Natural history of cirrhotic patients with small esophageal varices: a prospective study

Clinical outcomes and prognostic factors in non-cirrhotic non-neoplastic patients with portal vein thrombosis: A single-centre experience

INTRODUCTION

The knowledge of natural history and prognostic factors of portal vein thrombosis (PVT) is still based on a limited number of studies.

AIM

To describe our single-center experience with 79 consecutive non-neoplastic non-cirrhotic patients with PVT (15 recent/64 chronic PVT).

RESULTS

Among patients with recent PVT, 7 received anticoagulation alone, 4 systemic thrombolysis, 3 direct thrombolysis through a TIPS and 1 TIPS alone. Portal recanalization was achieved in 11 patients. In patients with chronic PVT, the rate of variceal progression was high (20% at one year and 50% at two years). The thrombotic involvement of splenic and superior mesenteric veins was the only risk factor for variceal enlargement. The cumulative bleeding rates were 10% at one year and 20% at two years. A multisegmental thrombosis and large varices at entry and a previous variceal bleeding were the independent predictors for variceal bleeding. The cumulative rate of new thrombotic events was 14% at one year and 18% at two years. Eight patients died, 2 because of thrombotic events. There were no bleeding-related deaths. Two-year cumulative survival rate was 90%.

CONCLUSIONS

Our study supports the importance of anticoagulation especially when a more extended thrombosis is present. Moreover, in patients with chronic PVT, the timing of follow-up endoscopy should be based on the extension of thrombosis and not, as in cirrhosis, on the size of varices at first endoscopy.

Oesophageal varices predict complications in compensated advanced non-alcoholic fatty liver disease

Background & Aims

We aimed to evaluate the impact of oesophageal varices (OV) and their evolution on the risk of complications of compensated advanced chronic liver disease (cACLD) caused by non-alcoholic fatty liver disease (NAFLD). We also assessed the accuracy of non-invasive scores for predicting the development of complications and for identifying patients at low risk of high-risk OV.

Methods

We performed a retrospective assessment of 629 patients with NAFLD-related cACLD who had baseline and follow-up oesophagogastroduodenoscopy and clinical follow-up to record decompensation, portal vein thrombosis (PVT), and hepatocellular carcinoma.

Results

Small and large OV were observed at baseline in 30 and 15.9% of patients, respectively. The 4-year incidence of OV from absence at baseline, and that of progression from small to large OV were 16.3 and 22.4%, respectively. Diabetes and a ≥5% increase in BMI were associated with OV progression. Multivariate Cox regression revealed that small (hazard ratio [HR] 2.24, 95% CI 1.47-3.41) and large (HR 3.86, 95% CI 2.34-6.39) OV were independently associated with decompensation. When considering OV status and trajectories, small (HR 2.65, 95% CI 1.39-5.05) and large (HR 4.90, 95% CI 2.49-9.63) OV at baseline and/or follow-up were independently associated with decompensation compared with the absence of OV at baseline and/or follow-up. The presence of either small (HR 2.8, 95% CI 1.16-6.74) or large (HR 5.29, 95% CI 1.96-14.2) OV was also independently associated with incident PVT.

Conclusion

In NAFLD-related cACLD, the presence, severity, and evolution of OV stratify the risk of developing decompensation and PVT.

Impact and implications

Portal hypertension is the main driver of liver decompensation in chronic liver diseases, and its non-invasive markers can help risk prediction. The presence, severity, and progression of oesophageal varices stratify the risk of complications of non-alcoholic fatty liver disease. Easily obtainable laboratory values and liver stiffness measurement can identify patients at low risk for whom endoscopy may be withheld, and can also stratify the risk of liver-related complications.

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

Objectives

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

Methods

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

Results

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

Conclusions

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

The Risk of Bleeding in Small/Straight Esophageal Varices with Red Color Sign on Endoscopy: A Retrospective Analysis from the Natural Course

Red color sign-positive (RC-positive) esophageal varices present a high bleeding risk, necessitating prophylactic treatment. Among RC-positive esophageal varices, those classified morphologically as small straight varices (Form level 1: F1) are difficult to treat. Moreover, the appropriate time for therapeutic intervention remains undefined. This study assessed the bleeding risk in RC-positive F1 esophageal varices. After extracting 541 cases of F1 esophageal varices diagnosed during 1 January 2012−29 February 2020, 76 cases of RC-positive F1 esophageal varices were divided into two groups in terms of treatment intervention at diagnosis: 49 cases with (treatment group) and 27 cases without (follow-up group). We assessed the bleeding rates, bleeding-associated factors, and early-bleeding-associated factors. The treatment group’s bleeding rate was 10% (5/49). The follow-up group’s bleeding rate was 78% (21/24). The subsequent bleeding rate was low in the treatment group (p < 0.001). The median period of sustained absence of bleeding was longer in the treatment group than in the follow-up group (1156 [274−1582] days vs. 105 [1−336] days; p < 0.001). In the follow-up group, a significant number of bleedings had varices that included a hematocystic spot (HCS) as RC or combined with RC (p = 0.017). Early bleeding occurred often in varices that included HCS or combined with RC (p = 0.024). Red wale marking (RWM) only was not a factor of early bleeding (p = 0.012). In conclusion, RC-positive varices should be treated even as F1 varices. Patients with RWM only show the possibility of not accepting early treatment intervention. A fast response is crucially important in HCS cases because of its associated bleeding and early bleeding.

Variceal Bleeding: Beyond Banding

Despite advances in the management of complications of portal hypertension, variceal bleeding continues to be associated with significant morbidity and mortality. While endoscopic variceal band ligation remains first line therapy for treating bleeding and high-risk non-bleeding esophageal varices, alternate therapies have been explored, particularly in cases of refractory bleeding. The therapies being explored include stent placement, hemostatic powder use, over-the-scope clips and others. For gastric variceal bleeding, endoscopic ultrasound-guided therapies have recently emerged as promising interventions for hemostasis. The aim of this article is to highlight these alternative therapies and their potential role in the management of gastric and esophageal variceal bleeding.

Overview of Complications in Cirrhosis

BACKGROUND

Cirrhosis is the outcome of chronic liver disease of any etiology due to progressive liver injury and fibrosis. Consequently, cirrhosis leads to portal hypertension and liver dysfunction, progressing to complications like ascites, variceal bleeding, hepatic encephalopathy, hepatorenal syndrome, hepatopulmonary syndrome, cirrhotic cardiomyopathy, sarcopenia, hepatocellular carcinoma, and coagulation disorders. End-stage liver disease leads to an impaired quality of life, loss of social and economic productivity, and reduced survival.

METHODS

This narrative review explains the pathophysiology of complications of cirrhosis, the diagnostic approach and innovative management, with focus on data from India. A comprehensive literature search of the published data was performed in regard with the spectrum, diagnosis, and management of cirrhosis and its complications.

RESULTS

There is a change in the epidemiology of metabolic syndrome, lifestyle diseases, alcohol consumption and the spectrum of etiological diagnosis in patients with cirrhosis. With the advent of universal vaccination and efficacious long-term viral suppression agents for chronic hepatitis B, availability of direct-acting antiviral agents for chronic hepatitis C, and a booming liver transplantation programme across the country, the management of complications is essential. There are several updates in the standard of care in the management of complications of cirrhosis, such as hepatorenal syndrome, hepatocellular carcinoma, and hepatic encephalopathy, and new therapies that address supportive and palliative care in advanced cirrhosis.

