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Elbasiony M, Abed H, Alaskalany HM, Saleh A. Transient elastography and platelet count as noninvasive predictors of gastroesophageal varices in patients with compensated hepatitis C virus-related liver cirrhosis. Med J Armed Forces India 2023; 79:710-717. [PMID: 37981928 PMCID: PMC10654393 DOI: 10.1016/j.mjafi.2021.08.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2021] [Accepted: 08/15/2021] [Indexed: 11/20/2022] Open
Abstract
Background Early detection of esophageal varices (EV) before the first attack of bleeding is crucial for primary prophylaxis. The current work aims to investigate the use of a combination of FibroScan and platelet count as noninvasive means to identify EV in patients with compensated cirrhosis. Methods Sixty-two patients with compensated hepatitis C virus (HCV)-related cirrhosis were divided into two groups with and without EV. All patients were exposed to complete history, physical examination, laboratory, and endoscopic evaluation. FibroScan was performed for all patients, and the two groups were compared. Results A statistically significant higher mean liver stiffness measurement (LSM) (KPa), lower mean platelet count to splenic diameter ratio (PSR), and higher mean fibrosis-4 (FIB4) score were noticed in those with EV with P < 0.0005. A cutoff value of ≥23.1 for LSM, ≥3.71 for FIB4, and ≥130 mm for splenic diameter have a sensitivity of 94%, 97%, and 97% and a specificity of 81%, 81%, and 68%, respectively, in the detection of varices. Platelet count of ≥112,500 (×103/dl) and of ≥771.33 for PSR have a sensitivity of 84% and 77% and a specificity of 87% and 90%, respectively, to rule out the presence of varices. LSM, FIB4 score, and splenic diameter are predictors of the presence of varices where platelet count and PSR are negative predictors. Conclusion The combination of LSM by transient elastography (TE), PSR, or platelet count can be used to detect a relevant category of patients with compensated cirrhosis who have a very low possibility of EV where endoscopy can be avoided.
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Affiliation(s)
- Mohamed Elbasiony
- Department of Internal Medicine, Hepatology & Gastroenterology Unit, Faculty of Medicine, Mansoura University, Egypt
| | - Hassan Abed
- Nabaroh Central Hospital, Ministry of Health, Egypt
| | - Hassan M. Alaskalany
- Department of Internal Medicine, Hepatology & Gastroenterology Unit, Faculty of Medicine, Mansoura University, Egypt
| | - Ahmed Saleh
- Department of Internal Medicine, Hepatology & Gastroenterology Unit, Faculty of Medicine, Mansoura University, Egypt
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Fofiu R, Bende F, Popescu A, Șirli R, Miuţescu B, Sporea I. Assessing Baveno VI Criteria Using Liver Stiffness Measured with a 2D-Shear Wave Elastography Technique. Diagnostics (Basel) 2021; 11:diagnostics11050737. [PMID: 33919033 PMCID: PMC8142982 DOI: 10.3390/diagnostics11050737] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 04/12/2021] [Accepted: 04/20/2021] [Indexed: 12/18/2022] Open
Abstract
The present study evaluates the performance of Baveno VI criteria, using liver stiffness (LS) assessed with a 2D-SWE elastography technique, for predicting high-risk varices (HRV) in patients with compensated advanced chronic liver disease (cACLD). A secondary aim was to determine whether the use of spleen stiffness measurements (SSMs), as additional criteria, increases the performance of the 2D-SWE Baveno VI criteria. Data were collected from 208 subjects with cACLD, who underwent abdominal ultrasound, liver and spleen stiffness measurements, and upper digestive endoscopy. HRV were defined as grade 1 esophageal varices (EV) with red wale marks, grade 2/3 EV, and gastric varices. A total of 35.6% (74/208) of the included subjects had HRV. The optimal LS cut-off value for predicting HRV was 12 kPa (AUROC-0.80). Using both LS cut-off value < 12 kPa and a platelet cut-off value > 150 × 109 cells/L as criteria to exclude HRV, 52/208 (25%) subjects were selected, 88.5% (46/52) were without EV, 9.6% (5/52) had grade 1 EV, and 1.9% (1/52) had HRV. Thus 98% of the subjects were correctly classified as having or not having HRV and 25% of the surveillance endoscopies could have been avoided. Using SS < 13.2 kPa and a platelet cut-off value > 150 × 109 cells/L as additional criteria for the patients that were outside the initial ones, 32.7% of the surveillance endoscopies could have been avoided.
