Preventing first variceal hemorrhage in cirrhosis

Our experience with liver and spleen elastography in the prediction of oesophageal varices

Background

Variceal bleeding is an important cause of mortality in patients with chronic liver disease (CLD). The gold standard for detection and grading of oesophageal varices (EV) is upper gastrointestinal endoscopy. However, it is expensive, time-consuming and invasive.

Objectives

This study aimed to find any association between splenic shear wave velocity (SWV) measured by acoustic radiation force imaging (ARFI) and the presence of EV.

Method

The quasi-experimental study included 50 patients with CLD and 50 subjects without CLD as the control group. Both underwent upper abdominal ultrasonography followed by elastographic assessment on a Siemens Acuson S2000TM ultrasound system. A comparison of the findings was made between the control and patient groups.

Results

Both groups had similar hepatic size while patients with CLD had larger splenic size and area (p < 0.05). The CLD patients had higher mean hepatic and splenic SWV compared with the control group (p < 0.05). The mean splenic size and splenic SWV were higher in patients with varices than in those without varices (p < 0.05).

Conclusion

Chronic liver disease causes significant increase in liver and splenic stiffness with splenic SWV values being higher for patients with varices emphasising the role of elastography as a non-invasive predictor for the presence of EVs. Splenic SWV had the highest sensitivity and specificity, which was augmented by a combination of hepatic and splenic SWV. Thus, splenic SWV alone or in combination with hepatic SWV is a useful technique for prediction of the presence of EVs.

Contribution

This study aims to find an alternative non-invasive and cost-effective technique for screening of EV.

Evaluation of liver and splenic stiffness by acoustic radiation force impulse for assessment of esophageal varices

BACKGROUND

In routine clinical practice, assessment of portal hypertension (PHT) among patients with liver cirrhosis is done by a upper gastrointestinal endoscopy (UGIE); however, its invasive nature limits its use. Recent advances in ultrasound imaging make it possible to evaluate the tissue stiffness of the liver and spleen reflecting the severity of underlying fibrosis. Liver stiffness and spleen stiffness can be used to predict the presence of esophageal varices/PHT among cirrhotic patients.

AIM

To predict the presence or absence of esophageal varices by measuring the stiffness of the liver and spleen by ultrasonography (USG)-based acoustic radiation force impulse (ARFI).

METHODS

This cross-sectional study included 90 subjects with liver cirrhosis. Liver and splenic stiffness were measured along with the USG abdomen, UGIE and aspartate aminotransferase to platelet ratio index (APRI).

RESULTS

Liver and spleen stiffness were significantly higher in cirrhotic patients compared to chronic hepatitis B. The best cut-off value of liver stiffness (LS) obtained by the receiver operating characteristic (ROC) curve was 2.16 m/s for predicting esophageal varices (AUROC 0.78, p 0.0002). The best cut-off value of splenic stiffness (SS) obtained by the ROC curve was 3.04 m/s for predicting esophageal varices (AUROC 0.698, p 0.0274). When both LS and SS were taken together, the accuracy in predicting esophageal varices increased to 92.22%. An equation to predict "esophageal varices = (0.225 LS + 0.377SS) - 0.555" was derived.

CONCLUSION

LS and SS values of ≥ 2.16 m/s and 3.04 m/s, respectively, predict esophageal varices independently; however, combined assessment is better with 92% accuracy.

Nasoenteric Tube Placement in Patients with Esophageal Varices: A Review of the Current Evidence and Society Guidelines

Esophageal varices are a common complication of portal hypertension and variceal bleeding can be associated with significant morbidity and mortality. Hospitalized patients with cirrhosis might require nasoenteric tube (NET) placement, commonly for nutritional support and/or medication administration. However, the fear of causing massive variceal bleeding among clinicians might lead to hesitancy or complete avoidance of NET placement in patients who either have a known history of esophageal varices or are at risk to have them. Several experts and society guidelines addressed this concern with variable recommendations and degrees of evidence. In this article, we present an extensive review of the literature and latest society guidelines that address the safety of NET placement in patients with esophageal varices.

