Determination of correlation of Adjusted Blood Requirement Index with outcome in patients presenting with acute variceal bleeding

Prospective validation of Baveno V definitions and criteria for failure to control bleeding in portal hypertension

New definitions and criteria were released at the Baveno V consensus meeting. The purposes of this study were to verify Baveno V definitions and criteria for failure to control bleeding and to determine the usefulness of the combined use of the Adjusted Blood Requirement Index [ABRI: (number of blood units)/(final hematocrit-initial hematocrit)+0.01] with Baveno V criteria. In all, 246 consecutive liver cirrhosis patients with acute bleeding associated with portal hypertension were enrolled prospectively between January 2010 and October 2012. The treatment outcome on day 5 was assessed by endoscopy. For the ABRI calculation, two hematocrit levels were used as the initial hematocrit: the first level measured upon patient arrival (ABRI-A) and the lowest level measured before transfusion (ABRI-B). Treatment failures were identified in 53 patients, of whom 24 died. Based on repeated endoscopic findings, 29 patients were identified as treatment failures, while according to Baveno V criteria, 47 patients were regarded as treatment failures. The area under the receiver operating characteristic curve (AUROC) of Baveno V criteria was 0.906, and the sensitivity, specificity, positive predictive value, negative predictive value, positive likelihood ratio, and negative likelihood ratio were 83.0%, 98.4%, 93.6%, 95.5%, 53.41, and 0.17, respectively. The AUROC of Baveno V criteria was significantly greater than those of Baveno IV (P=0.0001) and Baveno II/III (P<0.0001) criteria. Adding ABRI-A or -B to Baveno V criteria resulted in a significant reduction of the AUROC (P<0.05).

CONCLUSION

The Baveno V criteria are good predictors of treatment failure of early-stage acute gastrointestinal bleeding in patients with portal hypertension, while the addition of ARBI does not improve the prediction accuracy of the outcome of bleeding.

Multicenter prospective validation of the Baveno IV and Baveno II/III criteria in cirrhosis patients with variceal bleeding

The criteria for defining failure to control bleeding in cirrhosis patients were introduced at the Baveno II/III meetings and were widely used as endpoints in clinical trials. Because they lacked specificity, the Baveno IV criteria were proposed in 2005 and slightly modified in 2010 (Baveno V). These criteria included a new index for patients undergoing transfusion, called adjusted-blood-requirement-index (ABRI=number of blood units/(final-initial hematocrit+0.01)), with a cutoff value of 0.75. In this multicenter prospective study, we sought to 1) validate the Baveno IV/V criteria; 2) compare them to the Baveno II/III criteria; 3) assess ABRI performance using a standardized calculation. The key inclusion criteria were: 1) variceal bleeding; 2) cirrhosis; 3) no need to modify the transfusion policy. The patients were classified according to the Baveno IV, V, and II/III criteria. The gold standard for failure during a 5-day period was the clinical judgment of three independent experts, blinded to the Baveno assessments. A total of 249 patients were included. The experts' agreement in clinical judgment of the failure was 80%. Failure occurred in 20.5% of patients; the c-statistics were 0.72 versus 0.64 and 0.65 for Baveno IV versus Baveno II/III and Baveno V criteria (P=0.001 for both). ABRI did not improve the diagnostic performance of the Baveno IV criteria. The Baveno IV, but not Baveno II/III, criteria independently predicted survival.

CONCLUSION

The Baveno IV criteria demonstrated a higher accuracy than the Baveno II/III and Baveno V criteria for assessing failure to control bleeding and predicted survival independently. Together, our results show that ABRI is not a useful metric, and the Baveno IV criteria should replace the Baveno II/III criteria.

(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.

Revising the criteria for the predictors of variceal haemorrhage outcome

BACKGROUND AND STUDY AIMS

There are many criteria and definitions used to evaluate the failure to control and prevent variceal bleeding. Baveno criteria were developed in Baveno consensus workshops I-III. Some of these criteria are fairly difficult to apply and do not adequately reflect common situations that are observed in clinical practice. Therefore, new criteria were developed at the Baveno-IV workshop. In the present study, we aimed to evaluate the validity of Baveno II-IV criteria in the prediction of bleeding recurrence among patients with liver cirrhosis who presented with bleeding oesophageal varices.

PATIENTS AND METHODS

Fifty patients with liver cirrhosis and acute variceal bleeding were divided into two groups according to treatment response. Group I consisted of 44 patients for whom treatment to control bleeding was successful, and Group II included 6 patients for whom treatment failed. Baveno criteria were used in the evaluation of treatment outcome in these patients.

RESULTS

The overall accuracy of Baveno II and III criteria was 87.3% within the first 6h and 76.5% after 6h, with a mean accuracy 81.9%. The overall accuracy of Baveno IV criteria in this study was 83%. The criterion of death was also very specific (100%), with 100% PPV, but its sensitivity was very low (16.7%).

CONCLUSION

Baveno IV criteria are less complicated, much easier to apply and have nearly the same accuracy as Baveno II/III criteria. However, there are some criteria that need to be modified, such as the adjusted blood requirement index (ABR1), among others.