Invasive and noninvasive methods to diagnose portal hypertension and esophageal varices

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.

Non-invasive model for predicting high-risk esophageal varices based on liver and spleen stiffness

BACKGROUND

Acute bleeding due to esophageal varices (EVs) is a life-threatening complication in patients with cirrhosis. The diagnosis of EVs is mainly through upper gastrointestinal endoscopy, but the discomfort, contraindications and complications of gastrointestinal endoscopic screening reduce patient compliance. According to the bleeding risk of EVs, the Baveno VI consensus divides varices into high bleeding risk EVs (HEVs) and low bleeding risk EVs (LEVs). We sought to identify a non-invasive prediction model based on spleen stiffness measurement (SSM) and liver stiffness measurement (LSM) as an alternative to EVs screening.

AIM

To develop a safe, simple and non-invasive model to predict HEVs in patients with viral cirrhosis and identify patients who can be exempted from upper gastrointestinal endoscopy.

METHODS

Data from 200 patients with viral cirrhosis were included in this study, with 140 patients as the modelling group and 60 patients as the external validation group, and the EVs types of patients were determined by upper gastrointestinal endoscopy and the Baveno VI consensus. Those patients were divided into the HEVs group (66 patients) and the LEVs group (74 patients). The effect of each parameter on HEVs was analyzed by univariate and multivariate analyses, and a non-invasive prediction model was established. Finally, the discrimination ability, calibration ability and clinical efficacy of the new model were verified in the modelling group and the external validation group.

RESULTS

Univariate and multivariate analyses showed that SSM and LSM were associated with the occurrence of HEVs in patients with viral cirrhosis. On this basis, logistic regression analysis was used to construct a prediction model: Ln [P/(1-P)] = -8.184 -0.228 × SSM + 0.642 × LSM. The area under the curve of the new model was 0.965. When the cut-off value was 0.27, the sensitivity, specificity, positive predictive value and negative predictive value of the model for predicting HEVs were 100.00%, 82.43%, 83.52%, and 100%, respectively. Compared with the four prediction models of liver stiffness-spleen diameter to platelet ratio score, variceal risk index, aspartate aminotransferase to alanine aminotransferase ratio, and Baveno VI, the established model can better predict HEVs in patients with viral cirrhosis.

CONCLUSION

Based on the SSM and LSM measured by transient elastography, we established a non-invasive prediction model for HEVs. The new model is reliable in predicting HEVs and can be used as an alternative to routine upper gastrointestinal endoscopy screening, which is helpful for clinical decision making.

Indications and methods for measuring portal hypertension in cirrhosis

Background and objectives: Over the last decade our understanding of the pathophysiology of portal hypertension has increased. Novel diagnostic technologies have facilitated and improved the diagnosis and treatment of hepatic fibrosis and cirrhosis. With this review we aim to provide an overview of contemporary diagnostic principles of portal hypertension and indications for measuring portal pressure in cirrhosis.Methods: By review of current literature, we assessed new and old principles of measuring portal hypertension and the diagnostic values of the methods.Results: Invasive measurement of the portal pressure is still the gold standard to quantitate portal hypertension and to assess response to vasoactive treatment. The size of the portal pressure is important to assess since it contains information on the course of the disease and risk of developing hepatic decompensation, hepatocellular carcinoma, and mortality. Reliable non-invasive Elastography techniques are emerging that adequately assess portal pressure, but the available methods are not yet sufficiently accurate.Conclusion: Although elastography techniques provide valuable information and are good monitoring tools, liver vein catheterization remains valuable in diagnosing and monitoring portal hypertension, especially in combination with a trans-jugular liver biopsy.

A vein-viewing application enabled detecting abdominal wall varices related to the presence of non-treated gastroesophageal varices: a cross-sectional study

BACKGROUND

Gastroesophageal varices (GOV) are a life-threatening complication in chronic liver disease. A method for non-invasively predicting GOV is crucial for management. This study aimed to determine whether a vein-viewing application can detect abdominal wall varices (AWV) and elucidate the relationship between AWV and GOV.

METHODS

One-hundred patients with chronic liver diseases were prospectively enrolled. All the patients underwent esophagogastroduodenoscopy within three months of the enrollment. Unmanipulated images (UI) and vein-weighted images (VWI) were taken for assessing AWV by a vein-viewing application on iPhone. Two doctors independently evaluated both image types. We defined the grading of both UI and AWV as grade 0 (non-detectable), grade 1 (slightly detectable), and grade 2 (distinct).

RESULTS

The causes of liver diseases among the 71 men and 29 women (median age, 70.5 yr) included Hepatitis B (n = 19), Hepatitis C (n = 21), alcoholism (n = 33), primary biliary cholangitis (n = 3), autoimmune hepatitis (n = 4) and others (n = 20). GOV was indicated in 60 patients, and half of them had not been treated previously (non-treated). VWI could significantly visualize AWV than UI (72% vs. 24%, p = 0.0005). The presence of cirrhosis (chronic hepatitis vs. cirrhosis = 64.6% vs. 91.4%, p = 0.004) and GOV (52.3% vs. 74.3%, p = 0.032) were significantly higher in the VWI-AWV grade 2 group. Multivariate analysis demonstrated that VWI-AWV grade 2 was an independent factor related to the presence of non-treated GOV [OR = 3.05 (1.24-7.53), p = 0.016].