CONCLUSION

Prevention, early diagnosis, appropriate management of complications, timely transplantation are cornerstones in the management protocol of cirrhosis and portal hypertension. India needs improved access to care, outreach of public health programmes for viral hepatitis care, health infrastructure, and disease registries for improved healthcare outcomes. Low-cost initiatives like immunization, alcohol cessation, awareness about liver diseases, viral hepatitis elimination, and patient focused decision-making algorithms are essential to manage liver disease in India.

Baveno criteria perform better than expanded Baveno and Rete Sicilia Selezione Terapia-Hepatitis C virus criteria for predicting varices needing treatment

BACKGROUND AND AIMS

Endoscopy is the gold standard for the detection and staging of varices. Baveno, expanded Baveno, and Rete Sicilia Selezione Terapia-hepatitis C virus (RESIST-HCV) criteria predict varices non-invasively in patients with cirrhosis. We assessed the performance of these criteria for predicting varices needing treatment (VNT).

METHODS

Consecutive patients with compensated cirrhosis due to viral etiologies evaluated between January 2014 and May 2017 were included in this retrospective analysis of a prospectively maintained database. VNTs were defined as either large varies or small varices with red color signs on endoscopy. Performance characteristics to predict VNTs were estimated for the three criteria and spared endoscopy rate (SER) and missed VNT rates were determined.

RESULTS

Two hundred and ninety-five treatment-naïve cirrhosis patients, etiology hepatitis B (n = 154) or hepatitis C (n = 141), mean age 43.1 ± 13.2 years, 127 (43.1%) males were included. The median liver stiffness measurement (LSM) and platelet counts were 19.7 (interquartile range [IQR]: 14.8-28.8) kPa and 119 (IQR: 80-160) × 103/mm3, respectively. The SER and missed VNT rates were as follows-for Baveno criteria: 18.3% and 6.2%; expanded Baveno: 35.3% and 29.2%; and for RESIST-HCV criteria: 37.3% and 22.9%. The sensitivity, specificity, positive predictive value, and negative predictive value were 93.7%, 21.9%, 18.9%, and 94.7% for Baveno criteria; 70.8%, 42.3%, 19.3%, and 88.1% for expanded Baveno; and 77.1%, 44.5%, 21.3%, and 90.9% for RESIST-HCV criteria, respectively.

CONCLUSION

Baveno criteria are useful to avoid screening endoscopies in patients with cirrhosis of viral etiologies. In contrast, although expanded Baveno criteria and RESIST-HCV criteria spare more endoscopies, a high missed VNT rate limits their applicability.

Portal Hypertension and Ascites: Patient-and Population-centered Clinical Practice Guidelines by the Italian Association for the Study of the Liver (AISF)

Portal hypertension and ascites are two crucial events in the natural history of liver cirrhosis, whose appearance marks a downward shift in the prognosis of the disease. Over the years, several international and national societies have issued clinical practice guidelines for the diagnosis and management of portal hypertension and ascites. The present document addresses the needs of an updated guidance on the clinical management of these conditions. Accordingly, the AISF Governing Board appointed a multi-disciplinary committee of experts for drafting an update of the most recent EASL Clinical Practice Guidelines. The aim of this work was to adapt the EASL recommendations to national regulations and resources, local circumstances and settings, infrastructure, and cost/benefit strategies to avoid duplication of efforts and optimize resource utilization. The committee defined the objectives, the key issues and retrieved the relevant evidence by performing a systematic review of the literature. Finally, the committee members (chosen on the basis of their specific expertise) identified the guidelines' key questions and developed them following the PICO format (Population, Intervention, Comparison, Outcomes). For each of the PICO questions, the systematic review of the literature was made on the most important scientific databases (Pubmed, Scopus, Embase).

Incidence of Bleeding and Thrombosis in Patients with Liver Disease

Historically, liver disease has been associated with a bleeding tendency. Global hemostatic assays have demonstrated that hemostasis is overall rebalanced, in both acute liver failure and chronic liver disease. It is now recognized that many bleeding events in chronic liver disease are mediated by portal hypertension rather than an underlying hemostatic defect. This is acknowledged in recent guidelines, which recommend against coagulation testing prior to low risk procedures in this patient group, with avoidance also of attempts at correction of prolonged coagulation times. Over time, the incidence of bleeding events has decreased in both chronic liver disease and acute liver failure, with improved supportive care, targeted treatments for underlying cause of liver disease, and the advent of liver transplantation. Concurrently, there has been increased recognition of the risk of thrombosis in chronic liver disease, with a predilection for the splanchnic vasculature. This review describes the incidence of bleeding and thrombosis in chronic liver disease and acute liver failure, including the periprocedural and liver transplantation setting.

Risk assessment of first upper gastrointestinal bleeding using computerized tomoscanning in esophageal varices patients with cirrhosis and portal hypertension

To evaluate the risk of first upper gastrointestinal bleeding by computerized tomoscanning (CT) for esophageal varices patients with cirrhotic portal hypertension.One hundred thirty two esophageal varices patients with cirrhotic portal hypertension who are also complicated with gastrointestinal bleeding were recruited as bleeding group, while another 132 patients without bleeding as non-bleeding group. The diameter of esophageal varices, number of vascular sections, and total area of blood vessels were measured by CT scanning. The sensitivity and specificity of these indicators were calculated, and Youden index was adjusted with the critical point.The diameter of esophageal varices was 7.83 ± 2.76 mm in bleeding group, and 6.57 ± 3.42 mm in non-bleeding group. The Youden index was 0.32 with the critical point 5.55 mm. The area under the receiver operating characteristics (AUROC) was 0.72. The number of venous vessels was 4.5 ± 2 in bleeding group, whereas being 4 ± 2 in non-bleeding group. The Youden index was 0.35 with a critical point 4, and the area under the curve (AUC) was 0.68. The blood vessel area was 1.73 ± 1.15 cm in bleeding group, and 1.12 ± 0.89 cm in non-bleeding group. The Youden index was 0.48 with the critical point being 1.03 cm, and corresponding AUC was 0.82.Among all 3 indicators of the total area, diameter, and number of sections of the esophageal varices, the total area of esophageal varices showed more accuracy as a potential and novel indicator for bleeding prediction.

Natural history of patients with non cirrhotic portal hypertension: Comparison with patients with compensated cirrhosis

BACKGROUND

The knowledge of natural history of patients with portal hypertension (PH) not due to cirrhosis is less well known than that of cirrhotic patients.

AIM

To describe the clinical presentation and the outcomes of 89 patients with non-cirrhotic PH (25 with non-cirrhotic portal hypertension, INCPH, and 64 with chronic portal vein thrombosis, PVT) in comparison with 77 patients with Child A cirrhosis.

METHODS

The patients were submitted to a standardized clinical, laboratory, ultrasonographic and endoscopic follow-up. Variceal progression, incidence of variceal bleeding, portal vein thrombosis, ascites and survival were recorded.

RESULTS

At presentation, the prevalence of varices, variceal bleeding and ascites was similar in the 3 groups. During follow-up, the rate of progression to varices at risk of bleeding (p < 0.0001) and the incidence of first variceal bleeding (p = 0.02) were significantly higher in non-cirrhotic then in cirrhotic patients. A PVT developed in 32% of INCPH patients and in 18% of cirrhotics (p = 0.02).

CONCLUSIONS

In the patients with non-cirrhotic PH variceal progression is more rapid and bleeding more frequent than in cirrhotics. Patients with INCPH are particularly prompt to develop PVT. This observational study suggests that the management of patients with non-cirrhotic PH should take into consideration the natural history of portal hypertension in these patients and cannot be simply derived by the observation of cirrhotic patients.

