Platelet count, spleen length, and platelet count-to-spleen length ratio for the diagnosis of oesophageal varices in people with chronic liver disease or portal vein thrombosis

Outcomes of Portosystemic Shunts in Children with and without Liver Transplantation

Purpose

Limited data exist regarding outcome and morbidity associated with portosystemic shunts in the pediatric transplant population. Our study assesses the outcomes of pediatric patients who underwent a portosystemic shunt procedure, both with and without liver transplantation (LT).

Methods

This study retrospectively reviewed the medical records of pediatric patients aged 0-19 years who underwent shunt placement between 2003 and 2017 at a tertiary care center. The analysis included cases of shunt placement with or without LT.

Results

A total of 13 pediatric patients were included in the study with median age of 8.8 years. Among the cases, 11 out of 13 (84.6%) underwent splenorenal shunt, 1 (7.7%) underwent a mesocaval shunt, and another 1 (7.7%) underwent a Modified Rex (mesoportal) shunt. Additionally, 5 out of 13 (38.5%) patients had LT, with 4 out of 5 (80.0%) receiving the transplant before shunt placement, and 1 out of 5 (20.0%) receiving it after shunt placement. Gastrointestinal bleeding resulting from portal hypertension was the indication in all cases. A total of 10 complications were reported in 5 patients; the most common complication was anemia in 3 (23.1%) patients. At the most recent follow-up visit, the shunts were functional without encephalopathy, and no deaths were reported.

Conclusion

Shunt placement plays a crucial role in the management of patients with portal hypertension. Our study demonstrates favorable long-term outcomes in pediatric patients who underwent shunt placement. Long term shunt outcomes were similar and unremarkable in patients with LT and without LT.

Accuracy of non-invasive diagnosis of esophageal varices among cirrhotic patients in a low-income setting

Cirrhosis is a chronic liver disease that is frequently complicated by increased portal venous pressure and the formation of EV. The most common clinical manifestation of portal hypertension is esophageal varices, and ruptured varices are the most fatal complication of portal hypertension. The diagnosis and follow-up of esophageal varices is done by Esophagogastroduodenoscopy, but in most developing countries, the follow-up of cirrhotic patients by gastrointestinal endoscopy remains a challenge.

Objective

Assessment of diagnostic accuracy of noninvasive tests as predictors of esophageal varices among cirrhotic patients at University of Gondar comprehensive Hospital.

Method

Institution based cross-sectional study was conducted among cirrhotic patients from March 2022-October 2022. All study participants underwent screening for Esophageal Varices, Spleen Diameter, Platelet count and Platelet count/spleen diameter ratio. Data were analyzed using SPSS version 26. ROC curves were plotted for Spleen Diameter, Platelet count and Platelet count/spleen diameter ratio with specific cutoffs determined. Diagnostic performance was assessed using ROC curve. The diagnostic thresholds were specified with their sensitivity, specificity, positive predictive value, negative predictive value positive and negative likelihood ratios.

Result

A total of 206 patients were included. The mean age was 41.84 year and SD of (41.84 ± 12.398). About 79.4 % percent were males. Endoscopy confirmed esophageal varices were present in 176(85.4 %) cases. Sixty-seven percent of cases had decompensated cirrhosis (Child-Pugh class B&C). The platelet count to spleen diameter ratio less than 818 had a PPV of 94.7 % (AUROC = 0.835), while spleen diameter greater than 145 mm had 93.7 % PPV (AUROC = 0.783). At a platelet count cutoff <121,000/mm3, the PPV was 95.1 % (AUROC = 0.818).

Conclusion

In this study, platelet count, spleen diameter, and PC/SD all performed well for EV diagnostics, with PC/SD outperforming the others. This finding supports the use of these noninvasive indicators for the diagnosis and implementation of prophylactic treatment foe esophageal varices in health institutions where gastrointestinal endoscopy is unavailable.

Prediction of Esophageal Varices in Viral Hepatitis C Cirrhosis: Performance of Combined Ultrasonography and Clinical Predictors

Objectives

This study is aimed at evaluating the diagnostic performance of clinical predictors and the Doppler ultrasonography in predicting esophageal varices (EV) in patients with hepatitis C-related cirrhosis and exploring the practical predictors of EV.

Methods

We conducted a prospective study from July 2020 to January 2021, enrolling 65 patients with mild hepatitis C-related cirrhosis. We obtained clinical data and performed grayscale and the Doppler ultrasound to explore the predictors of EV. Esophagogastroduodenoscopy (EGD) was performed as the reference test by the gastroenterologist within a week.

Results

The prevalence of EV in the study was 41.5%. Multivariable regression analysis revealed that gender (female, OR = 4.04, p = 0.02), platelet count (<150000 per ml, OR = 3.13, p = 0.09), splenic length (>11 cm, OR = 3.64, p = 0.02), and absent right hepatic vein (RHV) triphasicity (OR = 3.15, p = 0.03) were significant predictors of EV. However, the diagnostic accuracy indices for isolated predictors were not good (AUROC = 0.63-0.66). A combination of these four predictors increases the diagnostic accuracy in predicting the presence of EV (AUROC = 0.80, 95% CI 0.69-0.91). Furthermore, the Doppler assessment of the right hepatic vein waveform showed good reproducibility (κ = 0.76).