CONCLUSIONS

The vein-viewing application non-invasively detected AWV related to the presence of cirrhosis and GOV, and VWI-AWV grade 2 was an independent factor related to the presence of non-treated GOV.

Novel imaging-based approaches for predicting the hepatic venous pressure gradient in a porcine model of liver cirrhosis and portal hypertension

AIMS

Hepatic venous pressure gradient (HVPG) is critical for staging and prognosis prediction of portal hypertension (PH). However, HVPG measurement has limitations (e.g., invasiveness). This study examined the value of non-invasive, imaging-based approaches including magnetic resonance elastography (MRE) and intravoxel incoherent motion (IVIM) diffusion-weighted imaging (DWI) for the prediction of HVPG in a porcine model of liver cirrhosis and PH.

MAIN METHODS

Male Bama miniature pigs were used to establish a porcine model of liver cirrhosis and PH induced by embolization. They were randomly assigned to an experimental group (n = 12) and control group (n = 3). HVPG was examined before and after transjugular intrahepatic portosystemic shunt (TIPS). MRE and IVIM-DWI were performed to obtain quantitative parameters including liver stiffness (LS) in MRE, tissue diffusivity (D), pseudo-diffusion coefficient (D*), and perfusion fraction (f) in IVIM-DWI. The correlation between HVPG and the parameters was assessed.

KEY FINDINGS

LS values were significantly greater in the experimental group, while f values were significantly decreased at 4, 8, and 12 weeks after embolization compared to the control group. Furthermore, HVPG was significantly lower immediately after versus before TIPS. In parallel, LS and f values showed significant alterations after TIPS, and these changes were consistent with a reduction in HVPG. Spearman analysis revealed a significant correlation between the parameters (LS and f) and HVPG. The equation was eventually generated for prediction of HVPG.

SIGNIFICANCE

The findings show a good correlation between HVPG and the quantitative parameters; thus, imaging-based techniques have potential as non-invasive methods for predicting HVPG.

Assessment of a biofluid mechanics-based model for calculating portal pressure in canines

BACKGROUND

Portal hypertension is a severe complication caused by various chronic liver diseases. The standard methods for detecting portal hypertension (hepatic venous pressure gradient and free portal pressure) are available in only a few hospitals due to their technical difficulty and invasiveness; thus, non-invasive measuring methods are needed. This study aimed to establish and assess a novel model to calculate free portal pressure based on biofluid mechanics.

RESULT

Comparison of each dog's virtual and actual free portal pressure showed that a biofluid mechanics-based model could accurately predict free portal pressure (mean difference: -0.220, 95% CI: - 0.738 to 0.298; upper limit of agreement: 2.24, 95% CI: 1.34 to 3.14; lower limit of agreement: -2.68, 95% CI: - 3.58 to - 1.78; intraclass correlation coefficient: 0.98, 95% CI: 0.96 to 0.99; concordance correlation coefficient: 0.97, 95% CI: 0.93 to 0.99) and had a high AUC (0.984, 95% CI: 0.834 to 1.000), sensitivity (92.3, 95% CI: 64.0 to 99.8), specificity (91.7, 95% CI: 61.5 to 99.8), positive likelihood ratio (11.1, 95% CI: 1.7 to 72.8), and low negative likelihood ratio (0.08, 95% CI: 0.01 to 0.6) for detecting portal hypertension.

CONCLUSIONS

Our study suggests that the biofluid mechanics-based model was able to accurately predict free portal pressure and detect portal hypertension in canines. With further research and validation, this model might be applicable for calculating human portal pressure, detecting portal hypertensive patients, and evaluating disease progression and treatment efficacy.

Prediction of esophageal varices in patients with HCV-related cirrhosis using albumin-bilirubin, platelets-albumin-bilirubin score, albumin-bilirubin-platelets grade, and GAR

Background

Development of esophageal varices (EVs) is the main complication of portal hypertension. Early detection prevents variceal bleeding. Baveno VI consensus recommended endoscopy if transient elastography (TE) > 20 kPa and platelets below 150,000/mm3.

Aim

Assessment of the reliability of the albumin-bilirubin (ALBI), platelets-albumin-bilirubin (PALBI), albumin-bilirubin-platelets (ALBI-PLT) score, and gamma-glutamyl transferase-platelets (GAR) ratio as non-invasive models for prediction of EVs presence and the need for endoscopy in patients with HCV-related cirrhosis.

Methods

HCV-related F4 fibrosis by TE or cirrhosis patients were included (n = 661). Full metabolic profile, CBC, ultrasonography, and endoscopy were done.