Gastroesophageal variceal hemorrhage in patients with chronic liver diseases attending university of Gondar Specialized comprehensive hospital in Ethiopia: Institutional based cross-sectional study

Introduction

Rupture and bleeding from Gastroesophageal Varices (GEVs) are major complications among patients with chronic liver disease (CLD) and are associated with a high mortality rate. Hence, identifying factors of Gastroesophageal Variceal Hemorrhage (GEVH) is essential for the management and prevention of this fatal outcome.

Objective

To assess the prevalence of GEVH and its associated factors among patients with CLD in Northwest Ethiopia.

Methods

An institutional based cross-sectional study design was employed on a total of 262 patients. The data was entered into Epi-Data version 3.1, and then exported and analyzed using STATA version 14. The distribution of variables was checked using kolmogorov-smirnov test. Bivariable logistic regression model was fitted to select variables for multivariable analysis. In the final model, adjusted odds ratio with 95% confidence level and P-value less than 0.05 were used to assess degree of association.

Results

The mean age of the study subjects was found to be 37.76 years (SD ± 11.62). The prevalence of GEVH was found to be 52% (95% CI: 49.6-54.2). Patients with grade F2 and F3 varices have 3.41 times (AOR: 3.41, 95% CI: 2.33-4.74) and 3.33 times (AOR: 3.33, 95% CI: 2.55-4.12) higher odds of bleeding, respectively. Patients not taking beta blocker have 2.38 times (AOR: 2.38, 95% CI: 1.82-3.90) increased odds of bleeding. Patients with more than three years of duration of illness have 2 times (AOR: 2.19, 95% CI: 1.39-3.99) increased odds of bleeding. Patients with platelet number less than 50,000/μl have 3.46 times (AOR: 3.46, 95% CI: 2.55-4.17) higher odds of bleeding.

Conclusion

GEVH is found to be high in patients with CLD seen at university of Gondar Hospital. Higher grade of varices, non-use of beta blockers, presence of infection, platelet number and age are associated with higher occurrence of bleeding, pointing the possibility of averting this fatal complication, for most of the identified factors are preventable.

Non-endoscopic predictors of esophageal varices in children with chronic liver disease and their utility in resource-constrained countries

BACKGROUND

Although endoscopy is the standard diagnostic screening test to identify esophageal varices in patients with chronic liver disease (CLD), selective endoscopy in patients who are at higher risk of having varices may be cost-effective in a resource-constrained country. The aim of this prospective study was to identify non-endoscopic parameters that may predict the presence of varices, especially high-risk esophageal varices in children with CLD.

METHODS

From January 2016 through March 2018, consecutive children with CLD without a history of variceal bleeding were prospectively included. Esophagogastroduodenoscopy was done in all the children to detect and to grade esophageal varices. Both univariate and multivariate logistic regression analyses were done using SPSS version 22 to identify factors associated with esophageal varices.

RESULTS

The mean age of 84 children was 9.7 ± 3.2 years (male 44). Esophageal varices were present in 71.4% of children and 55% of them had large varices. On univariate analysis, low platelet count (< 100,000/mm³) and splenomegaly were found to be associated with the presence of esophageal varices (p = 0.006 and 0.001, respectively) and large varices (p = 0.03 and 0.01, respectively). On multivariate analysis, both low platelet count and splenomegaly were independent predictors for the presence of esophageal varices (respectively, OR 11.21, 95% CI 1.2-96.9; and OR 11.39, 95% CI 3.19-40.59).

CONCLUSIONS

Splenomegaly and low platelet count independently predict the presence of any grade of esophageal varices and can be used as screening tests to select children for endoscopy. This strategy may help in relieving medical, social, and economic costs in resource-constrained countries.