Conclusion

Combining clinical and Doppler ultrasound features can be used as a screening test for predicting the presence of EV in patients with hepatitis C-related cirrhosis. The practical predictors identified in this study could serve as an alternative to invasive EGD in EV diagnosis. Further studies are needed to explore the diagnostic accuracy of additional noninvasive predictors, such as elastography, to improve EV screening.

Predicting the Severity of Esophageal Varices in Patients with Hepatic Cirrhosis Using Non-Invasive Markers

Background

The presence and extent of severity of esophageal varices (EV) in patients with liver cirrhosis (LC) are predicted using noninvasive clinical, biochemical, and imaging parameters. The aim of this study was to investigate the accuracy of noninvasive predictors of EV, such as the platelet count-to-spleen diameter ratio (PSR), platelet count-to-spleen volume ratio (PSVR), spleen size (SZ), and a combination of these markers in determining the severity of EV in patients with cirrhosis.

Methods

We recruited 82 inpatients with LC from the Department of Gastroenterology at the First Affiliated Hospital of Guangxi Medical University between January 2018 and December 2019 for this diagnostic investigation. All patients underwent endoscopy, ultrasound, computed tomography, and routine laboratory investigations. For the study, we evaluated and compared the diagnostic accuracy of PSR, PSVR, SZ, and their combinations.

Results

There were significant differences in the area under the receiver operating characteristic (ROC) curve (AUC) in the prediction of severe and moderate/severe EV for all the variables. PSR+PSVR had the highest AUC at 0.735 (95% CI: 0.626-0.826) and 0.765 (95% CI: 0.659-0.852) for predicting severe and moderate/severe EV, respectively. There were statistically significant differences in the AUCs (95% CI) for PSR, PSVR, and PSR+PSVR in predicting the existence of EV. As per the overall model quality chart, the combination of PSR+PSVR was the best indicator for detecting the presence of EV (AUC, 0.696; 95% CI: 0.584-0.792).

Conclusion

In our study, we found that these noninvasive parameters could predict the extent of severity of EV in patients with LC. We anticipate the use of a combination of PSR + PSVR to emerge as the superior indicator as studies progress.

Automated Multimodal Machine Learning for Esophageal Variceal Bleeding Prediction Based on Endoscopy and Structured Data

Esophageal variceal (EV) bleeding is a severe medical emergency related to cirrhosis. Early identification of cirrhotic patients with at a high risk of EV bleeding is key to improving outcomes and optimizing medical resources. This study aimed to evaluate the feasibility of automated multimodal machine learning (MMML) for predicting EV bleeding by integrating endoscopic images and clinical structured data. This study mainly includes three steps: step 1, developing deep learning (DL) models using EV images by 12-month bleeding on TensorFlow (backbones include ResNet, Xception, EfficientNet, ViT and ConvMixer); step 2, training and internally validating MMML models integrating clinical structured data and DL model outputs to predict 12-month EV bleeding on an H2O-automated machine learning platform (algorithms include DL, XGBoost, GLM, GBM, RF, and stacking); and step 3, externally testing MMML models. Furthermore, existing clinical indices, e.g., the MELD score, Child‒Pugh score, APRI, and FIB-4, were also examined. Five DL models were transfer learning to the binary classification of EV endoscopic images at admission based on the occurrence or absence of bleeding events during the 12-month follow-up. An EfficientNet model achieved the highest accuracy of 0.868 in the validation set. Then, a series of MMML models, integrating clinical structured data and the output of the EfficientNet model, were automatedly trained to predict 12-month EV bleeding. A stacking model showed the highest accuracy (0.932), sensitivity (0.952), and F1-score (0.879) in the test dataset, which was also better than the existing indices. This study is the first to evaluate the feasibility of automated MMML in predicting 12-month EV bleeding based on endoscopic images and clinical variables.

Liver and spleen stiffness for the diagnosis of oesophageal varices in adults with chronic liver disease

This is a protocol for a Cochrane Review (diagnostic). The objectives are as follows:

To assess the diagnostic accuracy of liver stiffness and spleen stiffness, separately or in combination, as measured by vibration‐controlled transient elastography (VCTE) in detection of any oesophageal varices in adults with chronic liver disease. We will regard a combination of tests as positive when at least one is positive.

To compare the diagnostic accuracy of individual tests (liver stiffness and spleen stiffness measured by VCTE) directly and versus the combination of both tests (considering positive when at least one is positive) in detecting any oesophageal varices.

To assess the diagnostic accuracy of liver stiffness and spleen stiffness, separately or in combination, as measured by other elastography techniques (2D‐shear wave elastography (2D‐SWE), point shear wave elastography (pSWE), magnetic resonance elastography (MRE)) in detection of any oesophageal varices in adults with chronic liver disease. We will regard a combination of tests as positive when at least one is positive.

To compare the diagnostic accuracy of liver stiffness and spleen stiffness measured by VCTE with other techniques (pSWE, 2D‐SWE, MRE) in detection of any oesophageal varices in adults with chronic liver disease.