Clinical states of cirrhosis and competing risks

The clinical course of cirrhosis is mostly determined by the progressive increase of portal hypertension, hyperdynamic circulation, bacterial translocation and activation of systemic inflammation. Different disease states, encompassing compensated and decompensated cirrhosis and a late decompensated state, are related to the progression of these mechanisms and may be recognised by haemodynamic or clinical characteristics. While these disease states do not follow a predictable sequence, they correspond to varying mortality risk. Acute-on-chronic liver failure may occur either in decompensated or in compensated cirrhosis and is always associated with a high short-term mortality. The increasing severity of these disease states prompted the concept of clinical states of cirrhosis. A multistate approach has been considered to describe the clinical course of the disease. Such an approach requires the assessment of the probabilities of different outcomes in each state, which compete with each other to occur first and mark the transition towards a different state. This requires the use of competing risks analysis, since the traditional Kaplan-Meier analysis should only be used in two-state settings. Accounting for competing risks also has implications for prognosis and treatment efficacy research. The aim of this review is to summarise relevant clinical states and to show examples of competing risks analysis in multistate models of cirrhosis.

Can Non-Selective Beta-Blockers (NSBBs) Prevent Enlargement of Small Esophageal Varices in Patients with Cirrhosis? A Meta-analysis

BACKGROUND

Non-selective beta-blockers (NSBBs) are recommended for prophylaxis of first variceal bleeding in patients of cirrhosis with large esophageal varices. However, the data is conflicting whether NSBBs can also prevent growth of small esophageal varices to large size.

AIM

To perform a meta-analysis of the randomized clinical trials comparing NSBBs with placebo for prevention of development of large esophageal varices in patients of cirrhosis with small esophageal varices.

METHODS

The PubMed, EMBASE, Science Direct, and Cochrane library databases were searched for relevant papers. A meta-analysis was performed using risk ratios (RRs) with 95% confidence interval (CI) as the effect sizes.

RESULTS

Overall, 314 trials were initially retrieved from the database searches, of which five randomized controlled trials were included in the meta-analysis. The incidence of development of large varices (RR = 0.91, 95%CI: 0.29-2.86; P = 0.87) was similar between NSBB and placebo groups. However, the heterogeneity among studies was significant (P < 0.01) with an I² of 93%. The incidences of first variceal bleeding (RR = 0.72, 95%CI: 0.25-2.12; P = 0.55) and death (RR = 0.76, 95%CI: 0.50-1.15; P = 0.19) were also similar between NSBB and placebo groups; with no heterogeneity. The incidence of adverse events was significantly higher in the NSBB group compared with the placebo group (RR = 4.66, 95%CI: 1.36-15.91; P = 0.01).

CONCLUSION

The results of this meta-analysis indicate that NSBBs are not effective in preventing growth of small varices and may lead to significant adverse effects. Hence, NSBBs should not be recommended for cirrhotic patients with small varices.

Effects of Eradicating Hepatitis C Virus Infection in Patients With Cirrhosis Differ With Stage of Portal Hypertension

BACKGROUND & AIMS

Clearance of hepatitis C virus (HCV) via antiviral treatment changes the course of liver disease. We evaluated the benefit of sustained virologic response (SVR) in patients with HCV and cirrhosis without (stage 1) and with (stage 2) esophageal varices (EV).

METHODS

We performed a prospective cohort study of 444 patients with HCV and compensated cirrhosis (218 with stage 1 and 226 with stage 2 disease) treated with peg-interferon and ribavirin from June 2001 through December 2009 at the University of Palermo, Italy and followed for a median of 7.6 years (range, 1-12.6 years). We used Cox regression analysis to identify variables associated with appearance or progression of EVs, development of hepatocellular carcinoma (HCC), liver decompensation, and overall survival.

RESULTS

In the intention-to-treat analysis, 67 patients with stage 1 disease (30.7%) and 41 patients with stage 2 disease (18.1%) achieved an SVR (P = .003). Patients with stage 1 disease and an SVR were less likely to develop EVs than stage 1 patients without an SVR (hazard ratio [HR], 0.23; 95% confidence interval [CI], 0.11-0.48; P < .001). However, SVR did not affect whether patients with stage 2 disease developed further EVs (HR, 1.58; 95% CI, 0.33-1.03; P = .07, by log-rank test). An SVR was associated with lower risk for HCC (HR, 0.25; 95% CI, 0.12-0.55; P < .001). Patients with stage 2 disease, regardless of SVR, were at greater risk than patients with stage 1 disease for liver decompensation (HR, 2.82; 95% CI, 1.73-4.59; P < .001) or death (HR, 1.77; 95% CI, 1.12-2.80; P = .015). A lower proportion of patients with stage 1 disease and an SVR died from HCC (2.9%), compared with those without an SVR (11.9%) (P = .03) or developed liver decompensation (none vs 7.1% without an SVR; P = .009). A lower proportion of patients with stage 2 disease and an SVR died from causes secondary to HCC (2.0%) compared with those without an SVR (18.4%) (P = .003). Death from causes secondary to liver decompensation did not differ significantly between patients with stage 2 disease with or without an SVR (12.1% vs 25.4%; P = .15).

CONCLUSIONS

In a prospective study of 444 patients with HCV and compensated cirrhosis, HCV eradication reduced risk for liver decompensation, HCC, and death, regardless of whether the patients had EVs.

The long-term benefits of nucleos(t)ide analogs in compensated HBV cirrhotic patients with no or small esophageal varices: A 12-year prospective cohort study

BACKGROUND & AIMS

Esophageal varices (EV) are a marker of disease severity in compensated cirrhosis due to hepatitis B virus (HBV) which predicts also the risk of hepatocellular carcinoma (HCC), clinical decompensation and anticipated liver related death. The dynamics and prognostic significance of EV in patients under long-term HBV suppression by nucleos(t)ide analogs (NUC), are poorly known.

METHODS

A standardized protocol (Baveno) including 414 upper gastrointestinal (GI) endoscopies was applied to 107 HBeAg-negative compensated cirrhotic patients (93% Child-Pugh A) during a median of 12 (range 2 to 17) years of NUC therapy. Patients who initially started on lamivudine (LMV) and then developed resistance (LMV-R), were rescued by early administration of adefovir, or were switched to tenofovir. Surveillance included serum HBV DNA every three months and abdominal ultrasound every six months.

RESULTS

Twenty-seven patients had baseline F1 EV which regressed in 18, remained unchanged in eight and progressed in one patient; the 12-year cumulative incidence of EV regression was 83% (95% CI: 52-92%). De novo F1/F2 EV developed in 6/80 patients with a 12-year cumulative incidence of 10% (95% CI: 5-20%). Six of seven patients with de novo varices or progression of pre-existing varices had either a clinical breakthrough due to LMV-R and/or developed a HCC. No bleedings from ruptured EV occurred, 12 patients died (9 HCC) and 15 were transplanted (13 HCC): the 12-year cumulative incidence of HCC and overall survival was 33% (95% CI: 24-42%) and 76% (95% CI: 67-83%), respectively.

CONCLUSIONS

Long-term pharmacological suppression of HBV in HBeAg-seronegative patients with compensated cirrhosis leads to a significant regression of pre-existing EV accompanied by a negligible risk of developing de novo EV.