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Roccarina D, Best LM, Freeman SC, Roberts D, Cooper NJ, Sutton AJ, Benmassaoud A, Plaz Torres MC, Iogna Prat L, Csenar M, Arunan S, Begum T, Milne EJ, Tapp M, Pavlov CS, Davidson BR, Tsochatzis E, Williams NR, Gurusamy KS. Primary prevention of variceal bleeding in people with oesophageal varices due to liver cirrhosis: a network meta-analysis. Cochrane Database Syst Rev 2021; 4:CD013121. [PMID: 33822357 PMCID: PMC8092414 DOI: 10.1002/14651858.cd013121.pub2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
BACKGROUND Approximately 40% to 95% of people with cirrhosis have oesophageal varices. About 15% to 20% of oesophageal varices bleed in about one to three years. There are several different treatments to prevent bleeding, including: beta-blockers, endoscopic sclerotherapy, and variceal band ligation. However, there is uncertainty surrounding their individual and relative benefits and harms. OBJECTIVES To compare the benefits and harms of different treatments for prevention of first variceal bleeding from oesophageal varices in adults with liver cirrhosis through a network meta-analysis and to generate rankings of the different treatments for prevention of first variceal bleeding from oesophageal varices according to their safety and efficacy. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, Science Citation Index Expanded, World Health Organization International Clinical Trials Registry Platform, and trials registers to December 2019 to identify randomised clinical trials in people with cirrhosis and oesophageal varices with no history of bleeding. SELECTION CRITERIA We included only randomised clinical trials (irrespective of language, blinding, or status) in adults with cirrhosis and oesophageal varices with no history of bleeding. We excluded randomised clinical trials in which participants had previous bleeding from oesophageal varices and those who had previously undergone liver transplantation or previously received prophylactic treatment for oesophageal varices. DATA COLLECTION AND ANALYSIS We performed a network meta-analysis with OpenBUGS using Bayesian methods and calculated the differences in treatments using hazard ratios (HR), odds ratios (OR), and rate ratios with 95% credible intervals (CrI) based on an available-case analysis, according to National Institute for Health and Care Excellence Decision Support Unit guidance. We performed the direct comparisons from randomised clinical trials using the same codes and the same technical details. MAIN RESULTS We included 66 randomised clinical trials (6653 participants) in the review. Sixty trials (6212 participants) provided data for one or more comparisons in the review. The trials that provided the information included people with cirrhosis due to varied aetiologies and those at high risk of bleeding from oesophageal varices. The follow-up in the trials that reported outcomes ranged from 6 months to 60 months. All but one of the trials were at high risk of bias. The interventions compared included beta-blockers, no active intervention, variceal band ligation, sclerotherapy, beta-blockers plus variceal band ligation, beta-blockers plus nitrates, nitrates, beta-blockers plus sclerotherapy, and portocaval shunt. Overall, 21.2% of participants who received non-selective beta-blockers ('beta-blockers') - the reference treatment (chosen because this was the most common treatment compared in the trials) - died during 8-month to 60-month follow-up. Based on low-certainty evidence, beta-blockers, variceal band ligation, sclerotherapy, and beta-blockers plus nitrates all had lower mortality versus no active intervention (beta-blockers: HR 0.49, 95% CrI 0.36 to 0.67; direct comparison HR: 0.59, 95% CrI 0.42 to 0.83; 10 trials, 1200 participants; variceal band ligation: HR 0.51, 95% CrI 0.35 to 0.74; direct comparison HR 0.49, 95% CrI 0.12 to 2.14; 3 trials, 355 participants; sclerotherapy: HR 0.66, 95% CrI 0.51 to 0.85; direct comparison HR 0.61, 95% CrI 0.41 to 0.90; 18 trials, 1666 participants; beta-blockers plus nitrates: HR 0.41, 95% CrI 0.20 to 0.85; no direct comparison). No trials reported health-related quality of life. Based on low-certainty evidence, variceal band ligation had a higher number of serious adverse events (number of events) than beta-blockers (rate ratio 10.49, 95% CrI 2.83 to 60.64; 1 trial, 168 participants). Based on low-certainty evidence, beta-blockers plus nitrates had a higher number of 'any adverse events (number of participants)' than beta-blockers alone (OR 3.41, 95% CrI 1.11 to 11.28; 1 trial, 57 participants). Based on low-certainty evidence, adverse events (number of events) were higher in sclerotherapy than in beta-blockers (rate ratio 2.49, 95% CrI 1.53 to 4.22; direct comparison rate ratio 2.47, 95% CrI 1.27 to 5.06; 2 trials, 90 participants), and in beta-blockers plus variceal band ligation than in beta-blockers (direct comparison rate ratio 1.72, 95% CrI 1.08 to 2.76; 1 trial, 140 participants). Based on low-certainty evidence, any variceal bleed was lower in beta-blockers plus variceal band ligation than in beta-blockers (direct comparison HR 0.21, 95% CrI 0.04 to 0.71; 1 trial, 173 participants). Based on low-certainty evidence, any variceal bleed was higher in nitrates than beta-blockers (direct comparison HR 6.40, 95% CrI 1.58 to 47.42; 1 trial, 52 participants). The evidence indicates considerable uncertainty about the effect of the interventions in the remaining comparisons. AUTHORS' CONCLUSIONS Based on low-certainty evidence, beta-blockers, variceal band ligation, sclerotherapy, and beta-blockers plus nitrates may decrease mortality compared to no intervention in people with high-risk oesophageal varices in people with cirrhosis and no previous history of bleeding. Based on low-certainty evidence, variceal band ligation may result in a higher number of serious adverse events than beta-blockers. The evidence indicates considerable uncertainty about the effect of beta-blockers versus variceal band ligation on variceal bleeding. The evidence also indicates considerable uncertainty about the effect of the interventions in most of the remaining comparisons.