Non-invasive diagnosis and follow-up of portal hypertension

Compensated advanced chronic liver disease (cACLD) describes the spectrum of advanced fibrosis/cirrhosis in asymptomatic patients at risk of developing clinically significant portal hypertension (CSPH, defined by a hepatic venous pressure gradient (HVPG) ≥10 mmHg). Patients with cACLD are at high risk of liver-related morbidity and mortality. In patients at risk of chronic liver disease, cACLD is strongly suggested by a liver stiffness (LSM) value >15 kPa or clinical/biological/radiological signs of portal hypertension, and ruled out by LSM <10 kPa, or Fibrotest® ≤0.58, or Fibrometer® ≤0.786. Patients with chronic liver disease (excluding vascular diseases) with a LSM <10 kPa are at low risk of developing portal hypertension complications. The presence of CSPH can be strongly suspected when LSM is ≥20 kPa. In a patient without clinical, endoscopic or radiological features of portal hypertension, measurement of the HVPG is recommended before major liver or intra-abdominal surgery, before extra-hepatic transplantation and in patients with unexplained ascites. Endoscopic screening for oesophageal varices can be avoided in patients with LSM <20 kPa and a platelet count >150 G/L (favourable Baveno VI criteria) at the time of diagnosis. There is no non-invasive method alternative for oeso-gastroduodenal endoscopy in patients with unfavourable Baveno criteria (liver stiffness ≥20 kPa or platelet count ≤50 G/l). Platelet count and liver stiffness measurements must be performed once a year in patients with cACLD with favourable Baveno VI criteria at the time of diagnosis. A screening oeso-gastroduodenal endoscopy is recommended if Baveno VI criteria become unfavourable.

Identifying predictors of varices grading in patients with cirrhosis using ensemble learning

Objectives

The present study was conducted to improve the performance of predictive methods by introducing the most important factors which have the highest effects on the prediction of esophageal varices (EV) grades among patients with cirrhosis.

Methods

In the present study, the ensemble learning methods, including Catboost and XGB classifier, were used to choose the most potent predictors of EV grades solely based on routine laboratory and clinical data, a dataset of 490 patients with cirrhosis gathered. To increase the validity of the results, a five-fold cross-validation method was applied. The model was conducted using python language, Anaconda open-source platform. TRIPOD checklist for prediction model development was completed.

Results

The Catboost model predicted all the targets correctly with 100% precision. However, the XGB classifier had the best performance for predicting grades 0 and 1, and totally the accuracy was 91.02%. The most significant variables, according to the best performing model, which was CatBoost, were child score, white blood cell (WBC), vitalism K (K), and international normalized ratio (INR).

Conclusions

Using machine learning models, especially ensemble learning models, can remarkably increase the prediction performance. The models allow practitioners to predict EV risk at any clinical visit and decrease unneeded esophagogastroduodenoscopy (EGD) and consequently reduce morbidity, mortality, and cost of the long-term follow-ups for patients with cirrhosis.

Platelet Count/Spleen Thickness Ratio and the Risk of Variceal Bleeding in Cirrhosis With Esophagogastric Varices

Introduction

The platelet count/spleen thickness ratio (PC/ST ratio) is associated with the grade of esophagogastric varices (EGV) in cirrhotic patients, but little is known about its relationship with esophagogastric variceal bleeding (EGVB). The aim of this study was to investigate the association between the PC/ST ratio and the risk of EGVB within 1 year in cirrhotic patients.

Methods

A total of 1,354 patients with cirrhosis who had EGV were enrolled in this cohort study. A logistic regression model was used to determine the association between the PC/ST ratio and the risk of EGVB within 1 year in patients with cirrhosis by adjusting the PC/ST ratio with all the important clinical variables and confounders.

Results

The quartile values of the PC/ST ratio were 1.01, 1.36, and 1.98, respectively. The PC/ST ratio was an independent risk factor for variceal bleeding in cirrhotic patients with moderate or severe EGV. After adjusting for multiple variables, the relationship was still unchanged. The odds ratios of the first EGVB in these patients were 5.07-fold at non-adjustment and 3.28-fold after multivariate adjustment. The odds ratios of rebleeding in these patients from the lowest to the highest quartile were 2.34-fold at non-adjustment and 2.01-fold after multivariable adjustment. The PC/ST ratio ≤ 1.36 elevated the 1-year risk of first-time variceal bleeding or rebleeding in cirrhotic patients with moderate or severe EGV (All P &lt; 0.05).

Conclusion

The PC/ST ratio ≤ 1.36 is an independent risk factor for the onset of first bleeding or rebleeding in cirrhotic patients with moderate or severe EGV.

Platelet count/spleen volume ratio has a good predictive value for esophageal varices in patients with hepatitis B liver cirrhosis

Background & aims

Platelet count/spleen longest diameter ratio (PSDR) is widely used in clinical practice due to its good performance in predicting esophageal varices (EV). We obtained spleen volume (SV) by magnetic resonance examination, the purpose of this study was to evaluate the clinical value of platelet count/spleen volume ratio (PSVR) and spleen volume in predicting EV in patients with hepatitis B cirrhosis. Methods: This study was a diagnostic accuracy experiment and retrospective, 199 patients with hepatitis B cirrhosis who met the criteria were selected as the research subjects. All patients were collected blood samples in the morning on an empty stomach within 2 days, and related indicators were tested. Within 10 days, they received electronic gastroscopy and abdominal magnetic resonance examination. According to the Child-Pugh score, the patients were divided into groups with or without EV and with or without high-risk esophageal varices (HRV), then statistical analysis of the two groups was performed.

Results

The area under the curve (AUC) of PSVR in predicting EV or HRV in each group (85.5%-92.6%) was higher than PSDR, SV, spleen diameter, and platelet count. The AUC of PSDR in diagnosing HRV was higher than SV, and the AUC of SV in diagnosing EV was higher than PSDR, but the difference was not significant (P>0.05). In Child-Pugh A patients, Multivariate logistic regression analysis showed PSVR could be a predictor of HRV (P<0.05), SV was a reliable predictor of EV (P<0.05).

