The epidemiology and pathogenesis of gastrointestinal varices

Porto-mesenteric four-dimensional flow MRI: a novel non-invasive technique for assessment of gastro-oesophageal varices

OBJECTIVES

To assess the role of 4D flow MRI in the assessment of gastro-oesophageal varices and in the prediction of high-risk varices in patients with chronic liver disease.

METHODS

Thirty-eight patients diagnosed with either oesophageal or gastric varices were included in this single-centre prospective study. 4D flow MRI was used to calculate peak flow, average flow and peak velocity at the portal vein confluence (PV1) and hilum (PV2), splenic vein hilum (SV1) and confluence (SV2), and superior mesenteric vein (SMV). PV and SV fractional flow changes were also measured.

RESULTS

ROC analysis revealed that both PV2 average flow and PV fractional average flow change had 100% sensitivity to predict high-risk patients with the PV fractional peak flow change having the widest area under the curve (AUC) and the highest specificity (92.3%). SV1 average flow, SV2 average flow, SV2 peak flow, and SV2 peak velocity increased significantly in patients with oesophageal compared to gastric varices included (p = 0.022, < 0.001, < 0.001 and 0.001, respectively).

CONCLUSION

Based on certain porto-mesenteric blood flow, velocity, and fractional flow change parameters, 4D flow MRI showed excellent performance in identifying high-risk patients and giving an idea about the grade and location of varices.

CRITICAL RELEVANCE STATEMENT

Variceal bleeding is a major consequence of unidentified risky upper GI varices. Thus, by identifying and locating high-risk varices early, either oesophageal or gastric, using a non-invasive method like MRI, adverse events might be avoided.

KEY POINTS

4D flow MRI can be used as a potential alternative for endoscopy to predict patients with high-risk varices. Based on portal vein fractional flow change, splenic flow and velocity, 4D MRI can predict and locate high-risk varices. Earlier identification of high-risk varices can allow for interventions to prevent adverse events.

Colonic Varices as an Unsettling Cause of Lower Gastrointestinal Bleeding

Colonic varicose veins are very rare and are usually discovered incidentally during colonoscopy or when complications occur, such as lower gastrointestinal (GI) bleeding. The primary cause of colonic varices is usually portal hypertension secondary to liver disease or very rarely due to pancreatic disease (e.g., pancreatic adenocarcinoma). Varicose veins secondary to cirrhosis are often seen in the upper GI tract but rarely in the lower GI tract. Here, we report a 54-year-old woman who presented with colonic varices due to decompensated alcoholic cirrhosis. The main intention of this case report was to raise awareness of the possibility of developing colonic varices from liver cirrhosis and to promptly identify and manage its side effects due to the major complication which is lower GI bleeding.

Partial splenic embolization as a rescue and emergency treatment for portal hypertension and gastroesophageal variceal hemorrhage

BACKGROUND

Partial splenic embolization (PSE) is a non-surgical procedure which was initially used to treat hypersplenism. Furthermore, partial splenic embolization can be used for the treatment of different conditions, including gastroesophageal variceal hemorrhage. Here, we evaluated the safety and efficacy of emergency and non-emergency PSE in patients with gastroesophageal variceal hemorrhage and recurrent portal hypertensive gastropathy bleeding due to cirrhotic (CPH) and non-cirrhotic portal hypertension (NCPH).

METHODS

From December 2014 to July 2022, twenty-five patients with persistent esophageal variceal hemorrhage (EVH) and gastric variceal hemorrhage (GVH), recurrent EVH and GVH, controlled EVH with a high risk of recurrent bleeding, controlled GVH with a high risk of rebleeding, and portal hypertensive gastropathy due to CPH and NCPH underwent emergency and non-emergency PSE. PSE for treatment of persistent EVH and GVH was defined as emergency PSE. In all patients pharmacological and endoscopic treatment alone had not been sufficient to control variceal bleeding, and the placement of a transjugular intrahepatic portosystemic shunt (TIPS) was contraindicated, not reasonable due to portal hemodynamics, or TIPS failure with recurrent esophageal bleeding had occurred. The patients were followed-up for six months.

RESULTS

All twenty-five patients, 12 with CPH and 13 with NCPH were successfully treated with PSE. In 13 out of 25 (52%) patients, PSE was performed under emergency conditions due to persistent EVH and GVH, clearly stopping the bleeding. Follow-up gastroscopy showed a significant regression of esophageal and gastric varices, classified as grade II or lower according to Paquet's classification after PSE in comparison to grade III to IV before PSE. During the follow-up period, no variceal re-bleeding occurred, neither in patients who were treated under emergency conditions nor in patients with non-emergency PSE. Furthermore, platelet count increased starting from day one after PSE, and after one week, thrombocyte levels had improved significantly. After six months, there was a sustained increase in the thrombocyte count at significantly higher levels. Fever, abdominal pain, and an increase in leucocyte count were transient side effects of the procedure. Severe complications were not observed.

CONCLUSION

This is the first study analyzing the efficacy of emergency and non-emergency PSE for the treatment of gastroesophageal hemorrhage and recurrent portal hypertensive gastropathy bleeding in patients with CPH and NCPH. We show that PSE is a successful rescue therapy for patients in whom pharmacological and endoscopic treatment options fail and the placement of a TIPS is contraindicated. In critically ill CPH and NCPH patients with fulminant gastroesophageal variceal bleeding, PSE showed good results and is therefore an effective tool for the rescue and emergency management of gastroesophageal hemorrhage.

