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The Turkish Journal of Gastroenterology... May 2017A major complication of portal hypertension in patients with cirrhosis is the development of esophageal varices with the associated risk of variceal bleeding. Hence, the... (Review)
Review
A major complication of portal hypertension in patients with cirrhosis is the development of esophageal varices with the associated risk of variceal bleeding. Hence, the Baveno consensus on portal hypertension in its first five editions had recommended surveillance with periodic upper endoscopies in these patients to identify in a timely fashion the development of esophageal varices and initiate a primary prophylaxis strategy in those at a high risk of bleeding. For the first time, the Sixth Baveno Consensus on Portal Hypertension (Baveno VI) recommended using non-invasive tools to rule out the presence of varices with a high risk of bleeding. According to Baveno VI, surveillance endoscopy is not necessary for patients with "compensated advanced chronic liver disease" (cACLD) who have normal platelets (>150×109/L) and a liver stiffness measure (LSM) <20 kPa. In this review, we will briefly describe the currently available non-invasive methods to predict the presence of varices, such as serum tests, imaging, and elastography. We will also discuss the rationale that led to Baveno VI recommendation and describe the studies that have validated Baveno VI criteria after its publication. Finally, we will mention some potential caveats and suggest some areas for future research.
Topics: Biomarkers; Consensus; Elasticity Imaging Techniques; Esophageal and Gastric Varices; Esophagoscopy; Gastrointestinal Hemorrhage; Humans; Hypertension, Portal; Liver Cirrhosis; Mass Screening; Practice Guidelines as Topic; Turkey
PubMed: 28492370
DOI: 10.5152/tjg.2017.16744 -
Journal of Veterinary Internal Medicine Mar 2022Esophageal varices (EV) are abnormally dilated veins in the esophagus caused by alterations of blood flow or pressure. Esophageal variceal hemorrhage is a major...
BACKGROUND
Esophageal varices (EV) are abnormally dilated veins in the esophagus caused by alterations of blood flow or pressure. Esophageal variceal hemorrhage is a major complication of hepatic disease in humans, but a lack of information exists regarding associated adverse events in dogs.
OBJECTIVE
To describe the clinical manifestations and associated etiologies and outcomes of dogs with EV.
ANIMALS
Twenty-five client-owned dogs with EV diagnosed via computed tomography (CT), endoscopy, or fluoroscopy.
METHODS
Retrospective case series. Cases were identified by review of the hospital imaging records database between 2010 and 2020. Signalment, clinical signs, and outcomes were documented. When present, additional collateral vasculature was also recorded. Cases were subcategorized into suspected etiology based upon the anatomic location or absence of an attributable underlying disease process, as well as the direction of blood flow.
RESULTS
Twenty-four of 25 cases were identified via CT, with a prevalence of 0.012% (24/1950 total studies). Presenting clinical signs were nonspecific, and more likely because of the underlying cause as opposed to complications secondary to EV themselves. Etiologic anatomic locations were similar in occurrence between the abdomen (N = 14) and thorax (N = 11). All cases with an abdominal etiologic location had presumed or confirmed portal hypertension and 9/11 cases with a thoracic etiologic location had pulmonary, caval, or systemic hypertension. No cases died or were euthanized as a direct result of EV or associated hemorrhage.
CONCLUSIONS AND CLINICAL IMPORTANCE
Esophageal varices are rarely reported in dogs and commonly identified concurrently with portal, pulmonary, and caval hypertension. Hemorrhage is not a common clinical manifestation of EV.
Topics: Animals; Dog Diseases; Dogs; Endoscopy, Gastrointestinal; Esophageal and Gastric Varices; Gastrointestinal Hemorrhage; Hypertension, Portal; Retrospective Studies
PubMed: 35001429
DOI: 10.1111/jvim.16355 -
BMC Gastroenterology Oct 2022Portal hypertensive gastropathy (PHG) is often underestimated in clinical diagnosis. Gastrointestinal bleeding in cirrhosis of PHG accounts for approximately 10% of...
BACKGROUND
Portal hypertensive gastropathy (PHG) is often underestimated in clinical diagnosis. Gastrointestinal bleeding in cirrhosis of PHG accounts for approximately 10% of upper gastrointestinal bleeding. However, the relationship between PHG and gender, laboratory parameters, liver function and varices is still controversial. In the present study, we aimed to retrospectively evaluate the incidence of PHG and to explore the relationship between PHG and gender, laboratory parameters, liver function and varicose veins.
METHODS
A retrospective analysis of 325 patients with cirrhosis who underwent esophagogastroduodenoscopy (EGD) in the Department of Gastroenterology of the Second Hospital of Hebei Medical University from 1 January 2018 to 31 December 2020 was performed. The relationships among age, gender, laboratory parameters, Child-Pugh stage, oesophageal varices (EV), gastric varices (GV) and ascites with PHG were analysed with univariate and multivariate logistic regression.