Results

The average age was 42.89 years mainly males. Patients with EVs had statistically significant (p < 0.05) higher TE values, ALBI, ALBI-PLT, and PALBI than those without EVs. Both groups were comparable for GAR. Large varices were statistically (p < 0.05) associated with higher ALBI, ALBI-PLT, and PALBI. Both small and large varices had comparable TE and GAR. EVs detection cutoffs (sensitivity, specificity): TE > 20 kPa (83.64%, 91.62%), ALBI >− 2.43 (81.28%, 74.89%), ALBI-PLT > 3 (77.34%, 72.93%), and PALBI >− 2.28 (62.1%, 76.4%). On comparison of the ROCs, TE was better than ALBI (p < 0.05), ALBI-PLT, and PALBI. ALBI was better than ALBI-PLT and PALBI. Both ALBI-PLT and PALBI are comparable (p > 0.05). Positive indirect hemagglutination of schistosomiasis, portal vein diameter, splenic vein diameter, TE, ALBI, ALBI-PLT, and PALBI were independent predictors of EVs existence. On multivariate analysis, portal vein diameter, TE, and ALBI score were significant.

Conclusion

The ALBI, ALBI-PLT, and PALBI are useful predictors of EVs presence and the need of diagnostic endoscopy especially in centers that lack FibroScan.

Pathophysiological-based treatments of complications of cirrhosis

Detailed knowledge and understanding of the pathophysiological mechanisms and changes in hepatic and splanchnic function leading to the development of haemodynamic changes and portal hypertension in patients with cirrhosis are essential since it guides the search for targets to ameliorate liver-related abnormalities. Recent research has focused on the gut-liver axis, changes in intestinal permeability, translocation of bacterial products, and inflammation as important drivers of haemodynamic alterations and thereby targets for treatment. Additionally, treatment strategies should focus on microbiotic modulation, antiangiogenics, anti-inflammatory strategies, and modulation of bile acid metabolism. This paper aims to review contemporary pathophysiological-based treatment principles of the major complications of cirrhosis and portal hypertension and future targets for treatment.

Emergent Transjugular Intrahepatic Portosystemic Shunt Creation in Acute Variceal Bleeding

Emergent transjugular intrahepatic portosystemic shunt (TIPS) creation is most commonly employed in the setting of acute variceal hemorrhage. Given a propensity for decompensation, these patients often require a multidisciplinary, multimodal approach involving prompt diagnosis, pharmacologic therapy, and endoscopic intervention. While successful in the majority of cases, failure to medically control initial bleeding can prompt interventional radiology consultation for emergent portal decompression via TIPS creation. This article discusses TIPS creation in emergent, acute variceal hemorrhage, reviewing the natural history of gastroesophageal varices, presentation and diagnosis of acute variceal hemorrhage, pharmacologic therapy, endoscopic approaches, patient selection and risk stratification for TIPS, technical considerations for TIPS creation, adjunctive embolotherapy, and the role of salvage TIPS versus early TIPS in acute variceal hemorrhage.

Liaoning Score for Prediction of Esophageal Varices in Cirrhotic Patients Who Had Never Undergone Endoscopy: A Multicenter Cross-Sectional Study in Liaoning Province, China

BACKGROUND AND AIMS

Endoscopy is necessary for assessment of esophageal varices (EVs) in cirrhotic patients, but its use is limited because of the poor compliance of patients and shortage of public health resources at primary hospitals or rural areas, especially in less well developed countries. A multicenter cross-sectional study aimed to establish a novel non-invasive score for prediction of EVs in cirrhotic patients who had never undergone endoscopy.

METHODS

Patients with liver cirrhosis regardless of acute upper gastrointestinal bleeding (AUGIB) who underwent the first-time upper gastrointestinal endoscopy at 11 hospitals in Liaoning Province, China were considered. Independent predictors for EVs were identified by multivariate logistic regression analysis and then combined into an equation. The diagnostic performance with area under curve (AUC) was further evaluated by receiver operating characteristic curve analysis.

RESULTS

Overall, 363 patients were included, of whom 260 had EVs and 180 presented with AUGIB. In all patients, AUGIB, ascites, and platelets were the independent predictors for EVs. The equation (i.e., Liaoning score) was 0.466 + 1.088 × AUGIB (1 = yes; 0 = no) + 1.147 × ascites (1 = yes; 0 = no) - 0.012 × platelets, which had an AUC of 0.807 (p < 0.0001). In patients with AUGIB, ascites and platelets were the independent predictors for EVs. The equation was as follows: 1.205 + 1.557 × ascites (1 = yes; 0 = no) - 0.008 × platelets, which had an AUC of 0.782 (p < 0.0001). In patients without AUGIB, platelets was the only independent predictor for EVs, which had an AUC of 0.773 (p < 0.0001).

CONCLUSION

The Liaoning score is based on easy-to-access regular clinical and laboratory data and has a good diagnostic performance for non-invasive prediction of EVs in cirrhotic patients.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02593799.