Conclusion

PSVR is better than PSDR, spleen diameter, platelet count in predicting EV; in the absence of serological results, SV could be used instead of PSDR. Both can predict EV or HRV of patients with hepatitis B cirrhosis.

A systematic review on application of deep learning in digestive system image processing

With the advent of the big data era, the application of artificial intelligence represented by deep learning in medicine has become a hot topic. In gastroenterology, deep learning has accomplished remarkable accomplishments in endoscopy, imageology, and pathology. Artificial intelligence has been applied to benign gastrointestinal tract lesions, early cancer, tumors, inflammatory bowel diseases, livers, pancreas, and other diseases. Computer-aided diagnosis significantly improve diagnostic accuracy and reduce physicians' workload and provide a shred of evidence for clinical diagnosis and treatment. In the near future, artificial intelligence will have high application value in the field of medicine. This paper mainly summarizes the latest research on artificial intelligence in diagnosing and treating digestive system diseases and discussing artificial intelligence's future in digestive system diseases. We sincerely hope that our work can become a stepping stone for gastroenterologists and computer experts in artificial intelligence research and facilitate the application and development of computer-aided image processing technology in gastroenterology.

Splenic Rhythms and Postprandial Dynamics in Physiology, Portal Hypertension, and Functional Hyposplenism: A Review

BACKGROUND

Before the discovery of immunological and haematological functions of the spleen, it had for centuries been considered to be a digestive organ of variable size with a role in the portal vein system and nutritional metabolism. In the 19th and 20th centuries, volume changes in the spleen related to nutrition were studied using plethysmographic measurements. Rhythmical and regulatory functions of the spleen were demonstrated in the haemodynamics of the splanchnic region and were described as a "hepatolienal pendulum," a "Windkessel function," or a "pressure compensation." These studies were mainly published in German-speaking countries and have not, as far as is known, been discussed in the English-speaking world so far.

SUMMARY

This review explores the historical development of the rhythmical regulatory function of the spleen in the splanchnic region. Older studies and results are followed up in the modern literature, wherever possible, up to the present. The clinical relevance is illustrated with portal hypertension (with congestive or hyperdynamic splenomegaly), coeliac disease, and chronic inflammatory bowel diseases (with functional hyposplenism). Key Message: The spleen's rhythmical regulatory function in nutrition is based on an autonomous rhythm comprising cycles of contractions and dilations of the spleen of around 1 min. These cycles can be influenced by sympathetically mediated single contractions with a release of pooled blood or by portal vein congestion. After food ingestion, the spleen responds either with contraction according to a vasomotor reaction or postprandial congestion with significant increases in volume. The spleen's rhythmical function is lost in the clinical picture of portal hypertension or in coeliac disease and chronic inflammatory bowel diseases. In the aforementioned gastrointestinal diseases, we recommend taking more account of the haemodynamics between the spleen, liver, and intestine. New innovative techniques for recording splenograms are required which, besides elastographic measurements of spleen stiffness, could offer an important tool for early detection, diagnosis, and therapeutic evaluation.

Optimal diagnostic tool for surveillance of oesophageal varices during COVID-19 pandemic

AIM

To study the diagnostic accuracy and utility of triphasic abdominal computed tomography (CT) in the diagnosis and grading of oesophageal varices (OVs) as an alternative to endoscopy during the COVID-19 pandemic.

MATERIALS AND METHODS

A prospective analysis was undertaken of retrospective data from cirrhotic patients who underwent oesophago-gastro-duodenoscopy (OGD) and a triphasic abdominal CT from January to December 2019. Endoscopists and radiologists provided their respective independent assessment of OV grading after being blinded to the clinical details. Performance of CT grading of OVs was compared with the reference standard endoscopic grading using weighted kappa (k). Non-invasive scores such, as aspartate transaminase (AST)-to-platelet ratio index (APRI), Fibrosis-4 (FIB-4) Index, platelet: spleen (PS) ratio were correlated between the two techniques.

RESULTS

OV grading between endoscopists and radiologists showed 81.73% agreement (85 out of 104 patients) in the comparative analysis of 104 cirrhotic patients, of which no varices (57.1%, n=4), small (85.1%, n=23), medium (72.2%%, n=26), and large varices (94.1%, n=32) with a weighted k score of 0.88 (95% confidence interval 0.82-0.94). Overall, the sensitivity of CT in the diagnosis of no, small, medium, and large OVs was 66.6%, 79.3%, 89.6%, and 94.1%, respectively, with an area under the receiver operating curve (AUROC) score of 0.775, 0.887, 0.839, and 0.914. Performance of APRI, FIB-4, and PS ratio correlated well with the severity of OVs with no difference between OGD and CT grading.

CONCLUSION

Triphasic abdominal CT can be an invaluable tool in the diagnosis and grading of OVs during the COVID-19 pandemic.