(99m)Tc-phytate trans-splenic portal scintigraphy in the diagnosis of cirrhotic portal hypertension and compensatory circulation

BACKGROUND AND AIM

The trans-splenic portal scintigraphy (TPS) was evaluated as a diagnostic tool in the post viral hepatitis cirrhotic patients of various classes of Child Pugh's (CP) classification. The main aim was to determine the portosystemic shunt index (PSSI) and to compare the results with various clinical grades of disease severity in liver cirrhosis.

METHODS

TPS was performed on 72 patients and 10 controls and PSSI was derived. All the 72 patients were categorized according to CP classification into three classes. The cirrhotic patients were categorized as CP A (n = 24),CP B (n = 22), and CP C (n = 26)according to CP criteria. PSSI was compared with different CP classes.

RESULTS

In the controlled population, the splenic vein was normal in shape and the mean PSSI was calculated to be 0.178 ± 0.031 (n = 10). For CP classes A, B, and C, the mean PSSI was 0.36 ± 0.04, 0.45 ± 0.05, and 0.54 ± 0.04 (n = 26), respectively. There was statistical significance among groups (p ≤ 0.01).The collateral vessels were mostly uphill or complex. The PSSI index increased as the CP score worsened from A to C.

CONCLUSION

PSSI is a useful and minimally invasive tool to detect and quantify the shunt severity, which correlates well with different clinical grades of disease severity.

Cost-effectiveness analysis of beta-blockers vs endoscopic surveillance in patients with cirrhosis and small varices

AIM: To evaluate the most cost-effectiveness strategy for preventing variceal growth and bleeding in patients with cirrhosis and small esophageal varices.

METHODS: A stochastic analysis based on decision trees was performed to compare the cost-effectiveness of beta-blockers therapy starting from a diagnosis of small varices (Strategy 1) with that of endoscopic surveillance followed by beta-blockers treatment when large varices are demonstrated (Strategy 2), for preventing variceal growth, bleeding and death in patients with cirrhosis and small esophageal varices. The basic nodes of the tree were gastrointestinal endoscopy, inpatient admission and treatment for bleeding, as required. All estimates were performed using a Monte Carlo microsimulation technique, consisting in simulating observations from known probability distributions depicted in the model. Eight-hundred-thousand simulations were performed to obtain the final estimates. All estimates were then subjected to Monte Carlo Probabilistic sensitivity analysis, to assess the impact of the variability of such estimates on the outcome distributions.

RESULTS: The event rate (considered as progression of varices or bleeding or death) in Strategy 1 [24.09% (95%CI: 14.89%-33.29%)] was significantly lower than in Strategy 2 [60.00% (95%CI: 48.91%-71.08%)]. The mean cost (up to the first event) associated with Strategy 1 [823 £ (95%CI: 106 £-2036 £)] was not significantly different from that of Strategy 2 [799 £ (95%CI: 0 £-3498 £)]. The cost-effectiveness ratio with respect to this endpoint was equal to 50.26 £ (95%CI: -504.37 £-604.89 £) per event avoided over the four-year follow-up. When bleeding episodes/deaths in subjects whose varices had grown were included, the mean cost associated with Strategy 1 was 1028 £ (95%CI: 122 £-2581 £), while 1699 £ (95%CI: 171 £-4674 £) in Strategy 2.

CONCLUSION: Beta-blocker therapy turn out to be more effective and less expensive than endoscopic surveillance for primary prophylaxis of bleeding in patients with cirrhosis and small varices.

Cirrhosis and its complications: Evidence based treatment

Cirrhosis results from progressive fibrosis and is the final outcome of all chronic liver disease. It is among the ten leading causes of death in United States. Cirrhosis can result in portal hypertension and/or hepatic dysfunction. Both of these either alone or in combination can lead to many complications, including ascites, varices, hepatic encephalopathy, hepatocellular carcinoma, hepatopulmonary syndrome, and coagulation disorders. Cirrhosis and its complications not only impair quality of life but also decrease survival. Managing patients with cirrhosis can be a challenge and requires an organized and systematic approach. Increasing physicians’ knowledge about prevention and treatment of these potential complications is important to improve patient outcomes. A literature search of the published data was performed to provide a comprehensive review regarding the management of cirrhosis and its complications.

A fiber-optic pressure sensor for measuring esophageal variceal pressure

AIM: To test the feasibility and validity of a fiber-optic pressure sensor for measuring esophageal variceal pressure.

METHODS: A fiber-optic pressure sensor was used to measure the pressure of artificial variceal model (5 mm in diameter) with different intraluminal pressures (ranging from 6 to 42 cmH₂O). Pressure measurements were performed by two independent operators, and the results were compared with actual intraluminal pressures. In clinical tests, the technique was used to measure variceal pressure in 25 patients with esophageal varices, and the correlation between variceal pressure and the risk factors for esophageal variceal bleeding was analyzed.

RESULTS: In vitro studies demonstrated a good correlation between the pressure measured with the fiber-optic pressure sensor and the actual intravariceal pressure (r ≥ 0.99 P < 0.01), and there were good correlations between the pressures measured by two operators (r ≥ 0.99). The determination of variceal pressure by this method was technically successful in all 25 patients. The variceal pressure measurements correlated with previous variceal bleeding history, the size of varices, the presence of red colour signs and the Child-Pugh classification (t = 4.42, P < 0.01).

CONCLUSION: Our preliminary results indicate that the fiber-optic pressure sensor is feasible and accurate in measurement of esophageal variceal pressure in vivo and in vitro, and warrants further investigation.

Management and prognosis of acute esophageal variceal bleeding: Analysis of 300 cases

AIM: To analyze the treatment, management duration and prognosis of acute esophageal variceal bleeding and to identify predictive factors for treatment failure.

METHODS: Clinical data for 300 patients with acute esophageal variceal bleeding treated at our hospital from January 2008 to January 2013 were analyzed retrospectively. Bleeding control was analyzed ≤ 2 h, > 2 h but ≤ 6 h, > 6 h but ≤ 5 d, or ≥ 5 d after treatment to find the relationship between bleeding control time and mortality. The effective rate and mortality were compared between patients treated with simple drugs and those treated with drugs combined with endoscopic therapy. Logistic regression analysis was used to identify predictive factors for treatment failure.

RESULTS: The number of patients having ineffective bleeding management was 75, 25 and 27 in the ≤ 2 h, >2 h but ≤ 6 h, and >6 h but ≤ 5 d groups, respectively, and the number of dead patients was 1, 3 and 16, respectively. The percentage of patients having ineffective bleeding management was higher in the ≤ 2 h group. The effective rate of drug therapy in management of bleeding was 57.67% (173/300), and the mortality was 9.67% (29/300). The effective rate of tissue adhesive injection or ligation combined with endoscopic therapy in controlling bleeding in patients after ineffective drug therapy was 90.00% (27/30), and the mortality was 0. Logistic regression analysis showed that admission systolic blood pressure ≤ 90 mmHg, increased total bilirubin, high liver function classification, and ascites were predictive factors for treatment failure.

CONCLUSION: Ascites, increased total bilirubin, admission systolic blood pressure ≤ 90 mmHg, and high Child-Pugh classification can predict treatment failure in patients with acute esophageal variceal bleeding. Invalid bleeding control is more common during ≤ 2 h after treatment. Mortality increases with time. If bleeding can not be controlled effectively 2 h after treatment, treatment conversion should be considered. Drugs in combination with endoscopic therapy are associated with higher efficacy and lower mortality in controlling bleeding.