Contrast-Enhanced CT May Be a Diagnostic Alternative for Gastroesophageal Varices in Cirrhosis with and without Previous Endoscopic Variceal Therapy

BACKGROUND AND AIMS

Liver fibrosis blood tests, platelet count/spleen diameter ratio (PSR), and contrast-enhanced CT are diagnostic alternatives for gastroesophageal varices, but they have heterogeneous diagnostic performance among different study populations. Our study is aimed at evaluating their diagnostic accuracy for esophageal varices (EVs) and gastric varices (GVs) in cirrhotic patients with and without previous endoscopic variceal therapy.

METHODS

Patients with liver cirrhosis who underwent blood tests and contrast-enhanced CT scans as well as endoscopic surveillance should be potentially eligible. EVs needing treatment (EVNTs) and GVs needing treatment (GVNTs) were recorded according to the endoscopic results. Area under the curves (AUCs) were calculated.

RESULTS

Overall, 279 patients were included. In 175 patients without previous endoscopic variceal therapy, including primary prophylaxis population (n = 70), acute bleeding population (n = 38), and previous bleeding population (n = 67), the diagnostic accuracy of contrast-enhanced CT for EVNTs was higher (AUCs = 0.816-0.876) as compared to blood tests and PSR; by comparison, the diagnostic accuracy of contrast-enhanced CT for GVNTs was statistically significant among primary prophylaxis population (AUC = 0.731, P = 0.0316), but not acute or previous bleeding population. In 104 patients with previous endoscopic variceal therapy (i.e., secondary prophylaxis population), contrast-enhanced CT was the only statistically significant alternative for diagnosing EVNTs and GVNTs but with modest accuracy (AUCs = 0.673 and 0.661, respectively).

CONCLUSIONS

Contrast-enhanced CT might be a diagnostic alternative for EVNTs in cirrhotic patients, but its diagnostic performance was slightly weakened in secondary prophylaxis population. Additionally, contrast-enhanced CT may be considered for diagnosis of GVNTs in primary prophylaxis population without previous endoscopic variceal therapy and secondary prophylaxis population.

Spleen and liver stiffness for noninvasive assessment of portal hypertension in cirrhotic patients with large esophageal varices

PURPOSE

Noninvasive evaluation of portal hypertension is needed for cirrhotic patients with large esophageal varices. This study was aimed at assessing the diagnostic value of liver/spleen stiffness in predicting hepatic vein pressure gradient (HVPG) in this special population.

METHODS

In the present prospective cohort study, liver/spleen stiffness was measured by transient elastography. Patients also underwent HVPG assessment, upper gastrointestinal endoscopy, and other noninvasive serum models.

RESULTS

Ninety-nine cirrhotic patients with large esophageal varices were enrolled. Liver/spleen stiffness strongly correlated with HVPG. In regards to significant portal hypertension, area under receiver operating characteristic curves (AUROCs) for liver/spleen stiffness were 0.74 and 0.91. Accuracy for detecting significant portal hypertension was 79% for spleen stiffness of 48.9 kPa (sensitivity: 76%, specificity: 100%, positive predictive value: 100%, negative predictive value: 38%) and 75% for liver stiffness of 16.0 kPa (sensitivity: 78%, specificity: 54%, positive predictive value: 92%, negative predictive value: 27%). Similarly, spleen stiffness had significant higher AUROCs for predicting HVPG ≥16 and ≥20 mm Hg than that of liver stiffness and other noninvasive serum models.

CONCLUSION

In cirrhotic patients with large esophageal varices, liver stiffness and spleen stiffness correlate with HVPG, and spleen stiffness is superior to liver stiffness in predicting portal hypertension.

Large oesophageal varice screening by a sequential algorithm using a cirrhosis blood test and optionally capsule endoscopy

BACKGROUND & AIMS

Large oesophageal varice (LEV) screening is recommended in cirrhosis. We performed a prospective study to improve non-invasive LEV screening.

DESIGN

287 patients with cirrhosis had upper gastrointestinal endoscopy (LEV reference), oesophageal capsule endoscopy (ECE), liver elastography and blood marker analyses. CirrhoMeter (cirrhosis blood test), the most accurate non-invasive LEV test, was segmented for cirrhosis (reference comparator) or LEV. VariScreen, a sequential and partially minimally invasive diagnostic algorithm, was developed by multivariate analysis. It uses CirrhoMeter first, then ECE if CirrhoMeter cannot rule LEV out or in, and finally endoscopy if CirrhoMeter+ECE combination remains uninformative.