Plateletcrit and Mean Platelet Volume in the Evaluation of Alcoholic Liver Cirrhosis and Nonalcoholic Fatty Liver Disease Patients

Platelet (PLT) indices have been proposed as potential markers in the assessment of liver fibrosis and exacerbation of liver failure. The aim of our study was to verify mean platelet volume (MPV), platelet distribution width (PDW), and plateletcrit (PCT) in alcohol-related liver cirrhosis (ALC) and nonalcoholic fatty liver disease (NAFLD) patients. One hundred forty-two patients with ALC, 92 with NAFLD, and 68 in control group were enrolled in this study. Hematological indices (MPV, PCT, and PDW) and serological (indirect and direct) markers of liver fibrosis (AAR, APRI, FIB-4, GPR, PICP, PIIINP, TGF-α, PDGF-AB, laminin) were measured in each participant. MELD score in ALC patients and NAFLD fibrosis score (NFS) together with BARD score in the NAFLD group were also obtained. Results were compared between research and control groups. Then, a correlation between evaluated indices was performed in study groups. Receiver operating characteristic curves (ROCs) and area under the curve (AUC) values were applied to assess the diagnostic accuracy of measured indices. Significant increase in PDW and decrease in PCT in comparison to controls were noted in examined ALC (60.4% vs. 51.2% and 0.1% vs. 0.21%, respectively, p < 0.0001) and NAFLD (54.75% vs. 51.2% and 0.19 vs. 0.21%, respectively, p < 0.01) patients. Decreased level of MPV was observed in NAFLD group (7.85 fl vs. 8.90 fl, p < 0.0001). Additionally, PCT correlated with NFS (p < 0.0001). Evaluated PLT indices correlated with MELD score (MPV and PDW, p < 0.001; PCT, p < 0.05). They correlated with indirect and direct markers of liver fibrosis in the whole research group, too. PCT was the parameter with the greatest diagnostic accuracy in ALC patients (AUC = 0,839 for cutoff < 0.17%); in NAFLD group, it was MPV (AUC = 0,808 for cutoff < 7.9 fl). PCT in ALC and MPV in NAFLD can be perceived as potential diagnostic markers.

Liver and spleen elastography as predictor of portal hypertension and esophageal varices

Liver stiffness is related to the degree of hepatic fibrosis which ultimately causes portal hypertension and gastroesophageal varices. Variceal bleeding is a worrisome and potentially fatal complication of cirrhosis, primary prophylaxis has demonstrated a reduction in decompensation and mortality. Portal hypertension and esophageal varices needing treatment could be predicted through noninvasive methods, including elastography, that evaluates the mechanical properties of liver or spleen tissue in concordance to the propagation of mechanical waves. The accurate prediction of the risk of gastroesophageal varices could spare unnecessary endoscopies in patients with low probability of finding varices needing treatment. In the current review, we discuss the elastography modalities available and the current evidence for its implementation in daily clinical practice.

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

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

Clinical Implications of Thrombocytopenia for the Cirrhotic Patient

Thrombocytopenia is a frequent complication in patients with cirrhosis. As many as 84% of patients with cirrhosis have thrombocytopenia, and it is an independent variable indicative of advanced disease and poor prognosis. Although there is great concern that it may aggravate bleeding during surgical procedures, there is limited evidence to inform decisions regarding the treatment of cirrhotic patients with thrombocytopenia undergoing invasive procedures. Finally, there is evidence that platelets play a significant role in liver regeneration. In this report, the clinical implications of thrombocytopenia in cirrhotic patients are reviewed. The utility of platelet counts in the prognosis of cirrhosis and relationship to complications of advanced liver disease, including portal hypertension, esophageal varices, and hepatocellular carcinoma. The impact of low platelet counts on bleeding complications during invasive procedures is outlined. Finally, the role of platelets and potential adverse impact in liver regeneration is reviewed.

The magnitude and correlates of esophageal Varices among newly diagnosed cirrhotic patients undergoing screening fibre optic endoscope before incident bleeding in North-Western Tanzania; a cross-sectional study

Background

Bleeding esophageal varices is a deadly complication of liver cirrhosis. Guidelines recommend an early diagnosis of esophageal varices before incident bleeding by screening all patients diagnosed with liver cirrhosis. Though it has been reported elsewhere that the presence of esophageal varices varies widely among cirrhotic patients this has not been assessed in Tanzania since endoscopy is not readily available for routine use in our setting. This study was designed to determine the prevalence of esophageal varices and assess the utility of clinical parameters in predicting the presence of varices among cirrhotic patients in northwestern Tanzania.

Methods

A cross-sectional analysis of adult patients with liver cirrhosis was done at Bugando Medical Centre. Demographic, clinical, laboratory and endoscopic data were collected and analyzed using STATA 13. The presence of esophageal varices was detected using endoscopic examination and associated factors were assessed by logistic regression. The predictive value of clinical predictors was also assessed by calculating sensitivity and specificity.

Results

A total of 223 patients were enrolled, where 88 (39.5%; 95%CI: 33.0–45.9) had esophageal varices. The varices were independently associated with increased age (OR: 1.02; 95%CI: 1.0–1.04; p = 0.030); increased splenic diameter (OR:1.3; 95%CI:1.2–1.5; p <  0.001), increased portal vein diameter (OR:1.2; 95%CI: 1.07–1.4; p = 0.003), having ascites (OR: 3.0; 95%CI: 1.01–8.7; p = 0.046), and advanced liver disease (OR: 2.9; 95%CI: 1.3–6.7; p = 0.008). PSDR least performed in predicting varices, (AUC: 0.382; 95%CI: 0.304–0.459; cutoff: < 640; Sensitivity: 58.0%; 95%CI: 46.9–68.4; specificity: 57.0%; 95%CI: 48.2–65.5). SPD had better prediction; (AUC: 0.713; 95%CI: 0.646–0.781; cut off: > 15.2 cm; sensitivity: 65.9%; (95% CI: 55–75.7 and specificity:65.2%; 95%CI: 56.5–73.2), followed by PVD, (AUC: 0.6392; 95%CI: 0.566–0.712;cutoff: > 1.45 cm; sensitivity: 62.5%; 95CI: 51.5–72.6; specificity: 61.5%; 95%CI: 52.7–69.7).

