Diagnosis and Management of Esophagogastric Varices

Development and validation of an integrated model for the diagnosis of liver cirrhosis with portal vein thrombosis combined with endoscopic characters and blood biochemistry data: a retrospective propensity score matching (PSM) cohort study

BACKGROUND

Liver cirrhosis complicated by portal vein thrombosis (PVT) is a fatal complication with no specific manifestations but often misdiagnosed, it crucially increases the mortality worldwide. This study aimed to identify risk factors and establish a predictive model for diagnosis of venous thrombosis clinical by routine blood tests and endoscopic characteristics.

METHODS

Patients from Gansu Provincial Hospital from October 2019 to December 2023 were enrolled. The retrospective modelling cohort was screened by propensity score matching (PSM) at a 1:1 ratio from the baseline characteristics before endoscopic diagnosis. Variables were collected from blood test and endoscopic signs using machine learning method (ML). Logistic regression determined risk factors. The predictive performance was evaluated by receiver operation curve (ROC), calibration curve, clinical decision analysis (DCA) and influence curve (CIC). Furthermore, external cohort was used for validation, an online nomogram was established.

RESULTS

A total of 1,058 patients were enrolled, and 470 patients were included after PSM 1: 1. The model identified 7 factors, including splenectomy, blood urea nitrogen (BUN), serum sodium, activated partial thromboplastin time (APTT), thrombin time (TT), D-dimer, and degree of oesophageal varices. The area under the curve (AUC) was 0.907 (95% CI, 0.877-0.931). The calibration curve, decision and clinical impact curves showed the model demonstrated a good predictive accuracy and clinical benefits. The validation got an AUC of 0.890 (95% CI, 0.831-0.934), A nomogram tool was finally established for application.

CONCLUSION

Blood test combined endoscopic characters could preliminarily predict the liver cirrhosis with portal vein thrombosis for cirrhotic patients undergoing endoscopic examination.

A survey of emergency medicine physicians' knowledge, attitude, and practice towards esophagogastric variceal bleeding

BACKGROUND

Esophageal-gastric variceal bleeding (EVB) is one of the leading causes of mortality in patients with cirrhotic portal hypertension. Rapid, accurate, and effective emergency care is crucial for successful patient outcomes.

AIMS

This study aims to evaluate the knowledge, attitudes, and practices of Chinese emergency physicians regarding EVB, with the goal of improving the diagnosis and treatment of gastrointestinal bleeding in emergency settings.

METHODS

A self-designed questionnaire based on clinical guidelines was developed to assess EVB knowledge, attitudes, and practices of Chinese emergency physicians in treating EVB. An online survey was conducted among emergency physicians nationwide. Data were analyzed using descriptive statistics and correlation analysis.

RESULTS

The knowledge score for EVB was 11.2 ± 3.5 (total score was 22), indicating a relatively low level of understanding. Statistically significant differences in knowledge scores were observed across hospital grades, educational backgrounds, years of experience, professional titles, and participation in relevant training programs (P < 0.05). The mean attitude score for EVB was above 4 (total score was 5), reflecting a generally positive attitude among physicians. In terms of practices, the score for treatment behavior of EVB was 2.7 ± 1.2, and behavior was positively correlated with knowledge and attitude (P < 0.05).

CONCLUSION

Chinese emergency physicians demonstrate a low level of knowledge about EVB treatment, although their attitudes remain positive. Their clinical practices in EVB management are also insufficient. Enhancing education on EVB and standardizing treatment protocols are necessary to improve patient outcomes.

Ratio of von Willebrand factor to ADAMTS13 is a useful predictor of esophagogastric varices progression after sustained virologic response in patients with hepatitis C virus-related liver cirrhosis

AIM

Esophagogastric varices (EGV) are a serious complication of hepatitis C virus (HCV)-related liver cirrhosis (HCV-LC). In most cases, portal hypertension improves after a sustained virologic response (SVR) is achieved with direct-acting antiviral (DAA) treatment; however, in some cases, EGV exacerbation occurs after HCV elimination. We investigated whether von Willebrand factor (VWF) and a disintegrin-like metalloproteinase with thrombospondin type-1 motif 13 (ADAMTS13) can predict EGV progression with HCV-LC after SVR achievement.