RESULTS

Diagnostic effectiveness rates for LEV were: cirrhosis-segmented CirrhoMeter: 14.6%, LEV-segmented CirrhoMeter: 34.6%, ECE: 60.6% and VariScreen: 66.4% (P ≤ .001 for overall or pair comparison). The respective missed LEV rates were: 2.8%, 5.6%, 8.3% and 5.6% (P = .789). Spared endoscopy rates were, respectively: 15.6%, 36.0%, 70.6% and 69%, (P < .001 for overall or paired comparison except ECE vs VariScreen: P = .743). VariScreen spared 38% of ECE and reduced missed LEV by 87% compared to classical ECE performed in all patients. Excepting cirrhosis-segmented CirrhoMeter, these spared endoscopy rates were significantly higher than that of the Baveno VI recommendation (using platelets and Fibroscan): 18.4% (P < .001). Ascites and Child-Pugh class independently predicted endoscopy sparing by VariScreen: from 86.0% in compensated Child Pugh class A to 24.1% in Child-Pugh class C with ascites.

CONCLUSION

VariScreen algorithm significantly reduced the missed LEV rate with ECE by 87%, ECE use by 38% and endoscopy requirement by 69%, and even 86% in compensated cirrhosis.

Comparison of physical parameter measurements between peripheral and portal blood samples in patients with portal hypertension

BACKGROUND

Measuring portal venous pressure is necessary to examine, diagnose, and treat portal hypertension, but current methods are invasive.

OBJECTIVE

This study aimed to determine whether a noninvasive peripheral blood measurement could be used to estimate portal venous pressure by investigating correlations between certain physical parameter measurements in the peripheral blood with those obtained in portal blood samples.

METHODS

A total of 128 peripheral and portal blood samples from patients (n= 128) were analyzed for blood rheology and routine blood parameters.

RESULTS

The mean peripheral and portal whole blood viscosities under the shear rates of 200 s-1 (BV 200 s-1) were 2.97 ± 0.50 mPa.s and 3.06 ± 0.39 mPa.s. The mean peripheral and portal BV 30 s-1 values were 3.96 ± 0.79 mPa.s and 4.16 ± 0.64 mPa.s. We observed strong correlations between peripheral and portal blood measurements of BV 200 s-1 (r2= 0.9649), BV 30 s-1 (r2= 0.9622), BV 5 s-1 (r2= 0.9610), and BV 1 s-1 (r2= 0.9623).

CONCLUSIONS

Our results indicate that peripheral blood can be used to evaluate certain parameters in portal blood for use in biofluid mechanics studies, and to provide noninvasive measurement of portal venous pressure.

Significance of ultrasonography in evaluating progression of liver cirrhosis

AIM

To evaluate the significance of ultrasonography in assessing the progression of liver cirrhosis.

METHODS

Seventy patients with cirrhosis were selected from July 2014 to September 2016 at Maternal and Child Health Care Hospital of Yuhang District of Hangzhou. According to whether the patients had gastrointestinal bleeding or not, they were divided into a non-bleeding group (n = 43) and a bleeding group (n = 27). Seventy healthy volunteers were included as a control group. Color Doppler ultrasound was used to measure the diameter, blood flow velocity, blood flow amount and shunt index of the portal vein, splenic vein, and left gastric vein.

RESULTS

The diameter and blood flow amount of the portal vein were significantly higher and the blood flow velocity of the portal vein was significantly lower in the bleeding group than in the non-bleeding group and control group (P < 0.05). The diameter and blood flow amount of the splenic vein were significantly higher and the blood flow velocity of the splenic vein was significantly lower in the bleeding group than in the non-bleeding group and control group (P < 0.05). The diameter and shunt index of the left gastric vein were significantly higher in the bleeding group than in the non-bleeding group and control group (P < 0.05), and in the non-bleeding group than in the control group (P < 0.05).

CONCLUSION

Color Doppler ultrasound can detect the hemodynamics of the portal vein, accurately predict gastrointestinal bleeding, and evaluate the progression of the disease in cirrhotic patients.

Usefulness of Contrast-Enhanced Ultrasonography for Predicting Esophageal Varices in Patients with Hepatitis B Virus (HBV)-Related Cirrhosis

Background

The aim of this study was to investigate the usefulness of contrast-enhanced ultrasonography (CEUS) in predicting of esophageal varices (EV) and assessing high-risk EV in patients with hepatitis B virus (HBV)-related cirrhosis.

Material/Methods

Patients with HBV-related cirrhosis who had undergone endoscopy were prospectively recruited. Hepatic dynamic CEUS was performed. Regions of interest (ROI) were drawn on the hepatic artery, hepatic vein, portal vein, and liver parenchyma to measure the corresponding features, such as arrival times. Spearman’s correlation analysis was used to determine the relations between several dynamic CEUS features and the degree of EV. Receiver operating characteristics (ROC) curves were constructed to investigate the diagnostic performance of CEUS in assessing the presence of EV and high-risk EV.