Hemodynamic effects of renin-angiotensin-aldosterone inhibitor and β-blocker combination therapy vs. β-blocker monotherapy for portal hypertension in cirrhosis: A meta-analysis

β-blockers are commonly used for the treatment of acute variceal bleeding in cirrhosis. Renin-angiotensin-aldosterone antagonists (angiotensin I-converting enzyme inhibitors, angiotensin receptor blockers and aldosterone antagonists) are potential therapies for portal hypertension. Several studies have compared the renin-angiotensin-aldosterone system (RAAS) inhibitor and β-blocker combination therapy vs. β-blocker monotherapy, with inconsistent results. The aim of the present study was to assess the efficacy of the RAAS inhibitor and β-blocker combination therapy vs. β-blocker monotherapy for hepatic vein pressure gradient (HVPG) reduction in cirrhosis. Studies were obtained using PubMed, Embase, Medline and Cochrane library databases up to July 2015, and the weighted mean difference (WMD) in HVPG reduction was used as a measure of treatment efficacy. In total, three studies (91 patients) were included. When compared to the β-blocker monotherapy, the RAAS inhibitor and β-blocker combination therapy resulted in a significant HVPG reduction [WMD 1.70; 95% confidence interval (CI): 0.52-2.88]. However, there was no significant difference in the heart rate reduction between the monotherapy and combination therapy groups (WMD -0.11; 95% CI: -3.51-3.29). In addition, no significant difference in the hemodynamic response was observed between the two groups (WMD 1.46; 95% CI: 0.93-2.30). In conclusion, the RAAS inhibitor and β-blocker combination therapy reduces portal hypertension significantly and to a greater extent than β-blocker monotherapy. Both therapies reduced the heart rate to similar levels; however, the RAAS inhibitor and β-blocker combination therapy reduced the mean arterial pressure to a greater extent. Due to the limited number of studies included, the data available do not allow a satisfactory comparison of adverse events. Moreover, further larger-scale trials are required in order to strengthen the results of the present study.

Risk factors related to transfusion requirements in patients undergoing implantation of ventricular assist devices

OBJECTIVE

The identification of transfusion risk factors in patients receiving left ventricular assist devices to allow for targeted use of blood conservation strategies and improved blood utilization.

DESIGN

This is a retrospective analysis of prospectively collected data between April 2009 and June 2012. Linear regression was used to determine factors associated with increased transfusion. Logistic regression was used to determine factors that were associated with more than the median number of units transfused.

SETTING

Single center, university hospital.

PARTICIPANTS

Patients (n=144) who underwent left ventricular assist device implantation.

INTERVENTION

Transfused blood product data for the day of surgery and for 3 days after were obtained from the blood bank.

MEASUREMENTS AND MAIN RESULTS

Beta-blockers were associated with 1.7±0.65 fewer red blood cell (RBC) units and 2.2±0.7 fewer fresh frozen plasma units transfused. Each year of older age was associated with 0.113±0.023 units of RBC, 0.543±0.101 platelet, and 0.098±0.017 plasma units transfused. International normalized ratio was associated with more platelet transfusion (20.813±5.757 units per 1.0 increase), but not with plasma or RBC transfusion. Lower platelet counts were associated with both platelet (-0.045±0.019 units per 10,000 μL(-1)) and plasma transfusions (-0.011±0.004). Myocardial infarction was associated with increased RBC and plasma transfusion, and cardiogenic shock was associated with increased platelet transfusions, but nitrate use was associated with reduced platelet transfusion.

CONCLUSION

Beta-blockers may be a modifiable factor to decrease transfusions. The association between international normalized ratio and platelet transfusions suggests that better determination of the type of coagulopathy may promote more appropriate transfusions.

Outcomes of TIPS for Treatment of Gastroesophageal Variceal Hemorrhage

Variceal hemorrhage is a life-threatening complication of cirrhosis that requires a multidisciplinary approach to management. The transjugular intrahepatic portosystemic shunt (TIPS) procedure is a minimally invasive image-guided intervention used for secondary prevention of bleeding and as salvage therapy in acute hemorrhage. This review focuses on the role of TIPS in the setting of variceal hemorrhage, with emphasis on the pathophysiology and conventional management of variceal hemorrhage, current and emerging indications for TIPS creation, TIPS clinical outcomes, and the role of adjuvant embolotherapy.