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Affiliation(s)
- Davide Roccarina
- Sheila Sherlock Liver Centre, Royal Free Hospital and the UCL Institute of Liver and Digestive Health, London, UK
| | - Lawrence Mj Best
- Division of Surgery and Interventional Science, University College London, London, UK
- Department of Therapy, I.M. Sechenov First Moscow State Medical University, Moscow, Russian Federation
| | - Suzanne C Freeman
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Danielle Roberts
- Division of Surgery and Interventional Science, University College London, London, UK
| | - Nicola J Cooper
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Alex J Sutton
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Amine Benmassaoud
- Sheila Sherlock Liver Centre, Royal Free Hospital and the UCL Institute of Liver and Digestive Health, London, UK
| | | | - Laura Iogna Prat
- Sheila Sherlock Liver Centre, Royal Free Hospital and the UCL Institute of Liver and Digestive Health, London, UK
| | - Mario Csenar
- Division of Surgery and Interventional Science, University College London, London, UK
| | - Sivapatham Arunan
- General and Colorectal Surgery, Ealing Hospital and Imperial College, London, Northwood, UK
| | | | | | | | - Chavdar S Pavlov
- Department of Therapy, I.M. Sechenov First Moscow State Medical University, Moscow, Russian Federation
| | - Brian R Davidson
- Division of Surgery and Interventional Science, University College London, London, UK
| | - Emmanuel Tsochatzis
- Sheila Sherlock Liver Centre, Royal Free Hospital and the UCL Institute of Liver and Digestive Health, London, UK
| | - Norman R Williams
- Surgical & Interventional Trials Unit (SITU), UCL Division of Surgery & Interventional Science, London, UK
| | - Kurinchi Selvan Gurusamy
- Division of Surgery and Interventional Science, University College London, London, UK
- Department of Therapy, I.M. Sechenov First Moscow State Medical University, Moscow, Russian Federation
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Spleen Stiffness for Predicting Varices Needing Treatment: Comparison between Two Different Elastography Techniques (Point vs. 2D-SWE). Can J Gastroenterol Hepatol 2021; 2021:6622726. [PMID: 34055675 PMCID: PMC8130909 DOI: 10.1155/2021/6622726] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Revised: 03/17/2021] [Accepted: 03/19/2021] [Indexed: 02/06/2023] Open
Abstract
The study aimed to establish the benefits of using spleen stiffness values measured by two elastography techniques as noninvasive markers for predicting varices needing treatment and comparing their performances. A prospective study was performed, including 107 subjects with compensated liver cirrhosis, who underwent upper digestive endoscopy, as well as spleen stiffness measurements by means of two elastography techniques: pSWE (point shear wave elastography using Virtual Touch Quantification-Siemens Acuson S2000) and 2D-SWE (2D-shear wave elastography-LOGIQ E9, General Electric). Reliable spleen stiffness measurements were obtained in 96.2% (103/107) patients by means of 2D-SWE and in 94.4% (101/107) subjects with pSWE; therefore, 98 subjects were included in the final analysis, of which 40.8% (40/98) had varices needing treatment. The optimal spleen stiffness cut-off value by 2D-SWE for predicting varices needing treatment was 13.2 kPa (AUROC 0.84), while for pSWE, it was 2.91 m/s (AUROC 0.90). Based on AUROC comparison, no difference between the performance of the two techniques for predicting varices needing treatment was found (p=0.1606). In conclusion, spleen stiffness measured by either 2D-SWE or pSWE is a reliable surrogate marker, with good feasibility, applicability, and predictive accuracy for varices needing treatment, with no significant difference between techniques.