Results

Fifty-eight patients (44 men; mean age 51.3 years) were included in this study. Of these, 18 (31.0%), 12 (20.7%), 11 (19.0%), and 17 (29.3%) of patients had grade 0, 1, 2, and 3 EV, respectively. Grade 2 and grade 3 EV were considered high-risk EV. Among the CEUS features, the area under the ROC curves of intrahepatic transit time (HV–HA, i.e., the difference between hepatic vein arrival time and hepatic artery arrival time) both for assessment of the presence of EV and high-risk EV (0.883 and 0.915, respectively) were larger than the other indices. HV–HA was negatively correlated with the grade of EV. An HV–HA of under 8.2 s indicated the presence of EV and under 7 s indicated high-risk EV.

Conclusions

Dynamic CEUS imaging is useful in assessing the presence of EV and high-risk EV in patients with HBV-related cirrhosis.

Phase-contrast MR flow imaging: A tool to determine hepatic hemodynamics in rats with a healthy, fibrotic, or cirrhotic liver

PURPOSE

To test a magnetic resonance (MR) scanning protocol as a noninvasive tool to determine hepatic hemodynamics and to assess the degree of liver fibrosis in an animal model of liver fibrosis and cirrhosis.

MATERIALS AND METHODS

Fifty-four male Wistar rats were studied. Thirty-nine received thioacetamide (TAA) in their drinking water for either 12 or 16 weeks. MR measurements were performed using flow-sensitive 2D phase-contrast MRI and a 9.4T preclinical scanner. The following hemodynamic parameters were investigated: portal cross-sectional area, mean portal flow velocity, and portal and aortic flow volume rate. Therefore, rats (n = 46) were divided into three groups: CON (control, n = 13), FIB (fibrosis, n = 25), and CIR (cirrhosis, n = 8). Furthermore, the degree of liver fibrosis was assessed by a self-established MR score and verified by a standardized histological score (n = 48).

RESULTS

Portal and aortic flow parameters could be reliably detected. A significant decrease in portal flow velocity was found in FIB (FIB vs. CON: -21%, P = 0.006 and CIR vs. CON: -17%, P = 0.105) and in portal flow volume rate in FIB and CIR (FIB vs. CON: -20%, P = 0.009 and CIR vs. CON: -25%, P = 0.024). If the histological score is taken as standard, the self-established MR score enabled discrimination between healthy and diseased livers (sensitivity to identify diseased livers: 89% and specificity to identify healthy livers: 100%).

CONCLUSION

This MR scanning protocol presents a noninvasive tool to determine hepatic hemodynamics in healthy and diseased rats.

LEVEL OF EVIDENCE

2 Technical Efficacy: Stage 1 J. Magn. Reson. Imaging 2017;46:1526-1534.

Effect of Pulse Shaping on Subharmonic Aided Pressure Estimation In Vitro and In Vivo

OBJECTIVES

Subharmonic imaging (SHI) is a technique that uses the nonlinear oscillations of microbubbles when exposed to ultrasound at high pressures transmitting at the fundamental frequency ie, f_o and receiving at half the transmit frequency (ie, f_o /2). Subharmonic aided pressure estimation (SHAPE) is based on the inverse relationship between the subharmonic amplitude of the microbubbles and the ambient pressure change.

METHODS

Eight waveforms with different envelopes were optimized with respect to acoustic power at which the SHAPE study is most sensitive. The study was run with four input transmit cycles, first in vitro and then in vivo in three canines to select the waveform that achieved the best sensitivity for detecting changes in portal pressures using SHAPE. A Logiq 9 scanner with a 4C curvi-linear array was used to acquire 2.5 MHz radio-frequency data. Scanning was performed in dual imaging mode with B-mode imaging at 4 MHz and a SHI contrast mode transmitting at 2.5 MHz and receiving at 1.25 MHz. Sonazoid, which is a lipid stabilized gas filled bubble of perfluorobutane, was used as the contrast agent in this study.

RESULTS

A linear decrease in subharmonic amplitude with increased pressure was observed for all waveforms (r from -0.77 to -0.93; P < .001) in vitro. There was a significantly higher correlation of the SHAPE gradient with changing pressures for the broadband pulses as compared to the narrowband pulses in both in vitro and in vivo results. The highest correlation was achieved with a Gaussian windowed binomial filtered square wave with an r-value of -0.95. One of the three canines was eliminated for technical reasons, while the other two produced very similar results to those obtained in vitro (r from -0.72 to -0.98; P <.01). The most consistent in vivo results were achieved with the Gaussian windowed binomial filtered square wave (r = -0.95 and -0.96).

CONCLUSIONS

Using this waveform is an improvement to the existing SHAPE technique (where a square wave was used) and should make SHAPE more sensitive for noninvasively determining portal hypertension.

Improving the management of gastrointestinal bleeding in patients with cirrhosis

Gastrointestinal bleeding remains a major cause of mortality in patients with cirrhosis. The most common source of bleeding is from gastroesophageal varices but non-variceal bleeding from peptic ulcer disease also carries a significant risk in patients with liver disease. The prognosis is related to the severity of the underlying liver disease, and deaths often occur due to liver failure, infection or renal failure. Optimal management should therefore not only achieve haemostasis but address these complications as well. The management of gastrointestinal bleeding in patients with cirrhosis includes a range of medical, endoscopic and radiological interventions. This article updates the recent developments in this area and highlights topics where further research is still required.

