Prognostic usefulness of ultrasonographic signs of portal hypertension in patients with child-pugh stage A liver cirrhosis

Diagnostic accuracy of abdominal ultrasound in the screening of esophageal varices in patients with cirrhosis

BACKGROUND

Abdominal ultrasound (US) may provide data on the presence of esophageal varices in cirrhosis. We assess the diagnostic accuracy of this procedure.

PATIENTS AND METHODS

Retrospective recording of clinical data was carried out in cirrhotic patients who underwent abdominal US and upper gastrointestinal endoscopy. We compared patients with and without large varices and assessed the value of US in predicting the presence of these lesions as well as other significant variables.

RESULTS

Of the 353 patients included, 123 (35%) had esophageal varices. The presence of US signs of portal hypertension independently predicted the existence of esophageal varices with a sensitivity of 87.9%, a specificity of 34.9%, a positive predictive value of 40.6%, and a negative predictive value of 85.1%, which could increase to 91.5% if the patient presented plasma albumin and platelet concentrations above the mean values (3.1 g/dl and 122×10 cells/l, respectively). Plasma albumin and platelet concentrations were the two other variables with independent predictive capacity. Applying these selection criteria, up to 30% of screening endoscopies may not be necessary, and up to 43% in patients with compensated cirrhosis. In patients with decompensated cirrhosis, however, US does not have predictive capacity. The results obtained are comparable with those reported for transient elastography.

CONCLUSION

Abdominal US is a highly reliable technique for detecting patients with a low risk of presenting esophageal varices. Its use may avoid up to 43% of screening endoscopies in patients with compensated cirrhosis. The results obtained are similar to those observed using transient elastography.

ASAT/ALAT ratio provides prognostic information independently of Child-Pugh class, gender and age in non-alcoholic cirrhosis

OBJECTIVE

The aspartate amino transferase/alanine amino transferase (ASAT/ALAT) ratio is increased in cirrhosis. Some studies indicate that the ratio may provide prognostic information as well. The purpose of this study was to further elucidate the role of the ASAT/ALAT ratio as a predictor of survival by assessing it together with classical risk factors such as age, gender and Child-Pugh (CP) class in a mixed cohort of patients with cirrhosis.

MATERIAL AND METHODS

Eighty-nine patients with alcoholic cirrhosis and 81 patients with non-alcoholic cirrhosis treated at Aker University Hospital between 1999 and 2004 were identified retrospectively. Survival data from these patients per August 2006 were retrieved from the Norwegian Death Registry. Clinical and biochemical data at time of diagnosis were assessed as predictors of survival using the Kaplan-Meier method and Cox regression models.

RESULTS

Median ASAT/ALAT ratio was significantly higher in alcoholic cirrhosis (2.42) as compared with non-alcoholic cirrhosis (1.42). In both groups, a ratio above the median was predictive of poor outcome, p=0.024 and p=0.032, respectively. Other significant predictors of death were CP class (p<0.001), clinical decompensation (p<0.001) and age (p=0.001). Cox regression analyses showed that the ASAT/ALAT ratio was a predictor of death independently of CP class, gender and age in non-alcoholic, but not in alcoholic cirrhosis. The estimated increased hazard (risk of dying) in non-alcoholic cirrhosis was 5% (CI: 1-8%) per 0.10 increase in ASAT/ALAT ratio.

CONCLUSIONS

A high ASAT/ALAT ratio is associated with increased mortality in cirrhosis. In non-alcoholic patients the ratio may provide prognostic information independently of classical risk factors.

Correlation between ultrasonographic and pathologic diagnosis of liver fibrosis due to chronic virus hepatitis

AIM: To evaluate the validity of ultrasonographic and pathologic diagnosis of liver fibrosis in patients with chronic viral hepatitis.

METHODS: The liver fibrosis status in 324 patients was evaluated by both needle biopsy and ultrasonography. Liver fibrosis was divided into S0 -S4 stages. S4 stage was designated as definite cirrhosis. The ultrasonographic examination included qualitative variables, description of liver surface and parenchyma, and quantitative parameters, such as diameter of vessels, blood flow velocity and spleen size.

RESULTS: Ultrasonographic qualitative description of liver surface and parenchyma was related with the severity of fibrosis. Among the quantitative ultrasonographic parameters, cut-off value of spleen length (12.1 cm) had a sensitivity of 0.600 and a specificity of 0.753 for diagnosis of liver cirrhosis. The diameters of spleen (8 mm) and portal vein (12 mm) had a diagnostic sensitivity of 0.600 and 0.767, and a diagnostic specificity of 0.781 and 0.446, respectively. The diagnostic accuracy for liver cirrhosis was moderately satisfactory, and the negative predictive values of these parameters reached near 0.95.