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Fofiu R, Bende F, Popescu A, Şirli R, Lupușoru R, Ghiuchici AM, Sporea I. Spleen and Liver Stiffness for Predicting High-Risk Varices in Patients with Compensated Liver Cirrhosis. ULTRASOUND IN MEDICINE & BIOLOGY 2021; 47:76-83. [PMID: 33067019 DOI: 10.1016/j.ultrasmedbio.2020.09.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Revised: 08/19/2020] [Accepted: 09/11/2020] [Indexed: 06/11/2023]
Abstract
The study evaluates the utility of spleen (SS) and liver stiffness (LS) associated with spleen size (SSZ) as non-invasive markers for predicting high-risk varices (HRV). One hundred thirty-two patients with compensated liver cirrhosis who underwent abdominal ultrasound SS (SSM) and LS measurements (LSM) using a 2-D shear wave elastography (2-D-SWE) technique from General Electric and upper endoscopy were included. Similar rates of reliable SSM and LSM were obtained (95.4% and 97.7% respectively); therefore, 124 patients were included in the final analysis. The optimal cutoff values for SS, LS and SSZ for predicting HRV were 13.2 kPa (area under the receiver operating characteristic curve [AUROC] = 0.84), 12.1 kPa (AUROC = 0.86) and 12.9 cm (AUROC = 0.71), respectively. Including these factors in multiple regression analysis, we obtained the scores for predicting HRV: 0.053 × SS + 0.054 × LS + 0.059 × SSZ - 1.84. The score's optimal cutoff value for predicting HRV was >0.34 (AUROC = 0.93). By comparing the AUROC's, the score including SSZ, SSM and LSM performed better than each independent factor for predicting HRV (p = 0.0091; p = 0.0341; p < 0.0001).
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Affiliation(s)
- Renata Fofiu
- Department of Gastroenterology and Hepatology, "Victor Babeș" University of Medicine and Pharmacy, Timișoara, Romania
| | - Felix Bende
- Department of Gastroenterology and Hepatology, "Victor Babeș" University of Medicine and Pharmacy, Timișoara, Romania.
| | - Alina Popescu
- Department of Gastroenterology and Hepatology, "Victor Babeș" University of Medicine and Pharmacy, Timișoara, Romania
| | - Roxana Şirli
- Department of Gastroenterology and Hepatology, "Victor Babeș" University of Medicine and Pharmacy, Timișoara, Romania
| | - Raluca Lupușoru
- Department of Gastroenterology and Hepatology, "Victor Babeș" University of Medicine and Pharmacy, Timișoara, Romania
| | - Ana-Maria Ghiuchici
- Department of Gastroenterology and Hepatology, "Victor Babeș" University of Medicine and Pharmacy, Timișoara, Romania
| | - Ioan Sporea
- Department of Gastroenterology and Hepatology, "Victor Babeș" University of Medicine and Pharmacy, Timișoara, Romania
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Ryu SR, Yoo JJ, Kang SH, Jeong SW, Kim MY, Cho YK, Chang Y, Kim SG, Jang JY, Kim YS, Baik SK, Kim YJ, Park SY, Baymbajav B. The cut-off value of transient elastography to the value of hepatic venous pressure gradient in alcoholic cirrhosis. Clin Mol Hepatol 2020; 27:197-206. [PMID: 33317252 PMCID: PMC7820198 DOI: 10.3350/cmh.2020.0171] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Accepted: 10/06/2020] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND/AIMS The hepatic venous pressure gradient (HVPG) reflects portal hypertension, but its measurement is invasive. Transient elastography (TE) is a noninvasive method for evaluating liver stiffness (LS). We investigated the correlation between the value of LS, LS to platelet ratio (LPR), LS-spleen diameter-to-platelet ratio score (LSPS) and HVPG according to the etiology of cirrhosis, especially focused on alcoholic cirrhosis. METHODS Between January 2008 and March 2017, 556 patients who underwent HVPG and TE were consecutively enrolled. We evaluated LS, LPR, and LSPS according to the etiology of cirrhosis and analyzed their correlations with HVPG. RESULTS The LS value was higher in patients with alcoholic cirrhosis than viral cirrhosis based on the HVPG (43.5 vs. 32.0 kPa, P<0.001). There were no significant differences in the LPR or LSPS between alcoholic and viral cirrhosis groups, and the areas under the curves for the LPR and LSPS in subgroups according to HVPG levels were not superior to that for LS. In alcoholic cirrhosis, the LS cutoff value for predicting an HVPG ≥10 mmHg was 32.2 kPa with positive predictive value (PPV) of 94.5% and 36.6 kPa for HVPG ≥12 mmHg with PPV of 91.0%. CONCLUSION The LS cutoff value should be determined separately for patients with alcoholic and viral cirrhosis. In alcoholic cirrhosis, the LS cutoff values were 32.2 and 36.6 kPa for predicting an HVPG ≥10 and ≥12 mmHg, respectively. However, there were no significant differences in the LPR or LSPS between alcoholic and viral cirrhosis groups.