Oral branched-chain amino acids have a beneficial effect on manifestations of hepatic encephalopathy in a systematic review with meta-analyses of randomized controlled trials

Supplements with branched-chain amino acid (BCAA) have cerebral, metabolic, and nutritional effects that may benefit patients with hepatic encephalopathy (HE). We therefore conducted a systematic review on the effects of oral BCAAs compared with control supplements or placebo for patients with cirrhosis and recurrent overt or minimal HE. The quantitative analyses included data from 8 trials (n = 382 patients). Individual patient data were retrieved from 4 trials to recalculate outcomes (n = 255 patients). The mean dose of the oral BCAA supplements was 0.25 g/(kg body weight · d). Random effects meta-analysis showed that improvements in HE manifestations were registered for 87 of 172 patients in the BCAA group compared with 56 of 210 controls [risk ratio = 1.71 (95% CI: 1.17, 2.51) number needed to treat = 5 patients]. The effect of BCAAs differed (P = 0.04) for patients with overt [risk ratio = 3.26 (95% CI: 1.47, 7.22)] and minimal HE [risk ratio = 1.32 (95% CI: 0.97, 1.79)]. Subgroup, sensitivity, regression, and sequential analyses found no other sources of heterogeneity or bias. BCAA supplements had no effect on mortality or markers of nutritional status and did not induce adverse events. In conclusion, oral BCAA supplements improve manifestations of HE but have no effect on survival.

Can ARFI elastography predict the presence of significant esophageal varices in newly diagnosed cirrhotic patients?

AIM

To establish an algorithm which includes the liver stiffness (LS) and/or spleen stiffness (SS) assessed by ARFI for the prediction of significant esophageal varices-EV (at least grade 2).

MATERIAL AND METHODS

Our study included 145 newly diagnosed cirrhotic patients admitted in our Department between September 2009-August 2011. 62 patients (42.7%) had significant EV. We performed 10 ARFI measurements in each patient, both in the liver and in the spleen; median values were calculated, expressed in meters/second. In 24 consecutive newly diagnosed cirrhotic patients admitted between September 2011-December 2011, we prospectively analyzed the value of the new score for predicting significant EV.

RESULTS

The LS and SS assessed by ARFI elastography, and the percentage of patients with ascites were stastically significant higher in patients with significant EV as compared with those without EV or grade 1 EV. By multiple regression analysis we obtained the following formula for predicting significant EV: prediction of significant EV (Pred EV(2-3)) score: -0.572 + 0.041 x LS (m/s) + 0.122 x SS (m/s) + 0.325 x ascites (1-absent, 2-present). The best Pred EV(2-3) cut-off value for predicting significant EV was > 0.395 (AUROC = 0.721, accuracy = 69.6%). The accuracy in the group of patients in which the value of this score was prospectively analyzed was similar with that obtained in the first cohort of patients (70.8 vs. 69.6%). In conclusion, the proposed Pred EV(2-3) score had a enough good value for predicting significant EV.

Cost-Effective Analysis of Transjugular Intrahepatic Portosystemic Shunt versus Surgical Portacaval Shunt for Variceal Bleeding in Early Cirrhosis

Upper gastrointestinal hemorrhage carries significant morbidity and mortality in patients with portal hypertension and cirrhosis. The optimal prevention strategy for rebleeding in these patients remains controversial with respect to the safety and efficacy of transjugular intrahepatic portosystemic shunt (TIPS) versus a portocaval surgical shunt (PC). We sought to determine the long-term cost-effectiveness of these two treatments. A Markov state transition decision analysis was created and Monte Carlo sensitivity analysis performed to follow patients with early cirrhosis who have an upper gastrointestinal bleed despite medical therapy into either TIPS or PC. Patients were followed throughout the transition states until either death or survival. Probabilities of gastrointestinal rebleed, hepatic encephalopathy, surgical and TIPS-related complications as well as death were obtained from an extensive literature review. Costs were derived from average Medicare reimbursements. The main outcome was dollars per life-year saved. For patients with mild to moderate cirrhosis with upper gastrointestinal variceal bleed, the average cost per life year saved was $17,771 (SD = 471) and $21,438 (SD = 308) for TIPS and PC, respectively. The average life expectancy was 5.0 years and 7.0 years for TIPS and PC, respectively. This yielded an incremental cost-effectiveness rate for portocaval shunt of $3,299 per life year saved. Compared with TIPS, surgical PC shunt resulted in improved survival with minimal increase in cost. Therefore, given the low incremental cost of PC, it should be adopted as a cost-effective strategy in managing this patient population.