Conclusion

Esophageal varices were prevalent among cirrhotic patients, most of which were at risk of bleeding. The non-invasive prediction of varices was not strong enough to replace endoscopic diagnosis. However, the predictors in this study can potentially assist in the selection of patients at high risk of having varices and prioritize them for endoscopic screening and appropriate management.

Liver Ultrasound Patterns in Children With Cystic Fibrosis Correlate With Noninvasive Tests of Liver Disease

OBJECTIVES

Early identification of children with cystic fibrosis (CF) at risk for severe liver disease (CFLD) would enable targeted study of preventative therapies. There is no gold standard test for CFLD. Ultrasonography (US) is used to identify CFLD, but with concerns for its diagnostic accuracy. We aim to determine if differences in standard blood tests, imaging variables and noninvasive liver fibrosis indices correlate with liver US patterns, and thus provide supportive evidence that a heterogeneous US liver pattern reflects clinically relevant liver disease.

METHODS

We studied baseline research abdominal US and bloodwork from 244 children with pancreatic insufficient CF, ages 3 to 12 years, enrolled in a prospective study of the ability of US to predict CF cirrhosis (PUSH study). Children with a heterogeneous (HTG) liver pattern on US (n = 62) were matched 1 : 2 in design with children with normal US (NL, n = 122). Analyses included children with nodular (NOD, n = 22) and homogeneous hyperechoic (HMG, n = 38) livers.

RESULTS

Univariate analysis showed significant differences between US groups for standard blood tests, spleen size, and noninvasive liver fibrosis indices. Multivariable models discriminated NOD versus NL with excellent accuracy (AUROC 0.96). Models also distinguish HTG versus NL (AUROC 0.76), NOD versus HTG (0.78), and HMG versus NL (0.79).

CONCLUSIONS

Liver US patterns in children with CF correlate with platelet count, spleen size and indices of liver fibrosis. Multivariable models of these biomarkers have excellent discriminating ability for NL versus NOD, and good ability to distinguish other US patterns, suggesting that US patterns correlate with clinically relevant liver disease.

The Right Liver Lobe Size/Albumin Concentration Ratio in Identifying Esophageal Varices among Patients with Liver Cirrhosis

BACKGROUND

It is necessity to work more on non-invasive markers like right liver lobe size/albumin concentration ratio for predicting esophageal varices. We aimed to see the right liver lobe/albumin ratio in identifying esophageal varices among patients with cirrhosis caused by hepatitis B and C.

METHODS

A cross-sectional study was conducted among all indoor patients admitted to the Department of Internal Medicine, Pakistan Atomic Energy Commission, General Hospital, Sector H-11/4 Islamabad, Pakistan, during May-December 2016. A non-probability purposive sampling technique was used for data collection. Diagnosed cases of cirrhosis caused by hepatitis B and C virus infection aged 25 years or more were included. A pre-designed questionnaire was used for data collection. Statistical analysis was done using SPSS software version 20.

RESULTS

A total number of 160 patients were included. Mean ± SD age was 56.04 ± 10.22 years, while 96 (60%) were men. Child-Turcotte-Pugh grades showed 41.88% of the patients with grade A, followed by grade B (38.12%), and grade C (20%). Esophageal varices were observed in 76.25% of the patients. The sensitivity was 86.89%, while specificity was 78.95%. The positive predictive value was 92.98% (95% confidence interval [CI] = 86.64% - 96.91%) and negative predictive value was 65.22% (CI = 49.75% - 78.64%) with a diagnostic accuracy of 85%.

CONCLUSION

The use of the studied non-invasive markers of portal hypertension particularly the right liver lobe size/albumin concentration ratio, can help physicians to restrict the use of endoscopic screening only to patients presenting a high probability of esophageal varices.

Hepatic Manifestations of Cystic Fibrosis

Cystic fibrosis liver disease (CFLD) remains the third leading cause of death in patients with cystic fibrosis. Although most patients with CFLD present in childhood, recent studies suggest a second wave of liver disease in adulthood. There are no clear guidelines for diagnosing CFLD. Treatment options for CFLD remain limited, and while UDCA is widely used, its long-term benefit is unclear. Those who develop hepatic decompensation or uncontrolled variceal bleeding may benefit from liver transplant, either alone, or in combination with lung transplant.

Noninvasive Predictors of High-Risk Varices in Patients with Non-Cirrhotic Portal Hypertension