METHODS

This retrospective study enrolled 47 patients with HCV-LC who achieved an SVR after DAA treatment. Eighteen patients experienced EGV progression after the SVR was achieved (EGV progression group). Twenty-nine patients did not experience EGV progression after the SVR was achieved (non-EGV progression group). Plasma VWF antigen levels and ADAMTS13 activity were measured the day before DAA treatment.

RESULTS

The EGV progression group had significantly higher plasma VWF antigen levels (p = 0.00331) and VWF-to-ADAMTS13 ratios (p = 0.000249) than the non-EGV progression group. Multivariate logistic regression models found that a VWF-to-ADAMTS13 ratio >2.3 was the only risk factor for EGV progression after the SVR was achieved (hazard ratio [HR], 18.4; 95% confidence interval [CI], 3.08-109; p = 0.00138). During the observation period, patients with a VWF-to-ADAMTS13 ratio >2.3 had a significantly higher cumulative incidence of EGV progression after SVR achievement than patients with a VWF-to-ADAMTS13 ratio ≤2.3 (HR, 6.4; 95% CI, 1.78-22.96; p = 0.0044).

CONCLUSIONS

The VWF-to-ADAMTS13 ratio before DAA treatment for HCV could predict EGV progression after SVR achievement.

Comprehensive approach to esophageal variceal bleeding: From prevention to treatment

Esophageal variceal bleeding is a severe complication often associated with portal hypertension, commonly due to liver cirrhosis. Prevention and treatment of this condition are critical for patient outcomes. Preventive strategies focus on reducing portal hypertension to prevent varices from developing or enlarging. Primary prophylaxis involves the use of non-selective beta-blockers, such as propranolol or nadolol, which lower portal pressure by decreasing cardiac output and thereby reducing blood flow to the varices. Endoscopic variceal ligation (EVL) may also be employed as primary prophylaxis to prevent initial bleeding episodes. Once bleeding occurs, immediate treatment is essential. Initial management includes hemodynamic stabilization followed by pharmacological therapy with vasoactive drugs such as octreotide or terlipressin to control bleeding. Endoscopic intervention is the cornerstone of treatment, with techniques such as EVL or sclerotherapy applied to directly manage the bleeding varices. In cases where bleeding is refractory to endoscopic treatment, transjugular intrahepatic portosystemic shunt may be considered to effectively reduce portal pressure. Long-term management after an acute bleeding episode involves secondary prophylaxis using beta-blockers and repeated EVL sessions to prevent rebleeding, complemented by monitoring and managing liver function to address the underlying disease. In light of new scientific evidence, including the findings of the study by Peng et al, this editorial aims to review available strategies for the prevention and treatment of esophageal varices.

Acute Variceal Hemorrhage in Germany-A Nationwide Study of 65,357 Hospitalized Cases: Variceal Hemorrhage in Germany

Background: Acute variceal hemorrhage (AVH) is a frequent cause of upper gastrointestinal bleeding (UGIB) in liver cirrhosis. Most cases require urgent endoscopic intervention due to potentially life-threatening courses. Different endoscopic hemostasis techniques can be used, in particular endoscopic variceal ligation (EVL) and endoscopic sclerotherapy (EST), depending on the bleeding side (esophageal, fundal, and gastric) as well as radiological interventions (e.g., embolization and transjugular intrahepatic portosystemic shunt [TIPS]). This study aimed to investigate trends in incidence, treatment modalities, and outcome parameters, such as in-hospital mortality and adverse events in Germany. Methods: We evaluated the current epidemiological trends, therapeutic strategies, and in-hospital mortality of AVH in Germany based on the standardized hospital discharge data provided by the German Federal Statistical Office from 2010 to 2019. Results: A total of 65,357 AVH cases, predominately males (68.3%), were included in the analysis. The annual incidence rate (hospitalization cases per 100,000 persons) was 8.9. The in-hospital mortality was 18.6%. The most common underlying disease was alcohol-related liver cirrhosis (60.6%). The most common clinical complication was bleeding anemia (60.1%), whereas hypovolemic shock (12.8%) was the less frequent. In esophageal variceal hemorrhage (EVH), EVL was the most frequently performed endoscopic therapy, while in gastric variceal hemorrhage (GVH), EST and fibrin glue injection were the most commonly performed therapies. EVL showed the lowest in-hospital mortality (12.3%) in EVH, while EST showed favorable results (14% in-hospital mortality) in GVH. Combination therapies overall showed a higher in-hospital mortality and were more frequent in GVH. The presence of hypovolemic shock, AKI, sepsis, artificial ventilation, ARDS, bleeding anemia, hepatic encephalopathy, and male sex was associated with a significantly worse outcome. Conclusion: Our study provides detailed insight into the incidence, patient-related risk factors, endoscopic treatment, and in-hospital mortality in a sizeable AVH collective in Germany. These data might help improve risk stratification and treatment strategies for AVH patients in the future.