Risk factors for hepatic encephalopathy in patients with cirrhosis and refractory ascites: relevance of serum sodium concentration

Hyponatraemia is common in patients with advanced cirrhosis and is associated with remarkable changes in brain cells, particularly a reduction in myoinositol and other intracellular organic osmolytes related to the hypo-osmolality of the extracellular fluid. It has been recently suggested that hyponatraemia may be an important factor associated with the development of overt hepatic encephalopathy (HE). To test this hypothesis, we retrospectively analysed the incidence and predictive factors of overt HE using a database of 70 patients with cirrhosis included in a prospective study comparing transjugular intrahepatic portosystemic shunts (TIPS) vs large-volume paracentesis in the management of refractory of ascites. Variables used in the analysis included age, sex, previous history of HE, treatment assignment (TIPS vs large volume paracentesis plus albumin), treatment with diuretics, serum bilirubin, serum creatinine and serum sodium concentration. Laboratory parameters were measured at entry, at 1 month and every 3 months during follow-up and at the time of development of HE in patients who developed this complication. During a mean follow-up of 10 months, 50 patients (71%) developed 117 episodes of HE. In the whole population of patients, the occurrence of HE was independently associated with serum hyponatraemia, serum bilirubin and serum creatinine. In conclusion, in patients with refractory ascites, the occurrence of HE is related to the impairment of liver and renal function and presence of hyponatraemia.

Role of endoscopy in primary prophylaxis for esophageal variceal bleeding

Cirrhosis is the leading cause of portal hypertension in the Western world. From a clinical standpoint, the most significant consequence of portal hypertension is the development of esophageal varices. Despite the many advances in the management of variceal bleeding, it remains a life-threatening complication of portal hypertension. Primary prophylaxis to prevent the first bleeding episode in patients with cirrhosis and esophageal varices is therefore critically important in the management of patients with cirrhosis.

PillCam ESO versus esophagogastroduodenoscopy in esophageal variceal screening: A decision analysis

OBJECTIVES

PillCam ESO has been evaluated as a possible strategy to screen patients with cirrhosis for esophageal varices, but current guidelines recommend patients undergo screening with esophagogastroduodenoscopy (EGD), as it is currently the gold standard. Although recent data have suggested that PillCam ESO may be an acceptable alternative for screening, there is limited data on its cost-effectiveness compared with other screening modalities. This study was performed to compare the cost-effectiveness of PillCam ESO versus EGD for esophageal variceal screening.

METHODS

Markov models were constructed to compare 2 screening strategies: PillCam ESO versus EGD. In each arm, patients were followed for a time horizon of 15 years in 1-year transition intervals. All variables, transition probabilities, and costs were derived from the medical literature, and sensitivity analyses were performed on the different variables in the model.

RESULTS

Base-case analysis shows that PillCam ESO is associated with an average expected cost of $22,589 and an average expected effectiveness measure of 12.81 life-years. EGD is associated with an average expected cost of $23,083 and an average expected effectiveness measure of 12.67 life-years. PillCam ESO was found to dominate EGD as a screening strategy for patients with cirrhosis. Sensitivity analyses found several variables within the model to have influential effects on the results.

CONCLUSIONS

PillCam ESO is the dominant strategy for screening patients with cirrhosis for esophageal varices. However, based on a small difference in costs and effectiveness between each strategy, the results would suggest that PillCam ESO and EGD are essentially equivalent strategies.