Non-cirrhotic portal hypertension (NCPH) comprises a heterogeneous group of liver disorders causing portal hypertension without cirrhosis and carries a high risk of variceal bleeding. Recent guidelines, based largely on patients with viral cirrhosis, suggest low likelihood of high risk varices (HRV) in patients with a liver stiffness measurement (LSM) <20 kPa and platelet count >150 × 10⁹/L. In NCPH, LSM is often higher than healthy controls but lower than matched cirrhotic patients. The aim of this study was to assess whether LSM or other noninvasive assessments of portal hypertension could predict HRV in NCPH patients. Methods. Records of patients with NCPH seen at a single centre between 2007 and 2018 were reviewed retrospectively. Primary outcome measure was presence or absence of HRV at gastroscopy within 12 months of clinical assessment. Association of LSM or other clinical features of portal hypertension (spleen size, platelet count, platelet count/spleen length ratio (PSL), LSM-spleen length/platelet count ratio score (LSP)) with HRV and ability of these variables to predict HRV was analysed. Results. Of 44 patients with NCPH who met inclusion criteria, 34% (15/44) had HRV. In a multivariate model, spleen size and PSL correlated with HRV but platelet count, LSM, and LSP did not (spleen size: β = 0.35, p = 0.02; OR 1.42, 95% CI 1.06-1.92; PSL: β = -1.47, p = 0.02; OR 0.23, 95% CI 0.07-0.80). There was no significant difference between spleen size and PSL in predicting HRV (AUROC 0.81 (95% CI 0.66 - 0.91) versus 0.71 (95% CI 0.54 - 0.84), respectively, p = 0.400). Spleen size >17.2cm had sensitivity 78.6% and specificity 64.3% for prediction of HRV. Conclusions. In NCPH patients, spleen size may predict risk of HRV at gastroscopy within 12 months. LSM and platelet count are not useful to assess risk of HRV in NCPH.

Measurement of splenic stiffness by 2D-shear wave elastography in patients with extrahepatic portal vein obstruction

OBJECTIVE:

To assess the accuracy of splenic stiffness (SS) measured by 2D-shear wave elastography (SWE) for predicting variceal bleeding in the patients with extrahepatic portal vein obstruction (EHPVO).

METHODS:

52 patients with EHPVO (mean age: 22.29 years; 26 each males and females) were included in the study after obtaining approval from the institute ethics committee. All patients initially underwent upper gastrointestinal endoscopy followed by ultrasonography, including 2D-SWE on the Aixplorer Supersonic Imagine scanner. The SS was measured through the anterior abdominal wall and an average of three measurements was taken. The SS was then compared with clinical symptoms, variceal grade, and other ultrasonography (USG) parameters. USG parameters were also compared with variceal grade.

RESULTS:

The mean SS was 44.92 ± 12.35 kPa. There was no significant difference in the mean SS of patients with high grade varices (44.30 kPa; n = 25) from those with low grade varices (46.91 kPa; n = 20). The ROC analysis showed a poor area under the curve of 0.477 for the prediction of high grade varices by the SS. The SS did not show any significant correlation with other ultrasonography parameters except splenic size, with which there was a weak but significant correlation. The measurement of SS by 2D-SWE was reliable and Cronbach's alpha was 0.905.

CONCLUSION:

The SS measured by 2D-SWE is not an accurate predictor of variceal grade and thus bleeding in patients of EHPVO.

ADVANCES IN KNOWLEDGE:

EHPVO is a vascular pathology with most patients showing splenomegaly and preserved liver function. Although, elastography of spleen has been shown to be useful in patients with cirrhosis for predicting portal hypertension, it does not seem to be helpful in patients with EHPVO.

Clinical Assessment and Management of Portal Hypertension

The development of portal hypertension in a patient with cirrhosis portends a poor prognosis. Untreated or progressive portal hypertension has serious clinical outcomes, which are often fatal. It is important to recognize portal hypertension early to delay progression and to treat complications of portal hypertension as they arise. This review will focus on the clinical assessment and management of portal hypertension.

Deciphering Platelet Kinetics in Diagnostic and Prognostic Evaluation of Hepatocellular Carcinoma

Liver pathophysiology can, directly and indirectly, impose morphological or biochemical abnormalities of the platelets. Conversely, platelets are also able to regulate the promitogenic and profibrotic signals on liver pathobiology. Platelet contribution to the liver pathophysiology is typically facilitated by the platelet-derived growth factors that are sequestered in different subsets of alpha and dense granules, and the release of these growth factors is synchronized according to the stage and type of liver disease or injury. Thus, platelets harbor clinically relevant information with potential diagnostic and prognostic implications in liver diseases. Hepatocellular carcinoma (HCC) largely influences the platelet kinetics, and a growing body of evidence has recognized its association with HCC occurrence or prognosis. This narrative review summarizes the progress made on implicating platelet as a diagnostic and prognostic tool for HCC; the review also dissects the contradictory results from earlier studies and reflects how combining platelet-based information may enable more reliable test for diagnostic and prognostic evaluation of HCC.

Comparison of simplified and traditional pericardial devascularisation combined with splenectomy for the treatment of portal hypertension

AIM

To compare the clinical outcomes of patients with portal hypertension (PH) who underwent treatment with splenectomy plus simplified pericardial devascularisation (SSPD) or splenectomy plus traditional pericardial devascularisation (STPD).

METHODS

We conducted a single-centre retrospective study of 1045 PH patients treated with either SSPD (S Group, 357 patients) or STPD (T Group, 688 patients) between January 2002 and February 2017. In all, 37 clinical indicators were compared to evaluate the efficacy of SSPD.

RESULTS

Perioperative indicators in the S Group were significantly better than those in the T Group (P < 0.05). In both groups, the postoperative long-term portal vein diameter and Model for End-Stage Liver Disease score were significantly lower than those in the preoperative and postoperative short-term groups (P < 0.05). The incidence of complications in the S Group was significantly lower than that in the T Group (P < 0.05). Compared to the T Group, postoperative short-term WBC (white blood cell) and platelet counts were significantly lower and the short-term Hb (haemoglobin) level was significantly higher in the S Group (P < 0.05). In the S Group, postoperative long-term total bilirubin, direct bilirubin, alanine transaminase, and aspartate transaminase and postoperative serum creatinine and cystatin C levels were significantly lower than those in the T Group (P < 0.05), and postoperative albumin was significantly higher than that in the T Group (P < 0.05).