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Affiliation(s)
- Se Ri Ryu
- Department of Internal Medicine, Soonchunhyang University Seoul Hospital, Soonchunhyang University College of Medicine, Seoul, Korea
| | - Jeong-Ju Yoo
- Department of Internal Medicine, Soonchunhyang University Bucheon Hospital, Soonchunhyang University College of Medicine, Bucheon, Korea
| | - Seong Hee Kang
- Department of Internal Medicine, Wonju Severance Christian Hospital, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Soung Won Jeong
- Department of Internal Medicine, Soonchunhyang University Seoul Hospital, Soonchunhyang University College of Medicine, Seoul, Korea
| | - Moon Young Kim
- Department of Internal Medicine, Wonju Severance Christian Hospital, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Young Kyu Cho
- Department of Internal Medicine, Soonchunhyang University Seoul Hospital, Soonchunhyang University College of Medicine, Seoul, Korea
| | - Young Chang
- Department of Internal Medicine, Soonchunhyang University Seoul Hospital, Soonchunhyang University College of Medicine, Seoul, Korea
| | - Sang Gyune Kim
- Department of Internal Medicine, Soonchunhyang University Bucheon Hospital, Soonchunhyang University College of Medicine, Bucheon, Korea
| | - Jae Young Jang
- Department of Internal Medicine, Soonchunhyang University Seoul Hospital, Soonchunhyang University College of Medicine, Seoul, Korea
| | - Young Seok Kim
- Department of Internal Medicine, Soonchunhyang University Bucheon Hospital, Soonchunhyang University College of Medicine, Bucheon, Korea
| | - Soon Koo Baik
- Department of Internal Medicine, Wonju Severance Christian Hospital, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Yong Jae Kim
- Department of Radiology, Soonchunhyang University Seoul Hospital, Soonchunhyang University College of Medicine, Seoul, Korea
| | - Su Yeon Park
- Department of Biostatistics, Soonchunhyang University Seoul Hospital, Soonchunhyang University College of Medicine, Seoul, Korea
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Lee HA, Kim SU, Seo YS, Lee YS, Kang SH, Jung YK, Kim MY, Kim JH, Kim SG, Suk KT, Jung SW, Jang JY, An H, Yim HJ, Um SH. Prediction of the varices needing treatment with non-invasive tests in patients with compensated advanced chronic liver disease. Liver Int 2019; 39:1071-1079. [PMID: 30589490 DOI: 10.1111/liv.14036] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2018] [Revised: 11/29/2018] [Accepted: 12/21/2018] [Indexed: 02/13/2023]
Abstract
BACKGROUNDS & AIMS The Baveno VI guidelines proposed criteria including liver stiffness (LS) and platelet count to avoid screening endoscopy in patients with compensated advanced chronic liver disease (cACLD). This study was performed to validate the Baveno IV criteria and to compare its diagnostic accuracy with other non-invasive models. METHODS Patients with cACLD who underwent laboratory tests, upper gastrointestinal endoscopy and abdominal ultrasound within 6 months of transient elastography were included. RESULTS A total of 1218 patients with cACLD were included. VNT occurred in 249 patients (20.4%). With the Baveno VI criteria, the VNT miss rate was 1.9% with a 25.7% saved endoscopy rate. Using two criteria of LS <20 kPa and platelet count >110 × 109 cells/L or LS <25 kPa and platelet count >120 × 109 cells/L, the saved endoscopy rate was 39.1% while maintaining the VNT miss rate <5%. The optimal LS and platelet count-based criteria for predicting VNT differed according to the underlying liver disease. The area under the receiver operating characteristic curve of LS-spleen diameter to platelet score (LSPS) was 0.780 (95% confidence interval: 0.774-0.820), which was significantly higher than other models. The optimal cut-off value of the LSPS for predicting VNT was 1.47. CONCLUSION Liver stiffness and platelet count-based criteria are useful for discriminating patients with very low risk of having VNT among patients with cACLD and are partly affected by the type of underlying liver disease. Conversely, the LSPS is a predictor of VNT in patients with cACLD regardless of the type of underlying liver disease.
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Affiliation(s)
- Han Ah Lee
- Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Seung Up Kim
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Yeon Seok Seo
- Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Young-Sun Lee
- Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Seong Hee Kang
- Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Young Kul Jung
- Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Moon Young Kim
- Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Ji Hoon Kim
- Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Sang Gyune Kim
- Department of Internal Medicine, Soonchunhyang University College of Medicine, Cheonan, Korea
| | - Ki Tae Suk
- Department of Internal Medicine, Hallym University College of Medicine, Chuncheon, Korea
| | - Soung Won Jung
- Department of Internal Medicine, Soonchunhyang University College of Medicine, Cheonan, Korea
| | - Jae Young Jang
- Department of Internal Medicine, Soonchunhyang University College of Medicine, Cheonan, Korea
| | - Hyonggin An
- Department of Biostatistics, Korea University College of Medicine, Seoul, Korea
| | - Hyung Joon Yim
- Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Soon Ho Um
- Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
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Karagiannakis DS, Voulgaris T, Siakavellas SI, Papatheodoridis GV, Vlachogiannakos J. Evaluation of portal hypertension in the cirrhotic patient: hepatic vein pressure gradient and beyond. Scand J Gastroenterol 2019; 53:1153-1164. [PMID: 30345856 DOI: 10.1080/00365521.2018.1506046] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Portal hypertension (PH) is a major complication of liver cirrhosis, as it predisposes to the development of serious clinical manifestations such as ascites, hepatic encephalopathy and variceal bleeding. Till now, the measurement of hepatic vein pressure gradient (HVPG) is the gold standard method to ascertain the presence and significance of PH, as many studies have shown its correlation with the appearance of varices and the possibility of variceal bleeding. However, the invasiveness of this procedure makes it difficult to be used in daily clinical practice. Several noninvasive methods with adequate capability of evaluating liver fibrosis, including elastographic techniques, are currently used as alternatives to HVPG in order to assess the presence and the severity of PH. The aim of this paper is to express an overview of the literature about the actual role of HVPG and all available noninvasive tests on the prediction of development of PH complications, to highlight their advantages and their potential limitations, and to provide the latest trends on clinical practice.