Variceal and other portal hypertension related bleeding

Variceal bleeding is one of the commonest and most severe complications of liver cirrhosis. Even with the current best medical care, mortality from variceal bleeding is still around 20%. When cirrhosis is diagnosed, varices are present in about 30-40% of compensated patients and in 60% of those who present with ascites. Once varices have been diagnosed, the overall incidence of variceal bleeding is in the order of 25% at two years. Variceal size is the most useful predictor for variceal bleeding, other predictors are severity of liver dysfunction (Child-Pugh classification) and the presence of red wale marks on the variceal wall. The current consensus is that every cirrhotic patient should be endoscopically screened for varices at the time of diagnosis to detect those requiring prophylactic treatment. Non-selective beta-adrenergic blockers (NSBB) and endoscopic band ligation (EBL) have been shown effective in the prevention of first variceal bleeding. The current recommendation for treating acute variceal bleeding is to start vasoactive drug therapy early (ideally during the transferral or to arrival to hospital, even if active bleeding is only suspected) and performing EBL. Once bleeding is controlled, combination therapy with NSBB + EBL should be used to prevent rebleeding. In patients at high risk of treatment failure despite of using this approach, an early covered-TIPS within 72 h (ideally 24 h) should be considered. Data on management of gastric variceal bleeding is limited. No clear recommendation for primary prophylaxis can be done. In acute cardiofundal variceal bleeding, vasoactive agents together with cyanoacrylate (CA) injection seem to be the treatment of choice. Further CA injections and/or NSBB may be used to prevent rebleeding. TIPS or Balloon-occluded retrograde transvenous obliteration when TIPS is contraindicated may be used as a rescue therapy.

Primary prophylaxis of bleeding from esophageal varices in cirrhosis

Prophylaxis of the first bleeding from esophageal varices became a clinical option more than 20 years ago, and gained a large diffusion in the following years. It is based on the use of nonselective beta-blockers, which decreases portal pressure, or on the eradication of esophageal varices by endoscopic band ligation of varices. In patients with medium or large varices either of these treatments is indicated. In patients with small varices only medical treatment is feasible, and in patients with medium and large varices with contraindication or side-effects due to beta-blockers, only endoscopic band ligation may be used. In this review the rationale and the results of the prophylaxis of bleeding from esophageal varices are discussed.

Portal hypertension and gastrointestinal bleeding: Diagnosis, prevention and management

Bleeding from esophageal varices is a life threatening complication of portal hypertension. Primary prevention of bleeding in patients at risk for a first bleeding episode is therefore a major goal. Medical prophylaxis consists of non-selective beta-blockers like propranolol or carvedilol. Variceal endoscopic band ligation is equally effective but procedure related morbidity is a drawback of the method. Therapy of acute bleeding is based on three strategies: vasopressor drugs like terlipressin, antibiotics and endoscopic therapy. In refractory bleeding, self-expandable stents offer an option for bridging to definite treatments like transjugular intrahepatic portosystemic shunt (TIPS). Treatment of bleeding from gastric varices depends on vasopressor drugs and on injection of varices with cyanoacrylate. Strategies for primary or secondary prevention are based on non-selective beta-blockers but data from large clinical trials is lacking. Therapy of refractory bleeding relies on shunt-procedures like TIPS. Bleeding from ectopic varices, portal hypertensive gastropathy and gastric antral vascular ectasia-syndrome is less common. Possible medical and endoscopic treatment options are discussed.

Gastrointestinal Bleeding in Cirrhotic Patients with Portal Hypertension

Gastrointestinal bleeding related to portal hypertension is a serious complication in patients with liver cirrhosis. Most patients bleed from esophageal or gastric varices, but bleeding from ectopic varices or portal hypertensive gastropathy is also possible. The management of acute bleeding has changed over the last years. Patients are managed with a combination of endoscopic and pharmacologic treatment. The endoscopic treatment of choice for esophageal variceal bleeding is variceal band ligation. Bleeding from gastric varices is treated by injection with cyanoacrylate. Treatment with vasoactive drugs as well as antibiotic treatment is started before or at the time point of endoscopy. The first-line treatment for primary prophylaxis of esophageal variceal bleeding is nonselective beta blockers. Pharmacologic therapy is recommended for most patients; band ligation is an alternative in patients with contraindications for or intolerability of beta blockers. Treatment options for secondary prophylaxis include variceal band ligation, beta blockers, a combination of nitrates and beta blockers, and combination of band ligation and pharmacologic treatment. A clear superiority of one treatment over the other has not been shown. Bleeding from portal hypertensive gastropathy or ectopic varices is less common. Treatment options include beta blocker therapy, injection therapy, and interventional radiology.

[Mexican consensus on portal hypertension]

The aim of the Mexican Consensus on Portal Hypertension was to develop documented guidelines to facilitate clinical practice when dealing with key events of the patient presenting with portal hypertension and variceal bleeding. The panel of experts was made up of Mexican gastroenterologists, hepatologists, and endoscopists, all distinguished professionals. The document analyzes themes of interest in the following modules: preprimary and primary prophylaxis, acute variceal hemorrhage, and secondary prophylaxis. The management of variceal bleeding has improved considerably in recent years. Current information indicates that the general management of the cirrhotic patient presenting with variceal bleeding should be carried out by a multidisciplinary team, with such an approach playing a major role in the final outcome. The combination of drug and endoscopic therapies is recommended for initial management; vasoactive drugs should be started as soon as variceal bleeding is suspected and maintained for 5 days. After the patient is stabilized, urgent diagnostic endoscopy should be carried out by a qualified endoscopist, who then performs the corresponding endoscopic variceal treatment. Antibiotic prophylaxis should be regarded as an integral part of treatment, started upon hospital admittance and continued for 5 days. If there is treatment failure, rescue therapies should be carried out immediately, taking into account that interventional radiology therapies are very effective in controlling refractory variceal bleeding. These guidelines have been developed for the purpose of achieving greater clinical efficacy and are based on the best evidence of portal hypertension that is presently available.

Transesophageal echocardiography during orthotopic liver transplantation in patients with esophagoastric varices

BACKGROUND

Hemodynamic monitoring using transesophageal echocardiography (TEE) in patients with signs of portal hypertension undergoing orthotopic liver transplantation (OLT) carries potential risk of esophageal and gastric variceal hemorrhage. The aim of our retrospective analysis was to evaluate the safety of intraoperative TEE monitoring during OLT in patients with esophagogastric varices.

METHODS

A retrospective analysis of 396 liver transplant recipients was performed at the Medical University of Vienna monitored by TEE during OLT between 2003 and 2010.

RESULTS

Varices were documented by esophagogastroduodenoscopy in 287 (72.5%) of 396 analyzed patients: 130 (32.8%) varices grade I (<5 mm under insufflation) and 157 (39.6%) varices grade II (>5 mm under insufflation). Red spot signs were identified in 40 patients (10.1%). Most varices (82.2%) were documented in the esophagus, 4.2% in the stomach, and 13.6% in both (esophagus and stomach). Only one major bleeding occurred, and it was only in a case of one patient with an esophageal varix, which was treated with a balloon tamponade during OLT. Although patients with varices demonstrated a significantly longer prothrombin time and lower platelet count, there was no significant difference in the requirement for blood products among patients with and without varices.

CONCLUSIONS

TEE is a relatively safe method for monitoring cardiac performance with a low incidence of major hemorrhagic complications in patients with documented esophagogastric varices undergoing OLT.