CONCLUSION: Ultrasonography can predict the degree of liver fibrosis or cirrhosis. A single ultrasonographic parameter is limited in sensitivity and specificity for the diagnosis of early cirrhosis. The presence or absence of liver cirrhosis in patients with chronic virus hepatitis can be detected using 2 or 3 quantitative and qualitative parameters, especially the length of spleen, the diameter of spleen vein and echo pattern of liver surface.

Prognostic significance of the hepatopulmonary syndrome in patients with cirrhosis

BACKGROUND AND AIMS

The hepatopulmonary syndrome (HPS) has been defined by chronic liver disease, arterial deoxygenation, and widespread intrapulmonary vasodilation. Mortality of patients with HPS is considered to be high, but the effect of HPS on survival in patients with cirrhosis remains unclear.

METHODS

A total of 111 patients with cirrhosis were studied prospectively by using transthoracic contrast echocardiography for detection of pulmonary vasodilation, blood gas analysis, and pulmonary function test. Twenty different clinical characteristics and survival times were noted.

RESULTS

Twenty-seven patients (24%) had HPS. Their mortality was significantly higher (median survival, 10.6 months) compared with patients without HPS (40.8 mo, P < 0.05), even after adjusting for liver disease severity (2.9 vs. 14.7 months in Child-Pugh class C with [n = 15] and without HPS [n = 35, P < 0.05]; 35.3 vs. 44.5 months in Child-Pugh class B with [n = 7] and without HPS [n = 23, P = NS]), and exclusion of patients who underwent liver transplantation during follow-up (median survival 4.8 vs. 35.2 months, P = 0.005). Causes of death were mainly nonpulmonary and liver-related in the 19 patients with and the 35 patients without HPS who died. In multivariate analysis, HPS was an independent predictor of survival besides age, Child-Pugh class, and blood urea nitrogen. Mortality correlates with severity of HPS.

CONCLUSIONS

The presence of HPS independently worsens prognosis of patients with cirrhosis. This should influence patient management and scoring systems and accelerate the evaluation process for liver transplantation.

Correlation of splenic ultrasonography, HBV e system and AFP levels in hepatitis B with hepatic fibrosis and carcinogenesis

AIM

To clarify the relationship of splenic ultrasonography in liver fibrosis and carcinogenesis associated with hepatitis B, the spontaneous conversion of HBeAg to Anti-HBe and AFP level.

METHODS

The indexes of spleen ultrasonography of liver fibrosis along with carcinogenensis related with hepatitis B, positive rates of HBeAg or Anti-HBe and AFP levels were compared in different liver fibrosis stages and hepatocellular carcinoma (HCC) related with hepatitis B.

RESULTS

The lengths of spleen (mm) in stages of liver fibrosis S1, S2, S3, S4 and HCC with hepatitis B were 104.6±13.1, 108.7±13.6, 110.5±15.4, 123.0±16.8 and 116.9±28.2, respectively; differences of splenic length between group S4 and groups S1, S2 or S3 were significant statistically (P<0.05). The thicknesses of spleen (mm) in groups S1, S2, S3, S4 and HCC were 35.2±6.3, 37.0±7.7, 37.8±9.6, 43.3±10.8 and 40.811.2, respectively; difference in splenic thickness between group S4 and S1 was significant statistically (P<0.05). The widths of splenic vein (mm) in groups S1, S2, S3, S4 and HCC were 6.0±1.4, 6.5±1.4, 6.8±1.7, 7.8±1.7 and 6.82.6 respectively; there were differences among groups S4 and S1 or S2 (P<0.05) statistically. The positive rates of HBeAg were 92%(23/25), 75.6%(31/41), 68.8%(22/32), 51.9%(14/27) and 13.5%(5/37); and the positive rates of anti-HBe were 4%(1/25), 19.5%(8/41), 25%(8/32), 33.3%(9/27) and 70.3%(26/37) in group S1, S2, S3, S4 and HCC, respectively; difference between each two group among group S1, S2, S3, S4 and HCC was significant(P<0.05). The AFP levels(μg/L) were 11.0±6.7, 49.4±74.5, 112.11±59.0, 179.32±0.8 and 367.46±17.1 in group S1, S2, S3, S4 and HCC, respectively; there were differences among groups HCC and S1 or S2; S4, S3 or S2 and S1 (P<0.05), statistically.

CONCLUSION

The length and thickness of spleen and width of splenic vein were increased as the deterioration of severity of hepatic fibrosis. The length of spleen is more sensitive in indicating the severity of liver fibrosis. Both AFP level and splenic size were elevated as the increase rate of spontaneous conversion from HBeAg to anti-HBe. The risk of hepatocellular carcinoma associated with hepatitis B exists in any stages of liver fibrosis.

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