Comparative Effectiveness of Endoscopic Versus Pharmacological Interventions for Variceal Rebleeding in Cirrhosis: A Systematic Review

Variceal bleeding is a critical complication in cirrhotic patients, significantly increasing morbidity and mortality risks, particularly after an initial bleeding episode. This systematic review evaluates and compares the effectiveness of endoscopic and pharmacological interventions in preventing variceal rebleeding. A comprehensive search of major databases, including PubMed, MEDLINE, Embase, the Cochrane Central Register of Controlled Trials, and Web of Science, was conducted to identify studies published within the past decade. The review focused on randomized controlled trials, clinical trials, and meta-analyses that assessed the efficacy and safety of these treatments in adult cirrhotic patients with a history of variceal bleeding. The findings suggest that endoscopic interventions, such as band ligation and early transjugular intrahepatic portosystemic shunt (TIPS) placement, effectively reduce immediate rebleeding rates and improve short-term survival, particularly in high-risk patients with advanced cirrhosis. In contrast, pharmacological strategies, including beta-blockers and vasoactive agents, provide effective long-term management with fewer adverse events, especially in patients with milder liver disease. The review underscores the importance of a personalized treatment approach that integrates both endoscopic and pharmacological therapies to optimize outcomes and reduce the burden of rebleeding. It also highlights the need for further high-quality research to clarify the long-term benefits, impact on quality of life, and cost-effectiveness of these interventions. These insights form the basis for refining clinical guidelines and improving patient-centered care in the management of variceal rebleeding.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

CRITICAL RELEVANCE STATEMENT

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

KEY POINTS

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

Assessing the predictive efficacy of noninvasive liver fibrosis indices and portal vein diameter in predicting esophageal variceal bleeding in patients with cirrhosis

BACKGROUND

The objective of this study is to evaluate the diagnostic accuracy of noninvasive serum liver fibrosis markers and portal vein diameter (PVD) in predicting the occurrence of esophageal variceal bleeding (EVB) in patients with cirrhosis.

METHODS

A cohort comprising 102 individuals diagnosed with cirrhosis was divided into two groups: the P group (without EVB) and the PE group (with EVB). We conducted a comprehensive analysis comparing various noninvasive serum liver fibrosis indices, the Child-Pugh classification, ratios of aspartate aminotransferase to alanine aminotransferase, aspartate aminotransferase to platelet ratio index, fibrosis index based on four factors (FIB-4), PVD, and spleen thickness (SPT) between these groups. Receiver operating characteristic (ROC) curves were constructed for variables showing significant differences between the two groups, with subsequent calculation of the area under the ROC curve (AUROC) for each variable.

RESULTS

Significant distinctions were noted in the serum liver fibrosis markers between the P and PE groups, encompassing hyaluronic acid (HA), type III procollagen (PC-III), type IV collagen (IV-C), PVD, SPT, and FIB-4 (p < 0.05), as evidenced by univariate analysis findings. The respective AUROC values for these markers were 0.653, 0.706, 0.710, 0.730, 0.660, and 0.633. Additionally, upon integration with PVD, SPT, and FIB4, the AUROC values for liver fibrosis markers surged to 0.793, 0.763, and 0.706 correspondingly, highlighting the enhanced diagnostic potential.

CONCLUSION

The integration of noninvasive liver fibrosis indices and PVD showcased remarkable diagnostic potential in EVB, underscoring its clinical relevance in predicting hemorrhagic events.