Endoscopic management of esophageal varices

The rupture of gastric varices results in variceal hemorrhage, which is one the most lethal complications of cirrhosis. Endoscopic therapies for varices aim to reduce variceal wall tension by obliteration of the varix. The two principal methods available for esophageal varices are endoscopic sclerotherapy (EST) and band ligation (EBL). The advantages of EST are that it is cheap and easy to use, and the injection catheter fits through the working channel of a diagnostic gastroscope. Endoscopic variceal ligation obliterates varices by causing mechanical strangulation with rubber bands. The following review aims to describe the utility of EBL and EST in different situations, such as acute bleeding, primary and secondary prophylaxis

Early primary prophylaxis with beta-blockers does not prevent the growth of small esophageal varices in cirrhosis: a randomized controlled trial

BACKGROUND

The efficacy of portal pressure reduction by beta-blockers and the utility of serial hepatic venous pressure gradient (HVPG) measurements for the management of small (≤5 mm) esophageal varices in patients of cirrhosis are not clear.

AIMS

The study had the following aims: to study (1) the effect of propranolol on the growth of small varices and (2) whether single or serial HVPG measurements result in a better outcome compared to no measurement in patients with small varices.

METHODS

Consecutive cirrhosis patients with small varices, without any history of variceal bleed, were randomized to receive propranolol or placebo and to undergo no HVPG, only baseline HVPG, or serial HVPG measurements.

RESULTS

A total of 150 cirrhotics (cirrhosis predominantly viral or alcohol induced) were included (77 in the beta-blocker and 73 in the placebo group). Baseline characteristics were similar. The actuarial 2-year risk of growth of varices (primary endpoint) was 11 and 16% in the propranolol and placebo group, respectively (P = 0.786). Variceal bleeding and mortality were also comparable in the two groups. Similarly, the outcome was not influenced by HVPG measurements (whether serial, only baseline, or no HVPG). A bilirubin level of ≥1.5 mg/dl was found to be an independent predictor of variceal progression.

CONCLUSIONS

In cirrhotics with small esophageal varices, nonselective beta-blockers are unable to prevent the growth of varices, variceal bleed, or mortality. HVPG monitoring of these patients did not change the outcome; however, the role of HVPG-guided therapy modification needs to be studied.

The course of esophageal varices in patients with hepatitis C cirrhosis responding to interferon/ribavirin therapy

BACKGROUND

Gastrointestinal haemorrhage from ruptured esophageal varices (EV) is a significant cause of morbidity and mortality in patients with HCV-related cirrhosis. The risk of developing EV and bleeding is influenced by hepatitis severity, which can be attenuated by successful interferon (IFN) therapy. Our aim was to prospectively assess whether a successful IFN therapy modifies development and/or progression of EV in patients with HCV-related compensated cirrhosis.

METHODS

Child-Pugh A patients with either no or small (F1) EV underwent surveillance with repeated endoscopy during and after completion of IFN-based therapy.

RESULTS

A total of 127 patients (59 years, 79 males, 65 HCV-1/4 and 17 F1 EV) received weight-based ribavirin (RBV) combined with either IFN-α2b 3 MU three times per week (n=36), weekly pegylated (PEG)-IFN-α2b 1.5 μg/kg (n=68) or weekly PEG-IFN-α2a 180 μg (n=23). Patients were followed-up for 18-108 months after treatment completion with a median endoscopic follow-up of 68 months for the 62 patients with a sustained virological response (SVR) and 57 months for the 65 non-SVR patients (P=0.3). De novo EV developed in 10 (9.1%) patients including 2/57 SVR and 8/53 non-SVR (3.5% versus 15.1%; P=0.047), whereas EV progressed in size in 3 patients, including 1/5 SVR and 2/12 non-SVR (P=0.87). Two non-SVR patients bled from EV and one died.

CONCLUSIONS

A successful IFN therapy prevents or delays the de novo onset of EV in patients with compensated cirrhosis due to HCV, but does not abrogate the need for continued endoscopic surveillance.

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.

Viral cirrhosis: an overview of haemostatic alterations and clinical consequences

Viral hepatitis is a major health problem worldwide, the principal cause of cirrhosis and hepatocarcinoma. Once cirrhosis occurs, the consequences of liver dysfunction and portal hypertension become evident and, sometimes, life threatening for patients. Among the various complications of liver cirrhosis, the alteration of haemostatic balance is often a hard challenge for the clinician, since it is capable to predispose both to bleeding or thrombosis. In this review, we analyze the principal aspects of procoagulant, anticoagulant and fibrinolytic capacity of cirrhotic patients, which appears to be variably altered in all these aspects, not only in the direction of a tendency to bleeding. Laboratory investigations, at present, may provide only a partial representation of this condition, because of the impossibility to obtain a test capable to furnish a global overview of the haemostatic system and to reproduce in vivo conditions. Furthermore, we describe the pathophysiological mechanisms underlying bleeding manifestations and thrombosis development in cirrhotic patients, which should be considered not only as obvious consequences of the advanced liver disease but, rather, as the result of a complex interaction between inherited and acquired factors.

Does therapy of oesophageal varices influences the progression of varices?

BACKGROUND

Aim of this study was to determine the progression time of oesophageal varices in patients with cirrhosis and to study whether therapy of varices has an impact on the progression time. Parameters associated with the progression of oesophageal varices were analyzed as well.

METHODS

One hundred and eighty-one cirrhotic patients (Child A/B/C: 105/69/15; Child score 7.6+/-2.0, initial variceal grade 1.7+/-0.9) undergoing repeated endoscopy for follow-up and/or treatment of oesophageal varices were retrospectively analyzed. A multivariate logistic regression analysis was applied to identify independent determinants of progression of oesophageal varices.

RESULTS

Of the 189 patients, 26 patients were on beta-blocker therapy only, 52 patients underwent ligation therapy only, and 37 patients received a combination of ligation and beta-blocker therapy of varices. The mean time of progression of oesophageal varices by one grade was 384+/-364 days. This interval did not vary significantly between patients who underwent no treatment or were on a beta-blocker and/or ligation therapy. The serum bilirubin (hazard ratio 1.030; 95% confidence interval, 1.004, 1.055; P<0.03) was the only parameter independently associated with the progression of varices. Initial eradication of varices was achieved after 2.2+/-1.5 ligation sessions. Rings of 6.1+/-2.5 were used in the first banding session and 11.5+/-8.9 rings were needed to achieve eradication of varices.

CONCLUSION

Therapy of oesophageal varices does not influence the progression time of oesophageal varices in patients with cirrhosis of the liver.

Does gastroesophageal reflux have an influence on bleeding from esophageal varices?

BACKGROUND

Mucosal breaks induced by gastroesophageal reflux of gastric contents were more frequently found on the right anterior wall of the lower esophagus. Bleeding from esophageal varices may be also derived from gastroesophageal reflux. The circumferential location of the ruptured esophageal varices was evaluated to elucidate the relationship between gastroesophageal reflux and variceal rupture.

METHODS

Between January 2004 and December 2006, 26 patients who had primary bleeding from esophageal varices and 74 patients without evidence of bleeding with positive red color signs on varices were enrolled in this study retrospectively. Locations of bleeding spots and nonbleeding red color signs of esophageal varices were retrospectively evaluated by endoscopic photographs, and the relationship between the location of red color signs and the risk of bleeding was evaluated. Other possible predictors for bleeding were also investigated by multivariate regression analysis.