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Affiliation(s)
- D S Karagiannakis
- a Academic Department of Gastroenterology , Laiko General Hospital Medical School University of Athens , Athens , Greece
| | - T Voulgaris
- a Academic Department of Gastroenterology , Laiko General Hospital Medical School University of Athens , Athens , Greece
| | - S I Siakavellas
- a Academic Department of Gastroenterology , Laiko General Hospital Medical School University of Athens , Athens , Greece
| | - G V Papatheodoridis
- a Academic Department of Gastroenterology , Laiko General Hospital Medical School University of Athens , Athens , Greece
| | - J Vlachogiannakos
- a Academic Department of Gastroenterology , Laiko General Hospital Medical School University of Athens , Athens , Greece
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Qi X, Berzigotti A, Cardenas A, Sarin SK. Emerging non-invasive approaches for diagnosis and monitoring of portal hypertension. Lancet Gastroenterol Hepatol 2019; 3:708-719. [PMID: 30215362 DOI: 10.1016/s2468-1253(18)30232-2] [Citation(s) in RCA: 85] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Revised: 05/13/2018] [Accepted: 06/25/2018] [Indexed: 02/08/2023]
Abstract
Clinically significant portal hypertension is associated with an increased risk of developing gastro-oesophageal varices and hepatic decompensation. Hepatic venous pressure gradient measurement and oesophagogastroduodenoscopy are the gold-standard methods for assessing clinically significant portal hypertension (hepatic venous pressure gradient ≥10 mm Hg) and gastro-oesophageal varices, respectively. However, invasiveness, cost, and feasibility limit their widespread use, especially if repeated and serial evaluations are required to assess the efficacy of pharmacotherapy. Although new techniques for non-invasive portal pressure measurement have been pursued for many decades, only recently have new tools been assessed and validated for larger clinical application. This Review focuses on the recent advances in non-invasive approaches for the diagnosis and serial monitoring of portal hypertension and varices for clinical practice.
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Affiliation(s)
- Xiaolong Qi
- CHESS Group, Hepatic Hemodynamic Lab, Institute of Hepatology, Nanfang Hospital, Southern Medical University, Guangzhou, China; CHESS Frontier Center, Lanzhou University, Lanzhou, China.
| | - Annalisa Berzigotti
- Hepatology Group, Swiss Liver Center, University Clinic for Visceral Surgery and Medicine, Inselspital, University of Bern, Bern, Switzerland
| | - Andres Cardenas
- GI/Liver Unit, Institute of Digestive Diseases and Metabolism, Hospital Clinic, University of Barcelona, Barcelona, Spain
| | - Shiv Kumar Sarin
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
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Paternostro R, Reiberger T, Bucsics T. Elastography-based screening for esophageal varices in patients with advanced chronic liver disease. World J Gastroenterol 2019; 25:308-329. [PMID: 30686900 PMCID: PMC6343095 DOI: 10.3748/wjg.v25.i3.308] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Revised: 11/27/2018] [Accepted: 12/20/2018] [Indexed: 02/06/2023] Open
Abstract
Elastography-based liver stiffness measurement (LSM) is a non-invasive tool for estimating liver fibrosis but also provides an estimate for the severity of portal hypertension in patients with advanced chronic liver disease (ACLD). The presence of varices and especially of varices needing treatment (VNT) indicates distinct prognostic stages in patients with compensated ACLD (cACLD). The Baveno VI guidelines suggested a simple algorithm based on LSM < 20 kPa (by transient elastography, TE) and platelet count > 150 G/L for ruling-out VNT in patients with cACLD. These (and other) TE-based LSM cut-offs have been evaluated for VNT screening in different liver disease etiologies. Novel point shear-wave elastography (pSWE) and two-dimensional shear wave elastography (2D-SWE) methodologies for LSM have also been evaluated for their ability to screen for “any” varices and for VNT. Finally, the measurement of spleen stiffness (SSM) by elastography (mainly by pSWE and 2D-SWE) may represent another valuable screening tool for varices. Here, we summarize the current literature on elastography-based prediction of “any” varices and VNT. Finally, we have summarized the published LSM and SSM cut-offs in clinically useful scale cards.