Computed tomography for prediction of esophageal variceal bleeding

This letter to the editor relates to the study entitled “The role of computed tomography for the prediction of esophageal variceal bleeding: Current status and future perspectives”. Esophageal variceal bleeding (EVB) is one of the most common and severe complications related to portal hypertension (PH). Despite marked advances in its management during the last three decades, EVB is still associated with significant morbidity and mortality. The risk of first EVB is related to the severity of both PH and liver disease, and to the size and endoscopic appearance of esophageal varices. Indeed, hepatic venous pressure gradient (HVPG) and esophagogastroduodenoscopy (EGD) are currently recognized as the “gold standard” and the diagnostic reference standard for the prediction of EVB, respectively. However, HVPG is an invasive, expensive, and technically complex procedure, not widely available in clinical practice, whereas EGD is mainly limited by its invasive nature. In this scenario, computed tomography (CT) has been recently proposed as a promising modality for the non-invasive prediction of EVB. While CT serves solely as a diagnostic tool and cannot replace EGD or HVPG for delivering therapeutic and physiological information, it has the potential to enhance the prediction of EVB more effectively when combined with liver disease scores, HVPG, and EGD. However, to date, evidence concerning the role of CT in this setting is still lacking, therefore we aim to summarize and discuss the current evidence concerning the role of CT in predicting the risk of EVB.

The Prediction and Treatment of Bleeding Esophageal Varices in the Artificial Intelligence Era: A Review

Esophageal varices (EVs), a significant complication of cirrhosis, present a considerable challenge in clinical practice due to their high risk of bleeding and associated morbidity and mortality. This manuscript explores the transformative role of artificial intelligence (AI) in the management of EV, particularly in enhancing diagnostic accuracy and predicting bleeding risks. It underscores the potential of AI in offering noninvasive, efficient alternatives to traditional diagnostic methods such as esophagogastroduodenoscopy (EGD). The complexity of EV management is highlighted, necessitating a multidisciplinary approach that includes pharmacological therapy, endoscopic interventions, and, in some cases, surgical options tailored to individual patient profiles. Additionally, the paper emphasizes the importance of integrating AI into medical education and practice, preparing healthcare professionals for the evolving landscape of medical technology. It projects a future where AI significantly influences the management of gastrointestinal bleeding, improving clinical decision-making, patient outcomes, and overall healthcare efficiency. The study advocates for a patient-centered approach in healthcare, balancing the incorporation of innovative technologies with ethical principles and the diverse needs of patients to optimize treatment efficacy and enhance healthcare accessibility.

Triage policy to postpone endoscopy for patients with low-risk varices is safe during the lockdown period of COVID-19 pandemic

BACKGROUND & AIMS

During the COVID-19 pandemic, most of the endoscopic services were electively postponed or suspended. We aimed to assess the safety of a triage policy in patients receiving esophageal variceal ligation during the COVID-19 pandemic.

METHODS

Triage policy of endoscopic variceal ligation (EVL) was implemented in our hospital during the lockdown period from 15th May 2021 to 26th July 2021. One experienced gastroenterologist reviewed the prior-scheduled list of patients for the EVL prophylaxisprogram. We compared the clinical characteristics and outcomes with those receiving endoscopy due to esophageal varices from 17th May 2020 to 28th July 2020.

RESULTS

Of the 124 patients receiving EVL, a higher percentage of esophageal variceal bleeding (EVB) was noted (9/32, 28.1% vs. 8/92, 8.7%, p = 0.006) during the lockdown period, with a higher percentage of EVB in the referrals (7/9, 77.8% vs. 2/14, 14.2%, p = 0.007). Among patients who received prophylactic EVL, 6 of 78 (7.7%) experienced EVB during the normal period, which is no different to 2 of 23 (8.7%) during the lockdown period. Twenty-three patients whose endoscopies were postponed by triage policy due to low-risk or eradicated varices did not experience EVB during the lockdown period. Child-Turcotte-Pugh (CTP) class C was predictive of EVB (relative risk 8.400, P = 0.033), entering the program of prophylactic EVL was the protective factor of EVB (relative risk 0.016, P = 0.002).

CONCLUSION

Entrance into the prophylaxis program does not only decreases risk of EVB but also fosters comprehensive triage to postpone endoscopy during the lockdown period.