RESULTS

Red color signs were frequently found in the right posterior wall of the lower esophagus. However, bleeding spots of esophageal varices were more frequently seen in the right anterior side (64.0%) than in others. The positive predictor for bleeding from esophageal varices was the presence of red color sign in the right anterior wall of the esophagus, and the administration of proton pomp inhibitor was the negative predictor.

CONCLUSIONS

Gastroesophageal acid reflex may be a risk factor of bleeding from esophageal varices. Attention should be paid to the circumferential location of red color signs in endoscopic screening of patients with esophageal varices to predict future bleeding.

Non-invasive (and minimally invasive) diagnosis of oesophageal varices

Current guidelines recommend screening all cirrhotic patients by endoscopy, to identify patients at risk of bleeding who should undergo prophylactic treatment. However, since the prevalence of varices in cirrhotic patients is variable, universal screening would imply a large number of unnecessary endoscopies and a heavy burden for endoscopy units. In addition, compliance to screening programs may be hampered by the perceived unpleasantness of endoscopy. Predicting the presence of oesophageal varices by non-invasive means might increase compliance and would permit to restrict the performance of endoscopy to those patients with a high probability of having varices. Over the years, several studies have addressed this issue by assessing the potential of biochemical, clinical and ultrasound parameters, transient elastography, CT scanning and video capsule endoscopy. The platelet count/spleen diameter ratio, CT scanning and video capsule endoscopy have shown promising performance characteristics, although none of them is equivalent to EGD. These methods are perceived by patients as preferable to endoscopy and thus might increase adherence to screening programs. Whether this will compensate for the lower sensitivity of these alternative techniques, and ultimately improve the outcomes if more patients undergo screening, is the crucial question that will have to be answered in the future.

The management of portal hypertension: rational basis, available treatments and future options

Variceal bleeding is the last step in a chain of events initiated by an increase in portal pressure, followed by the development and progressive dilation of varices until these finally rupture and bleed. This sequence of events might be prevented - and reversed - by achieving a sufficient decrease in portal pressure. A different approach is the use of local endoscopic treatments at the varices. This article reviews the rationale for the management of patients with cirrhosis and portal hypertension, the current recommendations for the prevention and treatment of variceal bleeding, and outlines the unsolved issues and the perspectives for the future opened by new research developments.

Portal hypertension: pre-primary and primary prophylaxis of variceal bleeding

In liver cirrhosis, variceal bleeding is the last in a chain of events initiated by the increase in portal pressure (estimated in clinical practice by the hepatic venous pressure gradient). When hepatic venous pressure gradient goes above 10 mmHg the patient is at risk of developing varices, and when hepatic venous pressure gradient reaches 12 mmHg variceal bleeding might develop. Currently, there is not any effective therapy for the prevention of the development of varices. When varices are small, beta-adrenergic blockers might prevent the enlargement of the varices, and may reduce the risk of variceal bleeding. In patients with medium to large varices, beta-blockers are clearly effective in reducing the risk of variceal bleeding. Endoscopic band ligation might be more effective than beta-blockers, but available evidence is still very weak.

Diagnosis and monitoring of portal hypertension

Currently, oesophago-gastroduodenoscopy is the standard method to diagnose the presence of oesophago-gastric varices and to estimate the risk of bleeding. It is recommended that all patients undergo endoscopic screening for varices at the time when cirrhosis is diagnosed. After screening endoscopy, patients with medium or large varices should be treated to prevent bleeding, while all other patients should undergo periodic surveillance endoscopy. However, at a given point in time a variable proportion of patients will not have varices, since the prevalence of varices is variable. Thus, screening all cirrhotic patients with endoscopy to detect the presence of varices implies a number of unnecessary endoscopies. In recent years a wealth of new methods have been proposed as alternatives to conventional oesophago-gastroduodenoscopy for the non-invasive or minimally invasive diagnosis of oesophageal varices. Three of these methods (the platelet count/spleen diameter ratio, Fibrotest and Fibroscan) are truly non-invasive. Of these, the former is promising and needs a proper validation, Fibrotest appears to be insufficiently precise, while Fibroscan needs further evaluation. Multidetector CT oesophagography and capsule endoscopy are not entirely "non-invasive", since the first requires air insufflation into the oesophagus via an orally passed tube, and the latter requires swallowing the capsule. Multidetector CT oesophagography is promising, but needs further evaluation; capsule endoscopy is safe and reliable and might be proposed as an alternative to oesophago-gastroduodenoscopy in patients unable or unwilling to undergo oesophago-gastroduodenoscopy.

New abdominal collaterals at ultrasound: a clue of progression of portal hypertension

BACKGROUND

Abdominal ultrasound can detect non-invasively the presence of abdominal portal-systemic collaterals in patients with liver cirrhosis. Abdominal portal-systemic collaterals may be protective from the formation and growth of oesophageal varices, but available data are inconclusive.

AIM

We aimed at investigating the relationship between abdominal portal-systemic collaterals and variceal formation and growth.

METHODS

We studied 126 cirrhotic patients without (n=43) or with small (n=83) oesophageal varices who entered a protocol of serial ultrasonographic and endoscopic examinations for a median of 55 months. Presence and kind of abdominal portal-systemic collaterals was recorded on first ultrasonography and on each control thereafter.

RESULTS

At inclusion, abdominal portal-systemic collaterals were found in 19/43 patients without varices and in 23/83 patients with small varices (NS). There was no difference in variceal formation and growth between patients with and without abdominal portal-systemic collaterals at inclusion. However, patients developing new abdominal portal-systemic collaterals during follow-up had a significantly higher rate of variceal formation (56.2% vs. 22.2%; p=0.024) and growth (52.9% vs. 30.6%; p=0.041) compared with patients with unchanged ultrasonography.

CONCLUSIONS

Abdominal collaterals are not protective from the formation or growth of oesophageal varices. Conversely, new abdominal portal-systemic collaterals emergence is a non-invasive clue of formation and progression of varices. Therefore, endoscopy is probably indicated whenever new abdominal portal-systemic collaterals are detected in cirrhotic patients.

Non-invasive diagnosis of cirrhosis and the natural history of its complications

Several methods have been studied in the attempt to reach a diagnosis of cirrhosis by non-invasive means. Although abdominal ultrasound can detect the hepatic and extra-hepatic changes consistent with cirrhosis, its ability to distinguish chronic hepatitis from compensated cirrhosis is limited. Serum markers can rule in or rule out fibrosis in up to 35% of patients but, in individual patients, cannot differentiate the stages of fibrosis reliably. Transient elastography (Fibroscan) might be of value for the non-invasive diagnosis of cirrhosis; however, its reproducibility needs to be further validated. Cirrhosis can be divided into 4 stages: stage 1, no varices, no ascites; stage 2, varices without ascites and without bleeding; stage 3, ascites+/-varices; stage 4, bleeding+/-ascites. Yearly mortality ranges from 1% in stage 1 to 57% in stage 4. The yearly incidence of oesophageal varices is 5-7%; their rate of enlargement is 10-12% per year. The incidence of variceal bleeding is about 25% at 2 years. Bleeding stops spontaneously in about 50% of cases but early rebleeding occurs in 30-40% of patients. Bleeding-related mortality has declined over time and is now around 20% at 6 weeks.

The prevalence and risk factors associated with esophageal varices in subjects with hepatitis C and advanced fibrosis

BACKGROUND

The factors predictive of the presence or the absence of esophageal varices in hepatitis C virus (HCV) and advanced fibrosis have not been defined.