Spleen Stiffness Is Superior to Liver Stiffness for Predicting Esophageal Varices in Chronic Liver Disease: A Meta-Analysis

Background and Aims

Liver stiffness (LS) and spleen stiffness (SS) are two most widely accessible non-invasive parameters for predicting esophageal varices (EV), but the reported accuracy of the two predictors have been inconsistent across studies. This meta-analysis aims to evaluate the diagnostic performance of LS and SS measurement for detecting EV in patients with chronic liver disease (CLD), and compare their accuracy.

Methods

Pubmed/Medline, Embase, Cochrane Library and Ovid were searched for all studies assessing SS and LS simultaneously in EV diagnosis. A total of 16 studies including 1892 patients were included in this meta-analysis, and the pooled statistical parameters were calculated using the bivariate mixed effects models.

Results

In detection of any EV, for LS measurement, the summary sensitivity was 0.83 (95% confidence interval [CI]: 0.78–0.87), and the specificity was 0.66 (95% CI: 0.60–0.72). While for SS measurement, the pooled sensitivity and specificity was 0.88 (95% CI: 0.83–0.92) and 0.78 (95% CI: 0.73–0.83). The summary receiver operating characteristic (SROC) curve values of LS and SS were 0.81 (95% CI: 0.77–0.84) and 0.88 (95% CI: 0.85–0.91) respectively, and the results had statistical significance (P<0.01). The diagnostic odds ratio (DOR) of SS (25.73) was significantly higher than that of LS (9.54), with the relative DOR value was 2.48 (95%CI: 1.10–5.60), P<0.05.

Conclusions

Under current techniques, SS is significantly superior to LS for identifying the presence of EV in patients with CLD. SS measurement may help to select patients for endoscopic screening.

Knowledge about non-invasive diagnostic tests for varices in liver cirrhosis: A questionnaire survey to the Gastroenterology Branch of the Liaoning Medical Association, China

BACKGROUND AND AIMS

Due to the invasiveness of upper gastrointestinal endoscopy, non-invasive diagnostic tests for varices in liver cirrhosis have been widely established by numerous studies. A questionnaire survey, which was aimed at understanding the current knowledge about non-invasive diagnostic tests for varices in liver cirrhosis, was distributed among the members of Gastroenterology Branch of the Liaoning Medical Association.

METHODS

A questionnaire assessing the knowledge about non-invasive diagnostic tests for varices was sent to 42 members who participated in the entire ninth committee. They were from 33 hospitals in 13 cities of Liaoning Province, China.

RESULTS

Overall, 97.6% (41/42) of participants responded to the questionnaire. A majority of participants were chief physicians (85.4%), had >20 years of experience in clinical work of digestive diseases (80.5%) and worked at tertiary hospitals (97.6%). In 46.3% of participants' departments, there were >200 patients with liver cirrhosis and gastroesophageal varices admitted every year. In 90.2% of participants' departments, upper gastrointestinal endoscopy was regularly employed for the diagnosis of gastroesophageal varices. Only six (15%) participants often used non-invasive diagnostic tests for varices in clinical practice. Thirty (75%) participants knew at least one non-invasive diagnostic test for varices. The knowledge of at least one non-invasive diagnostic test was significantly associated with the number of cirrhotic patients with varices (P = 0.038) or the regular use of gastrointestinal endoscopy to diagnose varices (P = 0.022).

CONCLUSIONS

This questionnaire survey suggested that non-invasive diagnostic tests for varices in liver cirrhosis were rarely or never used in clinical practices in Liaoning Province, China. Reliable, non-invasive indexes should be further explored in a well-designed multi-center observational study.

Correlations between ultrasonographic and gastroscopic findings of portal hypertension in patients with liver cirrhosis

AIM: To analyze the correlation between ultrasonographic and gastroscopic findings of portal hypertension in patients with liver cirrhosis, in order to provide a reference for the evaluation of the degree of cirrhosis and its prevention and treatment.

METHODS: From January 2013 to August 2015, 76 cirrhotic patients treated at Jishuitan Hospital were enrolled in the study. All the patients underwent ultrasonographic and gastroscopic examinations within 24 h. The correlations between the diameter of the portal vein, the diameter of splenic vein and the degree of gastric varices measured with two modalities were analyzed.

RESULTS: Ultrasonographic examinations revealed 43 (56.58%) cases of portal vein widening, 48 (63.16%) cases of increased inner diameter of the splenic vein, and 54 (71.05%) cases of splenic thickening. Gastroscopic examinations revealed 58 (76.32%) cases of gastric varices. The larger the diameter of the portal vein and the diameter of the splenic vein, the more serious the degree of gastric varices (P < 0.05).

CONCLUSION: There is a correlation between the diameter of the portal vein and the diameter of the splenic vein and the degree of gastric varices. Ultrasonography may be used as a non-invasive tool for assessing the risk of complications in cirrhosis patients with portal hypertension.