Platelet count can predict the grade of esophageal varices in cirrhotic patients: a cross-sectional study

Background: Bleeding from esophageal varices is a life-threatening complication in cirrhosis. Screening endoscopy is recommended in cirrhotic patients to identify patients at risk of variceal hemorrhage, but this is an invasive procedure and has limitations. Therefore, thrombocytopenia has been proposed to predict the existence and grade of esophageal varices. The aim of the current study was to determine a correlation between platelet count and grades of esophageal varices in patients with liver cirrhosis. Methods: This cross-sectional study was conducted at the POF Hospital, Wah Cantt from 1 st October, 2017 to 30 th May, 2018. Newly diagnosed cases of cirrhosis having varices of any grade on endoscopy were included. Endoscopic findings of patients were standardized using Paquet grading system. On the basis of platelet count, patients were divided into four subgroups. Platelet count groups were correlated with grading of esophageal varices using Spearman rank correlations. Chi Square test was used to see association between the platelet count and grade of esophageal varices. Results: 110 patients were included in the study, 55.5% (n=61) were male. Mean age of the patients was 59.89±9.01 years. Platelet count was <50,000/uL in 35.5% patients, 50,000-99,000/uL in 26.4%, 100,000-150000 in 12.7%, and >150,000/uL in 25.5% patients. Grade I esophageal varices were found in 23.6% of patients, whereas grade II, III and IV were found in 24.5%, 33.6% and 18.2% of patients, respectively. Mean platelet count was 213884.62/mm 3 in patients with grade I varices, whereas it was 119518.52/mm 3, 58386.49/mm 3 and 21600.00/mm 3 in patients with grade II, III and IV varices, respectively (p=<0.0001). A significant negative correlation between platelet count and grades of esophageal varices was found (p<0.001). Conclusion: Platelet count can predict the grade of esophageal varices in cirrhotic patients. There is significant negative correlation between platelet count and grades of esophageal varices.

Platelet count can predict the grade of esophageal varices in cirrhotic patients: a cross-sectional study

Background: Bleeding from esophageal varices is a life-threatening complication in cirrhosis. Screening endoscopy is recommended in cirrhotic patients to identify patients at risk of variceal hemorrhage, but this is an invasive procedure and has limitations. Therefore, thrombocytopenia has been proposed to predict the existence and grade of esophageal varices. The aim of the current study was to determine a correlation between platelet count and grades of esophageal varices in patients with liver cirrhosis. Methods: This cross-sectional study was conducted at the POF Hospital, Wah Cantt from 1 st October, 2017 to 30 th May, 2018. Newly diagnosed cases of cirrhosis having varices of any grade on endoscopy were included. Endoscopic findings of patients were standardized using Paquet grading system. On the basis of platelet count, patients were divided into four subgroups. Platelet count groups were correlated with grading of esophageal varices using Spearman rank correlations. Chi Square test was used to see association between the platelet count and grade of esophageal varices. Results: 110 patients were included in the study, 55.5% (n=61) were male. Mean age of the patients was 59.89±9.01 years. Platelet count was <50,000/uL in 35.5% patients, 50,000-99,000/uL in 26.4%, 100,000-150000 in 12.7%, and >150,000/uL in 25.5% patients. Grade I esophageal varices were found in 23.6% of patients, whereas grade II, III and IV were found in 24.5%, 33.6% and 18.2% of patients, respectively. Mean platelet count was 213884.62/mm 3 in patients with grade I varices, whereas it was 119518.52/mm 3, 58386.49/mm 3 and 21600.00/mm 3 in patients with grade II, III and IV varices, respectively (p=<0.0001). A significant negative correlation between platelet count and grades of esophageal varices was found (p<0.001). Conclusion: Platelet count can predict the grade of esophageal varices in cirrhotic patients. There is significant negative correlation between platelet count and grades of esophageal varices.

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.

Update on the management of gastrointestinal varices

Cirrhosis of liver is a major problem in the western world. Portal hypertension is a complication of cirrhosis and can lead to a myriad of pathology of which include the development of porto-systemic collaterals. Gastrointestinal varices are dilated submucosal veins, which often develop at sites near the formation of gastroesophageal collateral circulation. The incidence of varices is on the rise due to alcohol and obesity. The most significant complication of portal hypertension is life-threatening bleeding from gastrointestinal varices, which is associated with substantial morbidity and mortality. In addition, this can cause a significant burden on the health care facility. Gastrointestinal varices can happen in esophagus, stomach or ectopic varices. There has been considerable progress made in the understanding of the natural history, pathophysiology and etiology of portal hypertension. Despite the development of endoscopic and medical treatments, early mortality due to variceal bleeding remains high due to significant illness of the patient. Recurrent variceal bleed is common and in some cases, there is refractory variceal bleed. This article aims to provide a comprehensive review of the management of gastrointestinal varices with an emphasis on endoscopic interventions, strategies to handle refractory variceal bleed and newer endoscopic treatment modalities. Early treatment and improved endoscopic techniques can help in improving morbidity and mortality.