OBJECTIVES

To define the prevalence of esophageal varices and the factors that are positively and negatively with such varices in hepatitis C and advanced fibrosis.

DESIGN

A prospective study of esophageal varices and associated risk factors in subjects with hepatitis C and advanced fibrosis.

SETTING

Prerandomization data from the HALT-C (hepatitis C long-term antiviral treatment against cirrhosis) clinical trial.

PATIENTS AND INTERVENTION

Subjects with bridging fibrosis or cirrhosis, who were virologic nonresponders to treatment with pegylated interferon alpha 2a and ribavirin, underwent endoscopy.

RESULTS

Sixteen percent of subjects with bridging fibrosis (95/598) and 39% of subjects with cirrhosis (164/418) had varices (P < .0001); 2% of subjects with bridging fibrosis (13/598) and 11% of those with cirrhosis (48/418) had medium or large varices. Subjects with bridging fibrosis and varices had a significantly lower platelet count and higher bilirubin and international normalized ratio (INR) compared with those without varices, suggesting that the biopsy may have underestimated the severity of fibrosis. A platelet count >150,000/mm(3) was associated with a negative predictive value of 99% for esophageal varices. By logistic regression modeling, African American race and female sex were protective, whereas a lower platelet count and higher bilirubin and INR predicted varices (c statistic, 0.758).

CONCLUSIONS

The risk of having varices increases with decreasing platelet counts, increasing bilirubin, and INR. The probability of having medium or large varices at platelet counts >150,000/mm(3) is negligible in this population.

Effect of potassium canrenoate, an anti-aldosterone agent, on incidence of ascites and variceal progression in cirrhosis

BACKGROUND & AIMS

Because aldosterone-dependent sodium and water retention contribute to portal hypertension, the safety and effect of an antialdosteronic drug (Kcanrenoate) have been evaluated on the occurrence of de novo appearance of ascites and the development of esophageal varices or the progression of small varices.

METHODS

Inclusion criteria were as follows: Child-Pugh A viral pre-ascitic cirrhosis, with either F1 esophageal varices or no varices, but endoscopic and/or ultrasound evidence of portal hypertension. Thirteen Italian Liver Units prospectively enrolled 120 patients randomized to receive double-blind either Kcanrenoate (100 mg/day; 66 patients) or placebo (54 patients). Endoscopy and sonography were performed at entry and at 52 weeks unless the patient developed ascites earlier, whereas laboratory examinations were performed at entry and every 3 months thereafter. An intention-to-treat analysis was performed, with each end point assessed by the Fisher exact test; the cumulative risk for the appearance of any end point was analyzed by the adjusted log-rank test (Tarone-Ware), with censoring for drop-outs.

RESULTS

The progression of variceal status or appearance of ascites, analyzed independently, was not significantly more frequent on placebo (24.1% and 9.2%, respectively) than on Kcanrenoate (12.1% and 1.5%, respectively), whereas the cumulative occurrence of end points was decreased on Kcanrenoate (17.6% vs 38.3% with placebo; P < .05, Tarone-Ware test). The incidence of adverse events was negligible and did not differ between groups.

CONCLUSIONS

This preliminary study shows that 100 mg/day of Kcanrenoate is well tolerated and does not reduce the individual incidence of ascites and/or the appearance or progression of esophageal varices in preascitc cirrhosis, but may decrease their 1-year cumulative occurrence.

Esophageal Varices: Evaluation with Esophagography with Barium versus Endoscopic Gastroduodenoscopy in Patients with Compensated Cirrhosis—Blinded Prospective Study

PURPOSE

To prospectively evaluate the accuracy of esophagography with barium in diagnosis of esophageal varices (EV) in patients with compensated cirrhosis, with endoscopic gastroduodenoscopy as the reference standard.

MATERIALS AND METHODS

In this study, which was approved by the local Helsinki Committee and in which all patients consented to participate, 61 patients with cirrhosis (34 men, 27 women; mean age, 61 years; range, 36-76 years) received a diagnosis clinically or with liver biopsy. In 87% (n = 53) of patients, Child-Pugh classification was A; in 13% (n = 8), Child-Pugh classification was B. They were evaluated with endoscopic gastroduodenoscopy, according to Japanese general criteria. Esophagography was performed within 3 weeks of endoscopic gastroduodenoscopy, and EV were assigned grades as follows: 0, no EV were seen; 1, EV manifested as very mild irregularities of the folds; and 2, the irregularity of the folds (EV) was clearly present. They were also assigned grades for shape and size: grade F0, no EV detected; grade F1, small straight EV; grade F2, slightly enlarged tortuous EV occupying less than one-third of esophageal lumen; and grade F3, large coil-shaped EV that occupied more than one-third of esophageal lumen. The sensitivity and specificity and positive and negative predictive values of esophagography for identification of each grade of EV were calculated separately, as was the 95% confidence interval.

RESULTS

All large EV (grades F2 and F3) were diagnosed at esophagography. Sensitivity declined with small EV (grade F1) to 71. The overall sensitivity of esophagography was 89% (95% confidence interval: 75.9%, 96.5%), the overall specificity was 83% (95% confidence interval: 64.5%, 94.7%), the overall positive predictive value was 89%, and the overall negative predictive value was 83% (95% confidence interval: 64.5%, 94.7%). Overall accuracy was 87%.

CONCLUSION

Esophagography is highly accurate in diagnosis of EV and can be considered a viable noninvasive alternative for determination of patients who should be selected for prophylactic treatment.

Cardiac, neuroadrenergic, and portal hemodynamic effects of prolonged aldosterone blockade in postviral child A cirrhosis

OBJECTIVES

The present study was designed to determine the effects of long-term antialdosterone treatment on cardiac structural and functional alterations, portal and systemic hemodynamic as well as adrenergic dysfunction characterizing Child A cirrhotic patients with F1 esophageal varices.

METHODS

Twenty-two Child A postviral preascitic cirrhotic patients were randomly allocated to 200 mg/day K-Canrenoate (13 patients, age 59.6 +/- 2.2 yr, mean + SEM) or no-drug treatment (9 patients, age 61.8 +/- 2.3) for a 6-month-period. Measurements, which included hepatic venous pressure gradient (HVPG), left ventricular wall thickness, left ventricular end-diastolic volume and diastolic function (LVWT, LVEDV, and E/A ratio, echocardiography), and muscle sympathetic nerve activity (MSNA, microneurography, peroneal nerve), were obtained at baseline and following 6 months of drug or no-drug treatment. Ten healthy age-matched subjects served as controls.

RESULTS

Cirrhotic patients were characterized by increased HVPG, LVWT, and MSNA values and by a depressed E/A ratio. K-Canrenoate treatment significantly reduced HVPG (from 15.3 +/- 1.0 to 13.8 +/- 0.8 mmHg, p < 0.05), LVWT (from 21.8 +/- 0.5 to 20.7 +/- 0.6 mm, p < 0.02), and LVEDV (from 99.2 +/- 7 to 86.4 +/- 6 ml, p < 0.01), leaving E/A ratio and MSNA almost unaltered. No significant change was observed in the untreated group of cirrhotic patients followed for 6 months without intervention.

CONCLUSIONS

These data provide evidence that aldosterone blockade by long-term K-Canrenoate administration improves hepatic hemodynamics by lowering HVPG and ameliorates cardiac structure and function by favoring a reduction in LVWT and LVEDV as well. They also show, however, that this therapeutic intervention neither improves left ventricular diastolic dysfunction nor exerts sympathoinhibitory effects.