Diagnostic Accuracy of APRI, AAR, FIB-4, FI, and King Scores for Diagnosis of Esophageal Varices in Liver Cirrhosis: A Retrospective Study

BACKGROUND Aspartate aminotransferase-to-platelet ratio index (APRI), aspartate aminotransferase-to-alanine aminotransferase ratio (AAR), FIB-4, fibrosis index (FI), and King scores might be alternatives to the use of upper gastrointestinal endoscopy for the diagnosis of esophageal varices (EVs) in liver cirrhosis. This study aimed to evaluate their diagnostic accuracy in predicting the presence and severity of EVs in liver cirrhosis. MATERIAL AND METHODS All patients who were consecutively admitted to our hospital and underwent upper gastrointestinal endoscopy between January 2012 and June 2014 were eligible for this retrospective study. Areas under curve (AUCs) were calculated. Subgroup analyses were performed according to the history of upper gastrointestinal bleeding (UGIB) and splenectomy. RESULTS A total of 650 patients with liver cirrhosis were included, and 81.4% of them had moderate-severe EVs. In the overall analysis, the AUCs of these non-invasive scores for predicting moderate-severe EVs and presence of any EVs were 0.506-0.6 and 0.539-0.612, respectively. In the subgroup analysis of patients without UGIB, their AUCs for predicting moderate-severe varices and presence of any EVs were 0.601-0.664 and 0.596-0.662, respectively. In the subgroup analysis of patients without UGIB or splenectomy, their AUCs for predicting moderate-severe varices and presence of any EVs were 0.627-0.69 and 0.607-0.692, respectively. CONCLUSIONS APRI, AAR, FIB-4, FI, and King scores had modest diagnostic accuracy of EVs in liver cirrhosis. They might not be able to replace the utility of upper gastrointestinal endoscopy for the diagnosis of EVs in liver cirrhosis.

New Cutoff Point for Platelet Count/Spleen Diameter Ratio to Predict Esophageal Varices in Patients with Hepatitis C Virus-related Hepatic Cirrhosis

The esophagogastroduodenoscopy (EGD) with all its hazards remains the gold standard screening tool for esophageal varices. Noninvasive tools have been proposed and studied to replace the EGD. Platelet count (PC)/spleen diameter (SD) ratio as a noninvasive tool for predicting the presence of esophageal varices was proposed and studied in many previous studies.

Serum Liver Fibrosis Markers for Predicting the Presence of Gastroesophageal Varices in Liver Cirrhosis: A Retrospective Cross-Sectional Study

Background and Aims. A retrospective cross-sectional study was conducted to evaluate the role of hyaluronic acid (HA), laminin (LN), amino-terminal propeptide of type III procollagen (PIIINP), and collagen IV (CIV) in predicting the presence of gastroesophageal varices (GEVs) in patients with liver cirrhosis. Methods. We enrolled 118 patients with liver cirrhosis who underwent the tests for the four serum liver fibrosis markers and upper gastrointestinal endoscopy at the same admissions. The predictive values of the four serum liver fibrosis markers were evaluated by the areas under the receiving operator characteristics curves (AUROCs) with 95% confidence intervals (CIs). Results. The prevalence of GEVs was 88% (104/118). The AUROCs for HA, LN, PIIINP, and CIV levels in predicting the presence of GEVs were 0.553 (95% CI: 0.458 to 0.644, P = 0.5668), 0.490 (95% CI: 0.397 to 0.584, P = 0.9065), 0.622 (95% CI: 0.528 to 0.710, P = 0.1099), and 0.560 (95% CI: 0.466 to 0.652, P = 0.4909). The PIIINP level at a cut-off value of 31.25 had a sensitivity of 73.1% and a specificity of 57.1%. Conclusions. The present study did not recommend HA, LN, PIIINP, and CIV levels to evaluate the presence of GEVs in liver cirrhosis.

Extensive loculated ascites in hepatic amyloidosis

CONTEXT

Amyloidosis is a disease of extracellular deposition of misfolded proteinaceous subunits, which could be systemic or localized disease. Though hepatic amyloidosis was not uncommon in autopsy series, most cases of hepatic amyloidosis were asymptomatic. Ascites, jaundice, portal hypertension, and gastrointestinal bleeding from esophageal varices were reported in literature.

CASE REPORT

A 42-year-old man with end-stage renal disease on hemodialysis and recent small bowel obstruction presented with chronic abdominal pain. Computed tomography of abdomen and pelvis showed extensive loculated ascites and multiple small bowel loops tethered to adhesions and hepatomegaly. Finally, hepatic venography and liver biopsy confirmed hepatic amyloidosis with portal hypertension. The patient was waiting for liver transplant for definite treatment.

CONCLUSION

We report a rare case of hepatic amyloidosis with prior small bowel obstruction presented with extensive loculated ascites and multiple small bowel loops tethered to adhesions.