CONCLUSION

Compared to STPD, SSPD is a simple and easy procedure resulting in less tissue damage. Patients recovered smoothly and steadily with fewer complications. Short-term liver and kidney function damage was less severe, and long-term liver function recovery was better. Therefore, SSPD is worthy of clinical promotion and application for the treatment of PH.

Capsule endoscopy for the diagnosis of oesophageal varices in people with chronic liver disease or portal vein thrombosis

BACKGROUND

Current guidelines recommend performance of oesophago-gastro-duodenoscopy at the time of diagnosis of hepatic cirrhosis to screen for oesophageal varices. These guidelines require people to undergo an unpleasant invasive procedure repeatedly with its attendant risks, despite the fact that half of the people do not have identifiable oesophageal varices 10 years after the initial diagnosis of cirrhosis. Video capsule endoscopy is a non-invasive test proposed as an alternative method for the diagnosis of oesophageal varices.

OBJECTIVES

To determine the diagnostic accuracy of capsule endoscopy for the diagnosis of oesophageal varices in children or adults with chronic liver disease or portal vein thrombosis, irrespective of the aetiology. To investigate the accuracy of capsule endoscopy as triage or replacement of oesophago-gastro-duodenoscopy.

SEARCH METHODS

We searched the Cochrane Hepato-Biliary Group Diagnostic Test Accuracy Studies Register (October 2013), MEDLINE (Ovid SP) (1950 to October 2013), EMBASE (Ovid SP) (1980 to October 2013), ACP Journal Club (Ovid SP) (1991 to October 2013), Database of Abstracts of Reviews of Effects (DARE) (Ovid SP) (third quarter), Health Technology Assessment (HTA) (Ovid SP) (third quarter), NHS Economic Evaluation Database (NHSEED) (Ovid SP) (third quarter), and Science Citation Index Expanded (SCI-EXPANDED) (ISI Web of Knowledge) (1955 to October 2013). We applied no language or document type restrictions.

SELECTION CRITERIA

Studies that evaluated the diagnostic accuracy of capsule endoscopy for the diagnosis of oesophageal varices using oesophago-gastro-duodenoscopy as the reference standard in children or adults of any age, with chronic liver disease or portal vein thrombosis.

DATA COLLECTION AND ANALYSIS

We followed the available guidelines provided in the Cochrane Handbook for Diagnostic Test of Accuracy Reviews. We calculated the pooled estimates of sensitivity and specificity using the bivariate model due to the absence of a negative correlation in the receiver operating characteristic (ROC) space and of a threshold effect.

MAIN RESULTS

The search identified 16 eligible studies, in which only adults with cirrhosis were included. In one study, people with portal thrombosis were also included. We classified most of the studies at high risk of bias for the 'Participants selection' and the 'Flow and timing' domains. One study assessed the accuracy of capsule endoscopy for the diagnosis of large (high-risk) oesophageal varices. In the remaining15 studies that assessed the accuracy of capsule endoscopy for the diagnosis of oesophageal varices of any size in people with cirrhosis, 936 participants were included; the pooled estimate of sensitivity was 84.8% (95% confidence interval (CI) 77.3% to 90.2%) and of specificity 84.3% (95% CI 73.1% to 91.4%). Eight of these studies included people with suspected varices or people with already diagnosed or even treated varices, or both, introducing a selection bias. Seven studies including only people with suspected but unknown varices were at low risk of bias; the pooled estimate of sensitivity was 79.7% (95% CI 73.1% to 85.0%) and of specificity 86.1% (95% CI 64.5% to 95.5%). Six studies assessed the diagnostic accuracy of capsule endoscopy for the diagnosis of large oesophageal varices, associated with a higher risk of bleeding; the pooled sensitivity was 73.7% (95% CI 52.4% to 87.7%) and of specificity 90.5% (95% CI 84.1% to 94.4%). Two studies also evaluated the presence of red marks, which are another marker of high risk of bleeding; the estimates of sensitivity and specificity varied widely. Two studies obtained similar results with the use of a modified device as index test (string capsule). Due to the absence of data, we could not perform all planned subgroup analyses. Interobserver agreement in the interpretation of capsule endoscopy results and any adverse event attributable to capsule endoscopy were poorly assessed and reported. Only four studies evaluated the interobserver agreement in the interpretation of capsule endoscopy results: the concordance was moderate. The participants' preferences for capsule endoscopy or oesophago-gastro-duodenoscopy were reported differently but seemed in favour of capsule endoscopy in nine of 10 studies. In 10 studies, participants reported some minor discomfort on swallowing the capsule. Only one study identified other significant adverse events, including impaction of the capsule due to previously unidentified oesophageal strictures in two participants. No adverse events were reported as a consequence of the reference standard.

AUTHORS' CONCLUSIONS

We cannot support the use of capsule endoscopy as a triage test in adults with cirrhosis, administered before oesophago-gastro-duodenoscopy, despite the low incidence of adverse events and participant reports of being better tolerated. Thus, we cannot conclude that oesophago-gastro-duodenoscopy can be replaced by capsule endoscopy for the detection of oesophageal varices in adults with cirrhosis. We found no data assessing capsule endoscopy in children and in people with portal thrombosis.