Spectrum of anemia associated with chronic liver disease

Anemia of diverse etiology is a common complication of chronic liver diseases. The causes of anemia include acute or chronic gastrointestinal hemorrhage, and hypersplenism secondary to portal hypertension. Severe hepatocellular disease predisposes to hemorrhage because of impaired blood coagulation caused by deficiency of blood coagulation factors synthesized by hepatocytes, and/or thrombocytopenia. Aplastic anemia, which is characterized by pancytopenia and hypocellular bone marrow, may follow the development of hepatitis. Its presentation includes progressive anemia and hemorrhagic manifestations. Hematological complications of combination therapy for chronic viral hepatitis include clinically significant anemia, secondary to treatment with ribavirin and/or interferon. Ribavirin-induced hemolysis can be reversed by reducing the dose of the drug or discontinuing it altogether. Interferons may contribute to anemia by inducing bone marrow suppression. Alcohol ingestion is implicated in the pathogenesis of chronic liver disease and may contribute to associated anemia. In patients with chronic liver disease, anemia may be exacerbated by deficiency of folic acid and/or vitamin B12 that can occur secondary to inadequate dietary intake or malabsorption.

Management of Cirrhosis and Associated Complications

Liver cirrhosis is the encapsulation or replacement of injured tissue by collagen, resulting in end-stage liver disease and portal hypertension. The consequences of cirrhosis are impaired hepatocyte function, increase intrahepatic circulatory resistance, portal hypertension, and the development of hepatocellular carcinoma. Complications include encephalopathy, coagulopathy, varices, ascites, spontaneous bacterial peritonitis, epatorenal syndrome, and hepatopulmonary syndrome. Managing patients with acute or chronic liver failure is challenging, and liver failure may have profound effects on other organ systems. Most therapies are directed at managing the complications and bridging patients to liver transplantation. The clinician must be aware of the pathologic presentations and the appropriate management, including pharmacologic and nonpharmacologic therapies, goals and end points of therapy, and monitoring of therapy. This review focuses on the management of the complications directly associated with liver dysfunction (encephalopathy and coagulopathy) and portal hypertension (varices, ascites, spontaneous bacterial peritonitis, hepatorenal syndrome, hepatopulmonary syndrome).

Pathophysiologic basis for the medical management of portal hypertension

BACKGROUND

Portal hypertension is a potentially life-threatening complication of cirrhosis, resulting from increased intrahepatic resistance and portal inflow.

OBJECTIVE

Given the complex nature of this disorder, a more complete understanding of the pathophysiology of portal hypertension is necessary to develop new therapies that target specific pathways that regulate portal pressure.

METHODS

This review is based on a literature search of published articles and abstracts on the pathophysiology of portal hypertension, its complications and its treatment.

RESULTS/CONCLUSION

A number of therapies have been developed or are under investigation for the treatment of portal hypertension and its complications. These agents may reduce mortality and improve quality of life for patients with advanced liver disease.

Novel developments in esophageal vascular disorders

PURPOSE OF REVIEW

Esophageal variceal bleeding is a life-threatening complication of liver cirrhosis. The aim of this review is to discuss the most important studies published in 2007 concerning diagnosis of esophageal varices, primary and secondary prophylaxis and treatment of variceal bleeding.

RECENT FINDINGS

The specific areas reviewed are the noninvasive or minimally invasive diagnosis of oesophageal varices, prevention of the formation of varices and their progression from small to large, prevention of the first variceal hemorrhage, treatment of acute bleeding episodes and prevention of rebleeding, assessment of costs related to prophylaxis and treatment of variceal bleeding. Multidetector computed tomographic esophagography was found to identify the presence and grade the size of esophageal varices. Portal vein thrombosis was found to be an independent predictor of the aggravation of esophageal varices in patients with cirrhosis and hepatocellular carcinoma. The role of hepatic vein pressure gradient measurement in the prediction of decompensation of cirrhosis has been elucidated.

SUMMARY

Relevant studies are reviewed on the diagnosis and the natural history of esophageal varices, prevention of their formation and growth, prevention of the first variceal bleed, use of hepatic vein pressure gradient to predict the evolution of portal hypertension and to estimate the response to pharmacological treatment, prediction of bleeding, treatment of variceal bleeding and prevention of rebleeding, and cost strategies.