RESULTS
The occurrence of PHG was significantly associated with gender, haemoglobin, platelet count, prothrombin time, albumin, Child-Pugh stage, EV, GV and ascites (P < 0.05). Furthermore, there was a positive correlation between the severity of PHG and the degree of EV, GV and ascites (P < 0.05). Multivariate logistic regression showed that albumin, EV and GV levels were independently associated with the occurrence of PHG.
CONCLUSION
The incidence of PHG in cirrhosis was 87.4% in this study. The occurrence of PHG was related to gender, haemoglobin, platelet count, prothrombin time, albumin, Child-Pugh stage, EV, GV and ascites. Albumin, the degree of EV and GV are independent risk factors for the occurrence of PHG.
Topics: Albumins; Ascites; Esophageal and Gastric Varices; Gastrointestinal Hemorrhage; Humans; Hypertension, Portal; Liver Cirrhosis; Retrospective Studies; Risk Factors; Stomach Diseases
PubMed: 36241992
DOI: 10.1186/s12876-022-02468-7 -
BMC Gastroenterology Oct 2020Gastric varices are encountered less frequently than esophageal varices. Nonetheless, gastric variceal bleeding is more severe and associated with worse outcomes.... (Review)
Review
Gastric varices are encountered less frequently than esophageal varices. Nonetheless, gastric variceal bleeding is more severe and associated with worse outcomes. Conventionally, gastric varices have been described based on the location and extent and endoscopic treatments offered based on these descriptions. With improved understanding of portal hypertension and the dynamic physiology of collateral circulation, gastric variceal classification has been refined to include inflow and outflow based hemodynamic pathways. These have led to an improvement in the management of gastric variceal disease through newer modalities of treatment such as endoscopic ultrasound-guided glue-coiling combination therapy and the emergence of highly effective endovascular treatments such as shunt and variceal complex embolization with or without transjugular intrahepatic portosystemic shunt (TIPS) placement in patients who are deemed 'difficult' to manage the traditional way. Furthermore, the decisions regarding TIPS and additional endovascular procedures in patients with gastric variceal bleeding have changed after the emergence of 'portal hypertension theories' of proximity, throughput, and recruitment. The hemodynamic classification, grounded on novel theories and its cognizance, can help in identifying patients at baseline, in whom conventional treatment could fail. In this exhaustive review, we discuss the conventional and hemodynamic diagnosis of gastric varices concerning new classifications; explore and illustrate new 'portal hypertension theories' of gastric variceal disease and corresponding management and shed light on current evidence-based treatments through a 'new' algorithmic approach, established on hemodynamic physiology of gastric varices.
Topics: Embolization, Therapeutic; Esophageal and Gastric Varices; Gastrointestinal Hemorrhage; Humans; Hypertension, Portal; Portasystemic Shunt, Transjugular Intrahepatic
PubMed: 33126847
DOI: 10.1186/s12876-020-01513-7 -
Revista Espanola de Enfermedades... Aug 2016Transient elastography (TE) has been shown to be a valuable tool for the prediction of large esophageal varices. However, the conclusions have not been always consistent... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND AND PURPOSE
Transient elastography (TE) has been shown to be a valuable tool for the prediction of large esophageal varices. However, the conclusions have not been always consistent throughout the different studies. Therefore, we performed a further meta-analysis in order to evaluate the diagnostic accuracy of transient elastography for the prediction of large esophageal varices.
METHODS
We performed a systematic literature search in PubMed, EMBASE, Web of Science, and CENTRAL in The Cochrane Library without time restriction. The strategy we used was "(fibroscan OR transient elastography OR stiffness) AND esophageal varices". Accuracy measures such as pooled sensitivity, specificity, among others, were calculated using Meta-DiSc statistical software.
RESULTS
Twenty studies (2,994 patients) were included in our meta-analysis. The values of pooled sensitivity, specificity, positive and negative likelihood ratios and diagnostic odds ratio were as follows: 0.81 (95% CI, 0.79-0.84), 0.71 (95% CI, 0.69-0.73), 2.63 (95% CI, 2.15-3.23), 0.27 (95% CI, 0.22-0.34) and 10.30 (95% CI, 7.33-14.47). The area under the receiver operating characteristics curve was 0.83. The Spearman correlation coefficient was 0.246 with a p-value of 0.296, indicating the absence of any significant threshold effects. In our subgroup analysis, the heterogeneity could be partially explained by the geographical origin of the study or etiology; or it could be partially explained blindingly, through the appropriate interval and cut-off value of the liver stiffness (LS).