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Affiliation(s)
- Rafael Paternostro
- Department of Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna A-1090, Austria
| | - Thomas Reiberger
- Department of Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna A-1090, Austria
| | - Theresa Bucsics
- Department of Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna A-1090, Austria
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Cheng F, Cao H, Liu J, Jiang L, Han H, Zhang Y, Guo D. Meta-analysis of the accuracy of transient elastography in measuring liver stiffness to diagnose esophageal varices in cirrhosis. Medicine (Baltimore) 2018; 97:e11368. [PMID: 29995773 PMCID: PMC6076160 DOI: 10.1097/md.0000000000011368] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2017] [Accepted: 06/11/2018] [Indexed: 01/30/2023] Open
Abstract
BACKGROUD To assess the diagnostic performance of transient elastography (TE) in detecting the presence and size of esophageal varices (EV) in cirrhotic patients. METHODS We searched PubMed, Web of Science, Wiley Online Library, Science Direct, China National Knowledge Infrastructure, WeiPu, WanFang database, and Baidu Scholar to identify studies that evaluated the diagnostic accuracy of TE in liver stiffness measurement, compared with esophagogastroduodenoscopy (EGD), for the detection of the presence and degree of EV in cirrhosis. RESULTS We included 32 studies in the presence of any EV (grade 1-3; n = 4082), 27 studies on substantial EV (grade 2-3; n = 5221) and 5 studies on large EV (grade 3). The pooled sensitivity, specificity, and diagnostic odds ratio (DOR) were 0.8 (95% CI, 0.78-0.86), 0.68 (95% CI, 0.62-0.74), and 10 (95% CI, 7-14) for any EV; 0.81 (95% CI, 0.77-0.85), 0.72 (95% CI, 0.66-0.77), and 11 (95% CI, 8-15) for substantial EV; and 0.92 (95% CI, 0.83-0.96), 0.78 (95% CI, 0.70-0.85), and 40 (95% CI, 15-107) for large EV. Subgroup analysis revealed that the heterogeneity among studies on any EV could potentially be explained by study location, proportion of Child A, and time interval between TE and EGD; for substantial EV, the proportion of Child A, etiology of cirrhosis, and the time interval between TE and EGD were important heterogeneity factors. Publication bias was found among studies evaluating diagnostic performance of TE for any EV. CONCLUSION TE is a good tool for detecting the presence and degree of EV; however, in determination of the liver stiffness cutoff values means that TE is only cautiously used in clinical practice.
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Affiliation(s)
- Fan Cheng
- Department of Health Statistics, School of Public Health
| | - Hongyan Cao
- Department of Health Statistics, School of Public Health
- Department of Mathematics, School of Basic Medicine, Shanxi Medical University
| | - Jinchun Liu
- Department of Gastroenterology, The First Affiliated Hospital of Shanxi Medical University, Taiyuan, Shanxi, China
| | - Lijun Jiang
- Department of Gastroenterology, The First Affiliated Hospital of Shanxi Medical University, Taiyuan, Shanxi, China
| | - Hongjuan Han
- Department of Health Statistics, School of Public Health
- Department of Mathematics, School of Basic Medicine, Shanxi Medical University
| | - Yanbo Zhang
- Department of Health Statistics, School of Public Health
- Molecular Imaging Precision Medicine Collaborative Innovation Center, Shanxi Medical University,Taiyuan, Shanxi, China
| | - Dongxing Guo
- Department of Health Statistics, School of Public Health
- Department of Mathematics, School of Basic Medicine, Shanxi Medical University
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Karatzas A, Konstantakis C, Aggeletopoulou I, Kalogeropoulou C, Thomopoulos K, Triantos C. Νon-invasive screening for esophageal varices in patients with liver cirrhosis. Ann Gastroenterol 2018; 31:305-314. [PMID: 29720856 PMCID: PMC5924853 DOI: 10.20524/aog.2018.0241] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2017] [Accepted: 01/26/2018] [Indexed: 12/11/2022] Open
Abstract
Esophageal varices are one of the main complications of liver cirrhosis. Upper gastrointestinal endoscopy is the gold standard for the detection of esophageal varices. Many less invasive methods for screening of varices have been investigated and the most recent Baveno VI guidelines suggest that endoscopy is not necessary in patients with liver stiffness <20 kPa and platelets >150,000/μL. A critical review of the literature was performed concerning non-invasive or minimally invasive methods of screening for esophageal varices. Liver and spleen elastography, imaging methods including computed tomography, magnetic resonance imaging and ultrasound, laboratory tests and capsule endoscopy are discussed. The accuracy of each method, and its advantages and limitations compared to endoscopy are analyzed. There are data to support the Baveno VI guidelines, but there is still a lack of large prospective studies and low specificity has been reported for the liver stiffness and platelet count combination. Spleen elastography has shown promising results, as there are data to support its superiority to liver elastography, but it needs further assessment. Computed tomography has shown high diagnostic accuracy and can be part of the diagnostic work up of cirrhotic patients in the future, including screening for varices.
