liver stiffness using 2-dimensional shear wave elastography below 14kPa may be used to rule out clinically significant portal hypertension in cirrhosis patients, but this would need validation in populations of compensated liver disease. 2DSWE-SSI cannot predict varices needing treatment.

“Diagnostic And Therapeutic Relevance of Sushrutokta Endoscopic Procedures”

Vikar Darshan Pariksha (examination of pathology by inspection) is one of the important clinical method mentioned by Acharya Sushruta while examining the patient. Inspection is an active process. It is done with the eyes and the intellect. As per Acharya Sushruta, Built, features, Power, Colour, Pathology etc. should be examined by external inspection [S.Su.10/5]. Another less explored but equally important aspect of inspection examination is the internal inspection of pathologies through endoscopic procedures. Review of literature shows that Acharya Sushruta had described various diagnostic and therapeutic endoscopic procedures like Kantha Weekshan (Oropharyngoscopy) for viewing and removing throat pathologies and foreign bodies [S.Su. 27/17-18], Nasa Weekshan (Rhinoscopy) for viewing and removing the nasal polyp and tumor [S.Su. 8/14], Arsha Weekshan (Proctoscopy) for viewing and removing pile mass'S.Chi. 6/4 &amp; 11], Bhagandar Weekshan (Fistula in Ano Scope) for viewing the track and for application of the medication. Today is the era of minimally invasive procedures. With the help of endoscopic procedures not only diagnosis of the disease is done but also the various therapeutic procedures such as band ligation of oesophageal varices in patients of cirrhosis of liver etc are done. In conclusion, it is observed that the endoscopic procedures have been well documented in Ayurvedic science before they come into practice in modern medicine. Endoscopic procedures are important in diagnosis as well as in the treatment of the internal pathologies.

Sudden Death- Case series of Ruptured Esophageal Varices

IntroductionSudden death due to Gastroinstestinal (GI) causes amount to 10% of all sudden death. Esophageal varices is one of the GI causes of sudden death. It develops as a complication of liver cirrhosis. The prevalence of esohgaeal varices in cirrhosis patients is 50% and mortality rate varies between 20%-35% with male female ratio of 1:9. The one year bleeding rate of small and large varices is 5% and 15%. Mortality rate increases with increased age.Case-SeriesSix case of sudden death were seen in the mortuary of a tertiary hospital. The six cases were males, alcoholics. On autopsy, similar findings of cirrhotic liver and hemorrhagic mucosa of the stomach with bleeding spots on lower one third of esophagus were observed.DiscussionCollaterals develop with development of portal hypertension. Some sites are pre disposed to rupture like the esophageal varices. Risk factors of variceal rupture are red streaks in lumen of esophagus and deranged liver function tests. On gross examination, signs of deranged liver functions are noted. On internal examination, esophagus is everted attached to the stomach and varices are seen shine to through the mucosa. Liver had cirrhotic changes and spleen was enlarged and congested in all the six cases.ConclusionThe case series emphasizes the importance of fatal esophageal variceal hemorrhage as an important cause of sudden death occurring outside the hospital in alcohol-addicted individuals, often in isolated scenarios.

Can Non-Selective Beta-Blockers (NSBBs) Prevent Enlargement of Small Esophageal Varices in Patients with Cirrhosis? A Meta-analysis

Non-selective beta-blockers (NSBBs) are recommended for prophylaxis of first variceal bleeding in patients of cirrhosis with large esophageal varices. However, the data is conflicting whether NSBBs can also prevent growth of small esophageal varices to large size. To perform a meta-analysis of the randomized clinical trials comparing NSBBs with placebo for prevention of development of large esophageal varices in patients of cirrhosis with small esophageal varices. The PubMed, EMBASE, Science Direct, and Cochrane library databases were searched for relevant papers. A meta-analysis was performed using risk ratios (RRs) with 95% confidence interval (CI) as the effect sizes. Overall, 314 trials were initially retrieved from the database searches, of which five randomized controlled trials were included in the meta-analysis. The incidence of development of large varices (RR=0.91, 95%CI: 0.29-2.86; P=0.87) was similar between NSBB and placebo groups. However, the heterogeneity among studies was significant (P<0.01) with an I2 of 93%. The incidences of first variceal bleeding (RR=0.72, 95%CI: 0.25-2.12; P=0.55) and death (RR=0.76, 95%CI: 0.50-1.15; P=0.19) were also similar between NSBB and placebo groups; with no heterogeneity. The incidence of adverse events was significantly higher in the NSBB group compared with the placebo group (RR=4.66, 95%CI: 1.36-15.91; P=0.01). The results of this meta-analysis indicate that NSBBs are not effective in preventing growth of small varices and may lead to significant adverse effects. Hence, NSBBs should not be recommended for cirrhotic patients with small varices.

A study of platelet count/ spleen diameter ratio as a predictor of esophageal varices in patients of cirrhosis

Background: Todays guidelines are clear that there are no substitute markers to determine the presence and size of esophageal varices, and endoscopy is still the only valid method to investigate varices. Objective: To validate the PC/SD ratio as a predictor of the presence and absence of esophageal varices in patients with chronic hepatopathy. Methodology: This study is an analytical cross-sectional validation study of a diagnostic test. The study was done in cases diagnosed of having hepatic cirrhosis by histology or physical, biochemical, and imaging examinations compatible with the disease and treatment from February 1, 2013 to December 31, 2014. Various hematological, biochemical and radiological work up was done. Results: Of the total cases, 29(70.7%) had PC/SD ratio more than 909 and only 12(29.3%) had less than 909. The sensitivity of PC/SD ratio of 909 in predicting varix is 89.66% and specificity was 75%. Thus it can be considered a good and reliable tool for predicting varices. Conclusion: The use of platelet count/ splenic diameter ratio in cirrhotic patients for screening and follow up for esophageal varices can substantially reduce the cost of health care and discomfort for patients as well as reduce burden of endoscopy unit.

Improving survival of cirrhosis patients with hepatocellular carcinoma through application of standard of care

We read with great interest the article by Ripoll et al.1 recently published in Hepatology. In their study the authors observed that prophylaxis of rebleeding from esophageal varices in cirrhosis patients with hepatocellular carcinoma (HCC) is associated with improved outcome. Furthermore, confirming previous findings, they observed that patients with HCC who bled had a worse outcome as compared to a matched group of bleeding cirrhosis patients without liver cancer.1-3 One of the most interesting results of this study, however, was that fewer patients with HCC received secondary prophylaxis after bleeding, and that lack of secondary prophylaxis was an independent predictor of death. We feel that this study touches upon an important issue in the management of cirrhosis patients, and more so in cirrhosis patients with HCC. In fact, despite recent evidence of improved outcome, the mortality rate associated with variceal bleeding is still as high as 20%.4, 5 Furthermore, although primary prophylaxis of variceal hemorrhage may be associated with an overall benefit that goes beyond a simple decrease in bleeding rate, and the unavailability of accurate noninvasive methods able to obviate the need for endoscopy, the proportion of patients at risk of bleeding who actually undergo screening endoscopy is low.6-9 Moreover, the proportion of patients who, after a positive screening result, actually undergo primary prophylaxis is unknown. Noteworthy, the study by Ripoll et al.1 shows that less than half (43%) of eligible patients with cirrhosis and HCC were on primary prophylaxis of bleeding. This finding is clinically meaningful, as we have previously shown that in patients with HCC the presence of varices is independently associated with death, and death due to bleeding is significantly more frequent in patients with varices.10 However, due to insufficient data our study was not able to identify whether the presence of varices simply identified patients with more advanced disease—and therefore at higher risk of bleeding and death—and which was the proportion of patients on bleeding prophylaxis. In this regard, the study by Ripoll et al. shows us that cirrhosis patients with HCC who bled received a suboptimal management, and puts forward the hypothesis that this may be due to the perception that intensive management would not result in a meaningful clinical benefit when HCC is present. Instead, their results clearly show that lack of rebleeding prophylaxis is associated with increased mortality, even after adjustment for the severity of liver disease. This information calls us to a more thorough management of these patients. All in all, we feel that studies like this are extremely useful for clinical practice, providing data that should remind us that some measures, such as primary and secondary prophylaxis of variceal bleeding, are standard of care and not options in the management of cirrhosis patients, regardless of the presence of HCC. Edoardo G. Giannini, M.D., Ph.D.1 Franco Trevisani, M.D.2 1Dipartimento di Medicina Interna Unità di Gastroenterologia IRCCS Azienda Ospedaliera Universitaria San Martino IST Università di Genova Genova, Italy 2Dipartimento di Scienze Mediche Chirurgiche Unità di Semeiotica Medica, Alma Mater Studiorum Università di Bologna Bologna, Italy

Hepatobiliary Quiz—8 (2013)

1.Regarding the epidemiology of hepatitis E virus (HEV) the following are TRUE EXCEPT:1.Large scale water borne epidemics in high-endemicity regions are usually due to genotype 1 and 22.Genotypes 3 and 4 mainly cause zoonotic disease with only occasional clinical infection in humans3.Infection is more common in young healthy individuals in low-endemicity regions4.Person to person spread is a common mode for transmission of HEV5.In India, human infection is predominantly by genotype 1 and animal infection by genotype 42.Regarding chronic HEV infection the following are TRUE:1.Reducing dose of immunosuppressants often leads to clearance of HEV infection2.Pegylated interferon and ribavirin have been unsuccessful in treatment of chronic HEV infection in organ transplant recipients3.Treatment of patients positive for HEV RNA prior to organ transplant is not useful4.HEV infection in transplant recipients can cause severe neurological manifestations5.HEV infection is a cause of renal dysfunction after kidney and liver transplantation3.Regarding immunosuppressive regimens used after liver transplantation the following are TRUE:1.Combination of sirolimus with calcineurin inhibitors (CNI) is a good renal sparing regimen2.Low dose CNI with mycophenolate is a good regimen for patients with renal dysfunction3.Tacrolimus has been proven to cause less hepatitis C recurrence than cyclosporine4.Steroid boluses are associated with severe recurrence of hepatitis C5.Immunosuppression therapy should be reduced in patients with post transplant lymphoproliferative disorder4.Regarding renal failure in patients with cirrhosis the following are TRUE EXCEPT:1.Hepatorenal syndrome (HRS) is the most common cause of renal dysfunction in cirrhosis2.Urinary neutrophil gelatinase-associated lipocalin may help differentiate causes of renal failure in cirrhosis3.Treatment of pre-renal azotemia is diuretic withdrawal and volume expansion with albumin4.Terlipressin with albumin reverses renal failure in almost all patients with HRS5.Treatment of HRS with vasopressors and albumin does not decrease mortality5.Regarding hepatitis B virus (HBV) associated polyarteritis nodosa (PAN) the following are TRUE:1.PAN is due to type III immunity (immune complex) formation2.HBV associated PAN is more severe than PAN without virus infection3.Treatment of HBV associated PAN is with prolonged immunosuppression similar to PAN without virus infection4.Plasma exchange is not useful in HBV associated PAN5.Interferon can be used for treatment of HBV with PAN6.Regarding hepatitis C virus (HCV) and cryoglobulinemic vasculitis the following are TRUE:1.Presence of cryoglobulins in serum is a common finding in HCV infected individuals2.Symptoms of cryoglobulinemia are common in HCV infected individuals3.HCV related cryoglobulinemia is usually of type 14.Symptomatic cryoglobulinemia is an indication for anti-HCV therapy5.Immunosuppression is not useful for HCV associated cryoglobulinemia7.Regarding HEV infection in pregnancy the following are TRUE EXCEPT:1.Pregnant women are more likely to have HEV as cause of acute viral hepatitis (AVH) in both sporadic and epidemic settings2.HEV infection is more severe in pregnancy and more likely to cause acute liver failure3.Among patients with acute liver failure, HEV infection and pregnancy are poor prognostic variables4.Viral load and duration of viremia are similar in pregnant and non-pregnant patients5.Poor outcomes in pregnancy are believed to be secondary to immunosuppressive effects of progesterone8.Regarding management of esophageal varices in patients of cirrhosis who have never bled the following are TRUE:1.Probability of first bleed depends upon the size of the largest esophageal varix2.Non-selective β blockers (NSBB) are useful to prevent development of varices3.Endoscopic band ligation (EBL) is an accepted modality for primary prophylaxis of variceal bleed in patients with small esophageal varices4.Endoscopic band ligation (EBL) is an accepted modality for primary prophylaxis of variceal bleed in patients with large esophageal varices5.Carvedilol may be effective in patients who do not respond to propranolol9.Regarding microRNAs (miRs) in liver disease the following are TRUE:1.miR are only found intra-cellularly2.miR-122 is a liver specific miR3.Miravirsen has antiviral activity for HCV4.miR-122 has antiviral activity for HBV5.miR-29 is pro-fibrogenic10.Regarding acute on chronic liver failure (ACLF) due to AVH the following are TRUE EXCEPT:1.AVH is the most common acute precipitating event of ACLF in Asia2.HBV flare is more likely a cause of ACLF than AVH in HBV related cirrhosis3.Hepatitis A virus (HAV) is a more common cause of ACLF than HEV in Asia4.HAV related ACLF has worse outcome than HEV related ACLF5.Ribavirin is a potential therapy for HEV related ACLF

ESOPHAGEAL VARICES;

Bleeding from esophageal varices is associated with high morbidity and mortality. It is currently recommended that allpatients with liver cirrhosis undergo upper gastrointestinal endoscopy to identify those who have esophageal varices. This approachleads to unnecessary endoscopies. There is need to evaluate clinical, laboratory and imaging parameters that may predict the presence ofesophageal varices and help select patients for endoscopy. Objective: Identify hematological, biochemical and ultasonographicpredictors of oesophageal varices in patients of cirrhosis. Study design: Cross sectional Descriptive study. Setting: Department ofGeneral Medicine and Gastroenterology unit 1, Services Hospital, Lahore. Duration of study: 6 months (April 01, 2007 – September 30,2007). Sample size: Study was done on One hundred patients who had established cirrhosis with oesophageal varices. Results: Majority(77%) were male who had evidence of esophageal varices. Hematemesis was the presenting complaint in 75% of patients and majority(83%) had clinically palpable spleen. Esophageal varices were present in 75% of patents who had platelet count &lt;100, 000. In patientswho had portal vein diameter of &gt;20mm 41% had evidence of esophageal varices. Splenic measurement of &gt;13cm was associated withmaximum number of cases of esophageal varices i.e 82%. Conclusion: It is concluded from the study that male gender, clinically palpablespleen, low platelet count, portal vein diameter and splenic measurement can be used as non invasive parameters to predict esophagealvarices reducing the need of unnecessary endoscopies.

Early primary prophylaxis with beta-blockers does not prevent the growth of small esophageal varices in cirrhosis: a randomized controlled trial.

The efficacy of portal pressure reduction by beta-blockers and the utility of serial hepatic venous pressure gradient (HVPG) measurements for the management of small (≤5mm) esophageal varices in patients of cirrhosis are not clear. The study had the following aims: to study (1) the effect of propranolol on the growth of small varices and (2) whether single or serial HVPG measurements result in a better outcome compared to no measurement in patients with small varices. Consecutive cirrhosis patients with small varices, without any history of variceal bleed, were randomized to receive propranolol or placebo and to undergo no HVPG, only baseline HVPG, or serial HVPG measurements. A total of 150 cirrhotics (cirrhosis predominantly viral or alcohol induced) were included (77 in the beta-blocker and 73 in the placebo group). Baseline characteristics were similar. The actuarial 2-year risk of growth of varices (primary endpoint) was 11 and 16% in the propranolol and placebo group, respectively (P=0.786). Variceal bleeding and mortality were also comparable in the two groups. Similarly, the outcome was not influenced by HVPG measurements (whether serial, only baseline, or no HVPG). A bilirubin level of ≥1.5mg/dl was found to be an independent predictor of variceal progression. In cirrhotics with small esophageal varices, nonselective beta-blockers are unable to prevent the growth of varices, variceal bleed, or mortality. HVPG monitoring of these patients did not change the outcome; however, the role of HVPG-guided therapy modification needs to be studied.

Non-endoscopic prediction of presence of esophageal varices in cirrhosis.

To identify hematological, biochemical and ultrasonographic predictors of esophageal varices in patients of cirrhosis. Cross-sectional, analytical study. Department of Gastroenterology, Shaikh Zayed Postgraduate Medical Institute, Lahore, from September 2003 to March 2004. One hundred and one patients with established cirrhosis and no history of variceal bleed underwent physical examination, hematological, biochemical tests and abdominal ultrasound examination. Esophagogastroduodenoscopy (EGD) was carried out in all patients. Presence of varices on EGD was correlated with hematological, biochemical and ultrasonographic variables by regression analysis. Esophageal varices were seen in 65 patients while 36 patients had no varices. High grade varices were seen in 15 patients and 50 patients had low grade varices. Serum albumin less than 2.95 g/dl, platelet count less than 88 x 103/muL and portal vein diameter more than 11 mm were associated with presence of varices. High grade varices were predicted by serum albumin < 2.95 g/dl and portal vein diameter more than 11 mm. Patients with serum albumin < 2.95 g/dl, platelet count < 88 x 103/muL and portal vein diameter > 11 mm are more likely to have high grade varices. These patients are candidates for surveillance endoscopy.