CONCLUSIONS
Transient elastography could be used as a valuable non-invasive screening tool for the prediction of large esophageal varices. However, since LS cut-off values vary throughout the different studies and significant heterogeneity also exists among them, we need more reasonable approaches or flow diagram in order to improve the operability of this technology.
Topics: Elasticity Imaging Techniques; Esophageal and Gastric Varices; Humans; Hypertension, Portal; Liver Cirrhosis; Predictive Value of Tests
PubMed: 27444047
DOI: 10.17235/reed.2016.3980/2015 -
Hepatology Communications Feb 2021Despite scant evidence, current guidelines indicate that esophageal varices are a relative contraindication to transesophageal echocardiography (TEE). The aim of this...
Despite scant evidence, current guidelines indicate that esophageal varices are a relative contraindication to transesophageal echocardiography (TEE). The aim of this study is to compare the risk of gastrointestinal bleeding following TEE among cirrhotic patients with and without endoscopically-documented esophageal varices. This is a retrospective analysis of patients with cirrhosis who underwent upper endoscopy within 4 years of TEE at five institutions between January 2000 and March 2020. Primary outcome was overt gastrointestinal bleeding. Secondary outcomes were hemoglobin decline by at least 2 g/dL or blood transfusion within 48 hours following TEE. Of the 191 patients, 79 (41.4%) had esophageal varices (30.4% large). No patient experienced a primary outcome. Secondary outcomes occurred in 52 (27.2%): 28 (35.4%) with esophageal varices and 24 (21.4%) without varices. After propensity-score covariate adjustment, the odds ratio for a secondary outcome in patients with esophageal varices was 1.49 (95% confidence interval 0.74-2.99). Restricting analysis to those who underwent endoscopy within 1 year of TEE did not significantly alter results. The risk of a secondary outcome was identical between patients who had upper endoscopy prior (27.5%) versus subsequent (26.7%; = 1.00) to TEE. : Among patients with cirrhosis, there was no overt gastrointestinal bleeding after TEE. The likelihood of a 2 g/dL decline in hemoglobin or blood transfusion within 48 hours following TEE was not significantly higher in patients with esophageal varices after controlling for confounders. Patients who underwent upper endoscopy before TEE did not manifest a lower risk of secondary outcomes versus those who had endoscopy after TEE, suggesting that routine preprocedural endoscopy is of marginal utility.
Topics: Aged; Contraindications; Echocardiography, Transesophageal; Esophageal and Gastric Varices; Female; Gastrointestinal Hemorrhage; Humans; Liver Cirrhosis; Logistic Models; Male; Middle Aged; Retrospective Studies
PubMed: 33553975
DOI: 10.1002/hep4.1635 -
World Journal of Gastroenterology Jul 2017To assess "predictors" of esophageal varices (EV) and variceal bleeding using non-invasive markers in Albanian patients diagnosed with liver cirrhosis.
AIM
To assess "predictors" of esophageal varices (EV) and variceal bleeding using non-invasive markers in Albanian patients diagnosed with liver cirrhosis.
METHODS
One hundred thirty-nine newly diagnosed cirrhotic patients without variceal bleeding were included in this analysis. Model for end-stage liver disease (MELD), aspartate aminotransferase (AST) to alanine aminotransferase (ALT) ratio (AST/ALT), AST to platelet ratio index (APRI), platelet count to spleen diameter (PC/SD), fibrosis-4-index (FIB-4), fibrosis index (FI) and King's Score were measured for all participants. All patients underwent endoscopic assessment within two days of hospitalization. The major end point was the first esophageal variceal bleeding (EVB) event. The diagnostic performance of "predictors" for the presence of EV and EVB were assessed by sensitivity and specificity values obtained from the receiver operating characteristics procedure.
RESULTS
FIB-4 was the only strong and significant "predictor" of esophageal varices (multivariable-adjusted OR = 1.57 for one unit increment; 95%CI: 1.15-2.14). Furthermore, a cut-off value of 3.23 for FIB-4 was a significant predictor of esophageal varices, with a sensitivity of 72%, a specificity of 58% and a proportion of area under the curve (AUC) of 66% ( = 0.01). During the follow-up (median: 31.5 mo; interquartile range: 11-59 mo), 34 patients (24%) experienced a first EVB. FIB-4 was a poor predictor of EVB (the AUC was only 51%) for a cut-off value of 5.02. Furthermore, the AUC of AST/ALT, APRI, PC/SD, FI, MELD and King's Score ranged from 45% to 55%. None of the non-invasive markers turned out to be a useful predictor of EVB.
CONCLUSION
Despite the low diagnostic accuracy, FIB-4 appears the most efficient non-invasive liver fibrosis marker which can be used as an initial screening tool for cirrhotic patients.
Topics: Adult; Aged; Biomarkers; Esophageal and Gastric Varices; Female; Gastrointestinal Hemorrhage; Humans; Liver Cirrhosis; Male; Middle Aged; Prospective Studies
PubMed: 28765702
DOI: 10.3748/wjg.v23.i26.4806 -
Gastrointestinal Endoscopy Clinics of... Jul 2015Gastroesophageal variceal hemorrhage is a medical emergency with high morbidity and mortality. Endoscopic therapy is the mainstay of management of bleeding varices. It... (Review)
Review
Gastroesophageal variceal hemorrhage is a medical emergency with high morbidity and mortality. Endoscopic therapy is the mainstay of management of bleeding varices. It requires attention to technique and the appropriate choice of therapy for a given patient at a given point in time. Subjects must be monitored continuously after initiation of therapy for control of bleeding, and second-line definitive therapies must be introduced quickly if endoscopic and pharmacologic treatment fails.
Topics: Esophageal and Gastric Varices; Gastrointestinal Hemorrhage; Hemostasis, Endoscopic; Humans; Recurrence
PubMed: 26142034
DOI: 10.1016/j.giec.2015.03.004 -
Journal of Nippon Medical School =... 2012Bleeding from esophageal varices (EVs) or gastric varices (GVs) is a catastrophic complication of chronic liver disease. In this paper, we review the management of... (Review)
Review
Bleeding from esophageal varices (EVs) or gastric varices (GVs) is a catastrophic complication of chronic liver disease. In this paper, we review the management of bleeding EVs and GVs. DIAGNOSIS OF EVS AND GVS: The grading system for esophagogastric varices proposed by the Japan Society for Portal Hypertension classifies GVs into those involving the cardia (Lg-c), the fundus (Lg-f), and both the cardia and the fundus (Lg-cf). In this review, we divide GVs into 2 categories: Lg-c (cardiac varices: CVs) and Lg-cf or Lg-f (fundal varices: FVs). TREATMENT MODALITIES FOR EVS AND GVS: Treatment modalities for EVs and GVs include placement of a Sengstaken-Blakemore tube, pharmacologic therapy, surgery, interventional radiology, and endoscopic treatment. MANAGEMENT OF BLEEDING EVS AND GVS: In Japan, endoscopic treatment has recently become the therapy of choice for bleeding EVs or GVs. In other countries, especially the United States, vasoactive drugs and endoscopic treatment are routinely used to manage variceal hemorrhage. BLEEDING EVS: Endoscopic variceal ligation is useful for controlling bleeding from EVs. However, confirmation of ligation precisely at the site of bleeding is usually difficult in patients with massive variceal bleeding. The site of acute bleeding can generally be identified by means of water instillation and suction. Ligation is then performed at the bleeding point. If endoscopic hemostasis is unsuccessful, a Sengstaken-Blakemore tube is used as a temporary bridge to other treatments. Transportal obliteration is useful for blocking variceal blood flow. BLEEDING GVS: Endoscopic injection sclerotherapy with a tissue adhesive, such as N-butyl-cyanoacrylate or isobutyl-2-cyanoacrylate, is effective for acute bleeding from GVs. However, bleeding from the GV injection site and rebleeding from the rupture point have been reported in patients receiving endoscopic injection sclerotherapy. If endoscopic hemostasis is unsuccessful, a Sengstaken-Blakemore tube is used as a temporary bridge to other treatments. Balloon-occluded retrograde transvenous obliteration and transportal obliteration are useful for the treatment of uncontrolled bleeding from GVs. PREVENTION OF RECURRENT VARICEAL HEMORRHAGE: Given the high recurrence rate, survivors of an acute variceal hemorrhage should receive treatment to prevent recurrence. Complete eradication of EVs or GVs and maintenance of low portal venous pressure are essential for preventing recurrence of variceal hemorrhage.
Topics: Combined Modality Therapy; Embolization, Therapeutic; Endoscopy; Esophageal and Gastric Varices; Gastrointestinal Hemorrhage; Humans
PubMed: 22398787
DOI: 10.1272/jnms.79.19 -
Journal of Ayub Medical College,... 2022Infection with hepatitis C virus is reported to have infected almost 71 million people worldwide. This study was done to assess the frequency and associated factors...
BACKGROUND
Infection with hepatitis C virus is reported to have infected almost 71 million people worldwide. This study was done to assess the frequency and associated factors leading to oesophageal varices in patients presenting with hepatitis C related liver cirrhosis.
METHODS
A cross-sectional study was conducted at Patel Hospital, Karachi, Pakistan from 9th May to 5th October 2019. Patients of either gender having age >20 years presenting with HCV related liver cirrhosis, and Child Pugh class A, B and C were consecutively enrolled in the study. Data on variables like: age, gender, