Esophageal varices in cirrhotic patients: evaluation with liver CT

Association of splenic MR elastographic findings with gastroesophageal varices in patients with chronic liver disease

PURPOSE

To identify magnetic resonance imaging (MRI)-based parameters associated with gastroesophageal varices (GEVs) in patients with chronic liver disease.

MATERIALS AND METHODS

Ninety-three patients were divided into three groups based on endoscopic findings: group 1 with no GEVs (n = 49), group 2 with mild GEVs (n = 30), and group 3 with severe GEVs (n = 14). We used a multivariate logistic regression analysis to assess liver stiffness, aspartate aminotransferase-to-platelet ratio index, spleen stiffness and volume, portal vein velocity, cross-sectional area, and flow volumes potential independent associators of any (mild and severe) GEVs or severe GEVs.

RESULTS

The analysis showed that spleen and liver stiffness and spleen volume were independently associated with any GEVs (spleen stiffness, odds ratio [95% confidence interval], 1.25 [1.04-1.68], P = 0.018; liver stiffness, 1.52 [1.13-2.17], P = 0.006; spleen volume, 1.01 [1.00-1.01], P = 0.016), whereas spleen stiffness was associated with severe GEVs (1.82 [1.25-2.95]; P = 0.005).

CONCLUSION

Liver and spleen stiffness and spleen volume are associated with GEVs in patients with chronic liver disease. Compared with liver stiffness and spleen volume, spleen stiffness is more strongly associated with severe GEVs.

Multidetector CT oesophagography: an alternative screening method for endoscopic diagnosis of oesophageal varices and bleeding risk

BACKGROUND AND STUDY AIMS

Variceal bleeding is a frequent and life-threatening complication of portal hypertension. The aim of this study was to evaluate multidetector computed tomographic (MDCT) oesophagography as an alternative to endoscopy for screening oesophageal varices (EVs) and predicting bleeding risk.

PATIENTS AND METHODS

A total of 137 cirrhotic patients underwent MDCT followed by endoscopy and EVs were graded independently. The screening ability of CT for EV was evaluated by comparing the grades of EV at CT and at endoscopy. Prediction of bleeding risk by CT was determined by correlating the CT variceal grades, diameters and palisade vein dilatation with the endoscopic red colour (RC) sign. Extra-oesophageal findings were assessed by CT. Patients' acceptance for both examinations were compared.

RESULTS

At endoscopy, 47 (34%) patients had grade 0 EV, 52 (38%) patients had grade 1 EV, 29 (21%) patients had grade 2 EV and nine (7%) patients had grade 3 EV. The sensitivity, specificity, positive and negative predictive values and accuracy of CT oesophagography for defining EV in all grades were 99%, 98%, 99%, 98% and 99%, respectively. The MDCT variceal grades, diameters and palisade vein dilatation were correlated with the severity of the RC sign. Important extra-oesophageal findings were determined by CT only. The acceptance of patients for CT oesophagography was significantly more than that for endoscopy (p<0.001).

CONCLUSION

MDCT is a reliable, preliminary or adjunctive method that can be used for routine screening for EVs and the prediction of variceal bleeding.

High-risk esophageal varices in patients treated with locoregional therapy for hepatocellular carcinoma: Assessment with liver computed tomography

AIM: To assess the diagnostic performance of follow-up liver computed tomography (CT) for the detection of high-risk esophageal varices in patients treated with locoregional therapy for hepatocellular carcinoma (HCC).

METHODS: We prospectively enrolled 100 patients with cirrhosis who underwent transcatheter arterial chemoembolization, radiofrequency ablation or both procedures for HCCs. All patients underwent upper endoscopy and subsequently liver CT. Three radiologists independently evaluated the presence of high-risk esophageal varices with transverse images alone and with three orthogonal multiplanar reformation (MPR) images, respectively. With endoscopic grading as the reference standard, diagnostic performance was assessed by using receiver operating characteristic (ROC) curve analysis.

RESULTS: The diagnostic performances (areas under the ROC curve) of three observers with transverse images alone were 0.947 ± 0.031, 0.969 ± 0.024, and 0.916 ± 0.038, respectively. The mean sensitivity, specificity, positive predicative value (PPV), and negative predicative value (NPV) with transverse images alone were 90.1%, 86.39%, 70.9%, and 95.9%, respectively. The diagnostic performances, mean sensitivity, specificity, PPV, and NPV with three orthogonal MPR images (0.965 ± 0.025, 0.959 ± 0.027, 0.938 ± 0.033, 91.4%, 89.5%, 76.3%, and 96.6%, respectively) were not superior to corresponding values with transverse images alone (P > 0.05), except for the mean specificity (P = 0.039).

CONCLUSION: Our results showed excellent diagnostic performance, sensitivity and NPV to detect high-risk esophageal varices on follow-up liver CT after locoregional therapy for HCC.

Platelet count/spleen diameter ratio for non-invasive diagnosis of oesophageal varices: is it useful in compensated cirrhosis?

AIM

To assess the diagnostic accuracy of the platelet count/spleen diameter ratio for identification of oesophageal varices and/or hypertensive gastropathy in patients with compensated cirrhosis.

METHODS

Platelet count/spleen diameter ratio was calculated in 87 consecutive patients with compensated cirrhosis. A new cut-off with the highest sensitivity and specificity for the presence/absence of oesophageal varices and/or hypertensive gastropathy was identified. Performance of the platelet count/spleen diameter ratio considering previously reported cut-off values were then tested in our population.

RESULTS

A platelet count/spleen diameter ratio <936.4 had the best sensitivity and specificity for the diagnosis of oesophageal varices and for all endoscopic findings of portal hypertension. A value lower than 936.4 allowed identification of 64.5% of patients with oesophageal varices and 66.7% of patients with any sign of portal hypertension; a value higher than 936.4 excluded oesophageal varices in 64.3% of patients and any sign of portal hypertension in 68.6% of patients.

CONCLUSIONS

In patients with compensated cirrhosis, the platelet count/spleen diameter ratio is not a useful parameter to avoid unnecessary upper endoscopy, independently of the cut-off.

Diagnosis of portal vein tumor thrombus: the combination of enhanced multislice spiral computed tomography and portography

AIM: To evaluate the value of combined enhanced 16-slice spiral CT and portography reconstruction in the diagnosis of portal vein tumor thrombus.

METHODS: Fifty-two patients with portal vein tumor thrombus underwent 16-slice spiral CT examination. A plain scan and triple-phase enhanced scans (arterial phase, portal venous phase, and equilibrium phase) were performed. Scanning parameters were as follows: a slice thickness of 2.5 mm, a reconstruction interval of 0.625 mm, a flow rate of 3.5-4 mL/s, 80-100 mL of contrast agent, and scan time of 25-30 s, 45-60 s, and 120 s, respectively. Image reformation, including volume rendering (VR), multiplanar reformation (MPR) and maximum intensity projection (MIP), was performed by one radiologist. Two radiologists assessed the scope, shape and collateral vessels of the thrombus.

RESULTS: Thirty-five cases (67.3%) of portal vein tumor thrombus showed inhomogeneous enhancement in the arterial phase, and 47 cases (90.4%) had the enlarged portal vein and filling defect. Enhancement of the vessel wall was seen in 19 cases (36.5%), collateral circulation formation in 13 cases (25%), compression of the portal vein in 13 cases (25%), and arterioportal fistula in 6 cases (11.5%). Different portal vein reconstruction techniques showed different number of cases of portal vein tumor thrombus: 52 (100%) by MPR, 43 (82.7%) by MIP, 39 (75%) by VR.

CONCLUSION: The combination of enhanced CT and portography reconstruction can reveal portal vein tumor thrombus completely and has important clinical value.

Towards noninvasive detection of oesophageal varices

Current guidelines recommend that all cirrhotic patients should undergo screening endoscopy at diagnosis to identify patients with varices at high risk of bleeding who will benefit from primary prophylaxis. This approach places a heavy burden upon endoscopy units and the repeated testing over time may have a detrimental effect on patient compliance. Noninvasive identification of patients at highest risk for oesophageal varices would limit investigation to those most likely to benefit. Upper GI endoscopy is deemed to be the gold standard against which all other tests are compared, but is not without its limitations. Multiple studies have been performed assessing clinical signs and variables relating to liver function, variables relating to liver fibrosis, and also to portal hypertension and hypersplenism. Whilst some tests are clearly preferable to patients, none appear to be as accurate as upper GI endoscopy in the diagnosis of oesophageal varices. The search for noninvasive tests continues.

Detection and grading of esophageal varices on liver CT: comparison of standard and thin-section multiplanar reconstructions in diagnostic accuracy

OBJECTIVE

The objective of our study was to evaluate the performance of liver CT in the diagnosis of esophageal varices in patients with cirrhosis and to determine whether thin-section multiplanar reconstructions (MPRs) improve accuracy.

MATERIALS AND METHODS

We identified 109 patients with cirrhosis who underwent endoscopy within 10 weeks after dual-phase liver MDCT supplemented with thin-section axial and coronal portal venous phase reconstructions. Two blinded radiologists independently evaluated each CT examination for the presence and sizes of varices using standard 5-mm axial versus 1- to 3-mm multiplanar images in separate sessions. Sensitivity, specificity, and predictive value calculations and receiver operating characteristic analysis were performed using endoscopy as the reference standard. Interobserver variability and correlation of CT size to variceal grade were assessed.

RESULTS

Twenty-six cases of high-risk esophageal varices were identified; all except two were detected on CT by one of the readers on standard 5-mm images. For both readers, sensitivity and negative predictive value (NPV) for the discrimination of high-risk varices using a criterion of 2 mm or greater were nearly the same for the standard 5-mm images versus the 1- to 3-mm multiplanar images (sensitivity and NPV: reader 1, 96% and 98% vs 96% and 99%; reader 2, and 89% and 95% vs 89% and 96%, respectively). Standard 5-mm images yielded a lower specificity for high-risk esophageal varices than the thin-section multiplanar images, and this difference was statistically significant for reader 2. Substantial interobserver agreement was noted for both esophageal varices detection and size measurements.

CONCLUSION

Standard liver CT is sensitive for the detection of high-risk varices and deserves further investigation as a potential cost-effective screening tool for the evaluation of patients with cirrhosis. The addition of 1- to 3-mm MPRs may increase specificity for risk stratification based on size measurements.

Detection of esophageal varices using CT and MRI

BACKGROUND AND AIMS

The development of esophageal varices in cirrhotic patients carries a significant risk of hemorrhage and associated morbidity/mortality. Universal endoscopic screening, however, is invasive and expensive. Conversely, cirrhotic patients often have imaging findings which suggest portal hypertension. The aim of this study was to evaluate the ability of CT and/or MRI to detect esophageal varices compared to EGD.

METHODS

Medical records from 2000 to 2007 were retrospectively reviewed. CT and/or MRI images were included if performed within 90 days of EGD. Two blinded, experienced radiologists were asked to review images for the presence of esophageal varices, as well as other findings associated with portal hypertension. Sensitivity, specificity, PPV and NPV were calculated using EGD findings as the gold standard.

RESULTS

A total of 195 patients and 142 patients met criteria for CT and MRI, respectively. The sensitivity of CT to detect EGD varices was 58-89%, but increased to 65-100% when specifically looking at large endoscopic varices. Overall specificity was 68-82%, but increased to 97-100% when applying ≥4 mm varices criteria. CT was superior to MRI in the detection of endoscopic varices; the addition of other portal hypertension stigmata did not improve results.

CONCLUSIONS

The exclusion of large endoscopic varices by CT, using standardized criteria, may obviate the need or frequency of EGD screening in select patient populations. Alternatively, CT findings highly suggestive of esophageal varices in cirrhotic patients may warrant further investigation and/or treatment. Further studies are needed to validate these findings.

Chronic liver disease: systemic and splanchnic venous flow mapping with optimized cine phase-contrast MR imaging validated in a phantom model and prospectively evaluated in patients

PURPOSE

To validate magnetic resonance (MR) imaging cine phase-contrast blood flow mapping in vitro and in patients with chronic liver disease, with or without portal hypertension, and to assess the accuracy of azygos, splanchnic, and systemic blood flow measured with MR imaging in the detection of high-risk esophageal varices and compare these measurements with endoscopic evaluation, the reference standard.

MATERIALS AND METHODS

The local ethics committee approved this study. Patients gave written informed consent. Two phantoms were used to validate the MR imaging phase-contrast flow sequence. Patients with liver cirrhosis (n = 59), chronic liver disease without cirrhosis (n = 12), and nodular regenerative hyperplasia (NRH) (n = 11), and healthy control subjects with no liver disease (n = 25) were included. The patients underwent upper digestive system endoscopy. Mean abdominal aorta, portal venous, and azygos blood flow was measured on MR images, which were reviewed by two blinded observers to determine the presence and grade of esophageal varices. The reproducibility and intra- and interobserver variability of the blood flow measurements were assessed with intraclass correlation coefficients (ICCs). The performance of the MR blood flow measurements in staging high-risk varices was determined with receiver operating characteristic curve analysis. The correlation between MR visual analysis and endoscopic grading was assessed by using κ statistics.

RESULTS

MR flow rate measurements had excellent correlations with actual flow values in vitro (ICC > 0.990 for phantoms 1 and 2). Mean aortic flow was significantly higher in patients with cirrhosis than in control subjects (P < .001). Mean azygos flow was significantly higher in patients with cirrhosis than in patients with chronic liver disease without cirrhosis (P = .005) and control subjects (P < .001). Low intra- and interobserver variability (ICC > 0.990 for each blood flow type) and high reproducibility (ICC > 0.850 for each blood flow type) were demonstrated. The optimal cutoff mean azygos flow value was 2.3 mL/sec for varices with grades of 2 or higher.

CONCLUSION

MR imaging azygos flow measurement appears to be a promising technique for detecting high-risk esophageal varices in patients with portal hypertension.

Noninvasive assessment of portal hypertension in patients with cirrhosis

Severe portal hypertension is responsible for complications and death. Although measurement of the hepatic venous pressure gradient is the most accurate method for evaluating the presence and severity of portal hypertension, this technique is considered invasive and is not routinely performed in all centers. Several noninvasive techniques have been proposed to measure portal hypertension. Certain methods evaluate elements related to the pathogenesis of portal hypertension through the measurement of hyperkinetic syndrome, for example, or they investigate the development of hepatic fibrosis through the measurement of increased intrahepatic vascular resistance. Other methods evaluate the clinical consequences of portal hypertension, such as the presence of esophageal varices or the development of portosystemic shunts. Methods evaluating increased hepatic vascular resistance are fairly accurate and mainly involve the detection of hepatic fibrosis by serum markers and transient elastography. The radiological assessment of hyperkinetic syndrome probably has value but is still under investigation. The assessment of severe portal hypertension by the presence of varices may be performed with simple tools such as biological assays, computed tomography, and esophageal capsules. More sophisticated procedures seem promising but are still under development. Screening tools for large populations must be simple, whereas more complicated procedures could help in the follow-up of already diagnosed patients. Although most of these noninvasive methods effectively identify severe portal hypertension, methods for diagnosing moderate portal hypertension need to be developed; this shows that further investigation is needed in this field.

Effect of liver transplantation on spleen size, collateral veins, and platelet counts

BACKGROUND

The aim of this study was to evaluate the effect of liver transplantation on the spleen size, spontaneous splenorenal shunt (SRS) function, and platelet counts in patients with hypersplenism.

METHODS

Between December 2001 and February 2007, 462 adult patients underwent orthotopic liver transplantations (OLTX) at our institution. Of these patients, CT or MRI information was reviewed retrospectively in 55 patients. Volume measurements of the spleen and liver, spleen/liver volume ratio (S/L ratio), presence and size of SRS, and platelet counts were evaluated before and after OLTX.

RESULTS

Mean spleen volume decreased from 827 +/- 463 ml to 662 +/- 376 ml after OLTX (p < 0.01). Five (11%) patients returned to normal-range spleen size after OLTX. SRS was observed in 19 patients before OLTX (35%). The diameter of SRS also significantly decreased from 1.0 +/- 0.5 cm before OLTX to 0.7 +/- 0.5 cm after OLTX (p < 0.05). SRS disappeared in 16% of patients (3/19). S/L ratio significantly decreased from 0.65 +/- 0.33 to 0.38 +/- 0.17 (p < 0.01) after OLTX. Platelet counts significantly increased after OLTX (p < 0.01). Improvement of the platelet count in the group with postoperative S/L ratio >0.35 was not as good as that in the group with S/L ratio <0.35 (p < 0.01).

CONCLUSIONS

Spleen size and SRS size became significantly smaller after OLTX. However, patients with postoperative S/L ratio >0.35 tend to have lower platelet counts after OLTX.

Current staging and diagnosis of gastroesophageal varices

Portal hypertension is defined as an increase in hepatic sinusoidal pressure to 6 mm Hg or higher. Cirrhosis is the most common cause of portal hypertension in the western world and results from increased resistance to blood flow at the hepatic sinusoidal level.

Gastric varices in patients with portal hypertension: evaluation with multidetector row CT

BACKGROUND

Gastric varices (GVs) are a major cause of gastrointestinal bleeding in patients with portal hypertension. Few studies have evaluated GVs with multidetector row computed tomography (MDCT).

GOALS

To assess the diagnostic performance of MDCT in detecting GVs and revealing variceal hemodynamic changes in patients with cirrhosis.

STUDY

A total of 127 consecutive cirrhotic patients who underwent both liver MDCT and esophagogastroduodenoscopy (EGD) were analyzed retrospectively. Two independent radiologists reviewed MDCT images for the detection of GVs. The variceal hemodynamic changes were assessed by the 2 radiologists in consensus on MDCT portography.

RESULTS

On the basis of EGD, of the 127 patients, 36 had GVs (28.4%), including small GVs in 15 patients and large GVs (>or=5 mm) in 21 patients. In detecting and grading GVs, there were moderate agreements (kappa value: 0.514 to 0.563) between MDCT and EGD, but in differentiating large varices requiring prophylactic therapy, a substantial agreement (kappa value: 0.804 for radiologist 1 and 0.796 for radiologist 2) was found. For radiologist 1, the sensitivity, specificity, accuracy, and positive and negative predictive values of MDCT for the identification of large GVs were 85.7%, 96.2%, 94.5%, 81.8%, and 97.1%, respectively; whereas for radiologist 2, they were 81.0%, 97.2%, 94.5%, 85.0%, and 96.3%, respectively. In evaluating the afferent and efferent veins of varices, the sensitivity, specificity, accuracy, and positive predictive value of MDCT portography were more than 80.0%.

CONCLUSIONS

MDCT is an effective screening tool for differentiating large GVs and revealing the afferent and efferent veins of varices in patients with cirrhosis.

Evaluation of entire gastric fundic and esophageal varices secondary to posthepatitic cirrhosis: portal venography using 64-row MDCT

BACKGROUND

There are no reports regarding entire gastric fundic and esophageal varices evaluated with 64-row multidetector CT (MDCT). We attempt to clarify the feasibility of portal venography with this scanner in evaluation of these varices.

METHODS

A total of 33 patients, with clinically confirmed gastric fundic and esophageal varices secondary to posthepatitic cirrhosis, underwent thoracicoabdominal triphasic enhancement scans using 64-row MDCT along with conventional angiographic portography. CT portography and conventional portography were compared by statistical agreement to determine whether CT maximum intensity projection (CT-MIP) portography is useful in evaluation of entire gastric fundic and esophageal varices.

RESULTS

CT-MIP portography demonstrated gastric fundic and esophageal varices, and the inflowing and outflowing vessels of the varices. Gastric fundic varices were shown in 32 cases (97.0%), and esophageal varices were in 27 (81.8%). The inflowing vessels including the left gastric vein and posterior gastric vein/short gastric vein were illustrated in 31 (94.0%) and 17 (51.5%) cases, respectively. The outflowing vessels including the azygos vein, hemiazygos vein, and gastro-renal shunts were seen in 30 (90.9%), 8 (24.2%), and 12 (36.4%) cases, respectively. Findings of CT-MIP portography and conventional angiographic portography were in close agreement (Kappa value ranged from 0.621 to 1.000).

CONCLUSION

CT-MIP venography with 64-row MDCT could be considered as a method for detecting entire gastric fundic and esophageal varices developed from posthepatitic cirrhosis.

High-risk esophageal varices in patients treated with locoregional therapies for hepatocellular carcinoma: evaluation with regular follow-up liver CT

We evaluated the diagnostic performance of radiologists for the detection of high-risk esophageal varices on regular follow-up liver multi-detector row CT (MDCT) examinations in patients treated with locoregional therapies for hepatocellular carcinoma (HCC). A total of 110 cirrhotic patients that had undergone liver MDCT at 4 weeks or sooner before an upper endoscopy were evaluated. Three abdominal radiologists independently interpreted the CT images with the shortest interval of endoscopy in order to detect the presence of high-risk (grade 2 or 3) esophageal varices. With endoscopic grading as the reference standard, the diagnostic performances (areas under the ROC curves) of the three radiologists were 0.977 +/- 0.018, 0.957 +/- 0.024, and 0.939 +/- 0.028, respectively. The mean sensitivity and specificity of the three radiologists were 91.9% and 92.2%, respectively. Our results showed excellent diagnostic performances of radiologists to detect high-risk esophageal varices on regular follow-up liver MDCT in patients treated with locoregional therapies for HCC.

Evaluation of esophageal varices on liver computed tomography: receiver operating characteristic analyses of the performance of radiologists and endoscopists

BACKGROUND AND AIM

Recent liver multi-detector row computed tomography (MDCT) always covers the distal esophagus with an excellent image quality. The aim of this study was to compare the performance of faculty abdominal radiologists with those of radiology residents and endoscopists for the detection of esophageal varices and high-risk esophageal varices on liver MDCT.

METHODS

A total of 104 cirrhotic patients that had undergone liver MDCT 4 weeks or less before an upper endoscopy were evaluated. Two faculty abdominal radiologists, two radiology residents, and two endoscopists independently interpreted all of the CT images to detect the presence of esophageal varices and high-risk (grade 2 or 3) esophageal varices. With endoscopic grading as the reference standard, their performances were compared by using receiver operating characteristic (ROC) curve analysis.

RESULTS

The areas under the ROC curves for the detection of esophageal varices indicated better performance of the abdominal radiologists (A(z) = 0.868), compared with the radiology residents (A(z) = 0.798) (P = 0.007) and endoscopists (A(z) = 0.784) (P = 0.006). For the detection of high-risk esophageal varices, however, the performance of the abdominal radiologists (A(z) = 0.914) was similar to those of radiology residents (A(z) = 0.900) and endoscopists (A(z) = 0.907) (each P > 0.05).

CONCLUSIONS

Experienced readers have a better ability to detect esophageal varices on liver MDCT, but had no higher performance to evaluate high-risk esophageal varices. As the accuracy of detecting high-risk esophageal varices with clinical relevance on liver MDCT is excellent, even by endoscopists, the evaluation of esophageal varices from a recent liver MDCT may be useful to avoid the use of low-yield endoscopy.

Detection and grading for esophageal varices in patients with chronic liver damage: comparison of gadolinium-enhanced and unenhanced steady-state coherent MR images

The purpose of this study was to compare observer interpreted steady-state coherent coronal images and gadolinium-enhanced axial images in terms of the detection and grading of esophageal varices. Magnetic resonance imaging (MRI) and gastrointestinal endoscopy were performed within 2 weeks in 90 patients with chronic liver damage, including 55 with untreated esophageal varices, for periodic screening purposes. Two blinded readers retrospectively reviewed T1- and T2-weighted images with gadolinium-enhanced (gadolinium image set) and steady-state coherent (coherent image set) images. Sensitivity for the detection of esophageal varices was higher (P<.001) in the gadolinium image set (76%) than in the coherent image set (35%); on the other hand, specificity was higher (P<.001) in the coherent image set (91%) than in the gadolinium image set (66%). Furthermore, area under the ROC curve was higher for the gadolinium image set (Az=0.823) than the coherent image set (Az=0.761) (P=.48). Moderate and weak positive correlations with endoscopic grades were found for the gadolinium image (r=0.48, P<.01) and coherent image sets (r=0.34, P=.018). The addition of steady-state coherent imaging to the current routine liver imaging protocol did not improve the detection or grading of esophageal varices, whereas gadolinium-enhanced imaging was found to be potentially valuable. Nevertheless, endoscopy was confirmed to be mandatory in patients with esophageal varices suspected by MRI of the liver.

Predictors of esophageal varices in patients with HBV-related cirrhosis: a retrospective study

Background

All patients with liver cirrhosis are recommended to undergo an evaluation of esophageal varices (EV) to assess their risk of bleeding. Predicting the presence of EV through non-invasive means may reduce a large number of unnecessary endoscopies. This study was designed to develop a predictive model for varices in patients with Hepatitis B virus-related cirrhosis.

Methods

The retrospective analysis was performed in 146 patients with Hepatitis B virus-related cirrhosis. The data were assessed by univariate analysis and a multivariate logistic regression analysis. In addition, the receiver operating characteristic curves were also applied to calculate and compare the accuracy of the model and other single parameters for the diagnosis of esophageal varices.

Results

We found the prevalence of EV in patients with Hepatitis B virus-related cirrhosis to be 74.7%. In addition, platelet count, spleen width, portal vein diameter and platelet count/spleen width ratio were significantly associated with the presence of esophageal varices on univariate analysis. A multivariate analysis revealed that only the spleen width and portal vein diameter were independent risk factors. The area under the receiver operating characteristic curve of regression function (RF) model, which was composed of the spleen width and portal vein diameter, was higher than that of the platelet count. With a cut-off value of 0.3631, the RF model had an excellent sensitivity of 87.2% and an acceptable specificity of 59.5% with an overall accuracy of 80.1%.

Conclusion

Our data suggest that portal vein diameter and spleen width rather than platelet count may predict the presence of varices in patients with Hepatitis B virus-related cirrhosis, and that the RF model may help physicians to identify patients who would most likely benefit from screenings for EV.

Comparison of liver biopsy and transient elastography based on clinical relevance

BACKGROUND

Liver stiffness measurement (LSM) by transient elastography has recently been validated for the evaluation of liver fibrosis in chronic liver diseases. The present study focused on cases in which liver biopsy and LSM were discordant.

METHODS

Three hundred eighty-six patients with chronic hepatitis C who underwent a liver biopsy between December 2004 and April 2007 were studied. First, the optimal cut-off value of LSM was selected for the determination of cirrhosis based on the receiver operating characteristic curve. Then, the cases in which liver histology and evaluation by LSM were discordant were selected. Laboratory test results such as serum total bilirubin concentration, prothrombin activity, albumin concentration, platelet count and the aspartate aminotransferase to platelet ratio index, together with the presence of esophageal varices, were analyzed.

RESULTS

The optimal cut-off value was chosen to be 15.9 kPa for cirrhosis (fibrosis stage [F] 4) determination to maximize the sum of sensitivity (78.9%) and specificity (81.0%). There were 78 discordant cases: 51 patients showed an LSM of 15.9 kPa or higher and a fibrosis stage of F1 to F3 (high LSM group), and 27 patients had an LSM lower than 15.9 kPa and a fibrosis stage of F4 (low LSM group). Esophageal varices were seen in 11 patients in the high LSM group (n=51) and in no patients in the low LSM group (n=27) (P=0.0012). The aspartate aminotransferase to platelet ratio index was significantly higher in the high LSM group (1.49 versus 0.89, P=0.019). Other parameters did not differ significantly. However, platelet count, prothrombin activity and albumin concentration tended to be lower in the high LSM group.

CONCLUSIONS

Patients with a high LSM need proper attention for cirrhosis, even if liver biopsy does not reveal cirrhosis.

Non-invasive (and minimally invasive) diagnosis of oesophageal varices

Current guidelines recommend screening all cirrhotic patients by endoscopy, to identify patients at risk of bleeding who should undergo prophylactic treatment. However, since the prevalence of varices in cirrhotic patients is variable, universal screening would imply a large number of unnecessary endoscopies and a heavy burden for endoscopy units. In addition, compliance to screening programs may be hampered by the perceived unpleasantness of endoscopy. Predicting the presence of oesophageal varices by non-invasive means might increase compliance and would permit to restrict the performance of endoscopy to those patients with a high probability of having varices. Over the years, several studies have addressed this issue by assessing the potential of biochemical, clinical and ultrasound parameters, transient elastography, CT scanning and video capsule endoscopy. The platelet count/spleen diameter ratio, CT scanning and video capsule endoscopy have shown promising performance characteristics, although none of them is equivalent to EGD. These methods are perceived by patients as preferable to endoscopy and thus might increase adherence to screening programs. Whether this will compensate for the lower sensitivity of these alternative techniques, and ultimately improve the outcomes if more patients undergo screening, is the crucial question that will have to be answered in the future.

A prospective evaluation of computerized tomographic (CT) scanning as a screening modality for esophageal varices

Patients with cirrhosis require endoscopic screening for large esophageal varices. The aims of this study were to determine the cost-effectiveness and patient preferences of a strategy employing abdominal computerized tomography (CT) as the initial screening test for identifying large esophageal varices. In a prospective evaluation,102 patients underwent both CT and endoscopic screening for gastroesophageal varices. Two radiologists read each CT independently; standard upper gastrointestinal endoscopy was the reference standard. Agreement between radiologists, and between endoscopists regarding size of varices was determined using kappa statistic. Cost-effectiveness analysis was performed to determine the optimal screening strategy for varices. Patient preference was assessed by questionnaire. CT was found to have approximately 90% sensitivity in the identification of esophageal varices determined to be large on endoscopy, but only about 50% specificity. The sensitivity of CT in detecting gastric varices was 87%. In addition, a significant number of gastric varices, peri-esophageal varices, and extraluminal pathology were identified by CT that were not identified by endoscopy. Patients overwhelmingly preferred CT over endoscopy. Agreement between radiologists was good regarding the size of varices (Kappa = 0.56), and exceeded agreement between endoscopists (Kappa = 0.36). Use of CT as the initial screening modality for the detection of varices was significantly more cost-effective compared to endoscopy irrespective of the prevalence of large varices.

CONCLUSION

Abdominal CT as the initial screening test for varices could be cost-effective. CT also permits evaluation of extra-luminal pathology that impacts management.

Pseudotumoral azygos and paraesophageal varices of posterior mediastinum in a 15-month-old infant: a case report

A case of azygos and paraesophageal varices presenting as a posterior mediastinal mass in a 15-month-old infant with biliary atresia is described. The patient was evaluated for living donor liver transplantation because of repeated cholangitis after Kasai operation, and plain CT scan demonstrated a mass in posterior mediastinum. The operation of mediastinal tumor resection was planned before liver transplantation in order to exclude malignant disease, however, possibility of paraesophageal varices remained. Contrast-enhanced magnetic resonance imaging clearly demonstrated azygos and paraesophageal varices in posterior mediastinum. Living donor liver transplantation was performed successfully without ligation of paraesophagogastric varices. Contrast-enhanced CT demonstrated distinctly decreased mediastinal mass one month after transplantation.