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Affiliation(s)
- Andreas Karatzas
- Department of Radiology, Olympion Therapeutirio (Andreas Karatzas)
| | | | - Ioanna Aggeletopoulou
- Department of Gastroenterology, University Hospital of Patras (Ioanna Aggeletopoulou, Konstantinos Thomopoulos, Christos Triantos)
| | - Christina Kalogeropoulou
- Department of Radiology, University Hospital of Patras (Christina Kalogeropoulou), Patras, Achaia, Greece
| | - Konstantinos Thomopoulos
- Department of Gastroenterology, University Hospital of Patras (Ioanna Aggeletopoulou, Konstantinos Thomopoulos, Christos Triantos)
| | - Christos Triantos
- Department of Gastroenterology, University Hospital of Patras (Ioanna Aggeletopoulou, Konstantinos Thomopoulos, Christos Triantos)
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Roccarina D, Rosselli M, Genesca J, Tsochatzis EA. Elastography methods for the non-invasive assessment of portal hypertension. Expert Rev Gastroenterol Hepatol 2018; 12:155-164. [PMID: 28856972 DOI: 10.1080/17474124.2017.1374852] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The gold standard to assess the presence and severity of portal hypertension remains the hepatic vein pressure gradient, however the recent development of non-invasive assessment using elastography techniques offers valuable alternatives. In this review, we discuss the diagnostic accuracy and utility of such techniques in patients with portal hypertension due to cirrhosis. Areas covered: A literature search focused on liver and spleen stiffness measurement with different elastographic techniques for the assessment of the presence and severity of portal hypertension and oesophageal varices in people with chronic liver disease. The combination of elastography with parameters such as platelet count and spleen size is also discussed. Expert commentary: Non-invasive assessment of liver fibrosis and portal hypertension is a validated tool for the diagnosis and follow-up of patients. Baveno VI recommended the combination of transient elastography and platelet count for ruling out varices needing treatment in patients with compensated advanced chronic liver disease. Assessment of aetiology specific cut-offs for ruling in and ruling out clinically significant portal hypertension is an unmet clinical need. The incorporation of spleen stiffness measurements in non-invasive algorithms using validated software and improved measuring scales might enhance the non-invasive diagnosis of portal hypertension in the next 5 years.
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Affiliation(s)
- Davide Roccarina
- a UCL Institute for Liver and Digestive Health , Royal Free Hospital and UCL , London , UK
| | - Matteo Rosselli
- a UCL Institute for Liver and Digestive Health , Royal Free Hospital and UCL , London , UK
| | - Joan Genesca
- b Liver Unit, Department of Internal Medicine , Valld'Hebron University Hospital, VHIR, Universitat Autònoma de Barcelona, CIBERehd , Barcelona , Spain
| | - Emmanuel A Tsochatzis
- a UCL Institute for Liver and Digestive Health , Royal Free Hospital and UCL , London , UK
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Pateu E, Oberti F, Calès P. The noninvasive diagnosis of esophageal varices and its application in clinical practice. Clin Res Hepatol Gastroenterol 2018; 42:6-16. [PMID: 28870440 DOI: 10.1016/j.clinre.2017.07.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2017] [Accepted: 07/31/2017] [Indexed: 02/04/2023]
Abstract
Here, we review recent improvements made to different noninvasive tests used for the diagnosis of esophageal varices (EV) in the light of the recent Baveno VI recommendation and with an emphasis on clinical application. Like for fibrosis tests, these noninvasive EV tests can be classified as direct markers when they provide a visualization of EV (including all imaging procedures like endoscopy or radiology) and as indirect markers when they do not (blood markers or elastometry). Clinical descriptors expressed as percentages, especially the spared endoscopy rate and the missed high-risk esophageal varices (HREV) rate, are more eloquent in this setting than classical statistical descriptors like accuracy. Single biomarkers are insufficient, generally due to a missed HREV rate exceeding the acceptable limit of 5% indicated in the Baveno VI consensus. Thus, biomarker combinations are currently garnering the most interest. The Baveno VI recommendation states that in alcoholic and viral cirrhoses, screening endoscopy can be safely set aside for patients with liver stiffness<20kPa and platelets>150G/L. The Baveno rule's mean missed HREV rate is<5% but its spared endoscopy rate is<20%. New combinations or stepwise algorithms show promise but must be validated. Going forward, the Baveno rule provides a simple noninvasive method to rule out HREV in clinical practice but the need for further research continues. The noninvasive diagnosis of HREV will be significantly improved by new, simple and affordable combinations.
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Affiliation(s)
- Etienne Pateu
- Hepato-Gastroenterology Department, University Hospital, 49933 Angers, France
| | - Frédéric Oberti
- Hepato-Gastroenterology Department, University Hospital, 49933 Angers, France; HIFIH Laboratory, University Angers, Bretagne-Loire University, 49045 Angers, France
| | - Paul Calès
- Hepato-Gastroenterology Department, University Hospital, 49933 Angers, France; HIFIH Laboratory, University Angers, Bretagne-Loire University, 49045 Angers, France.
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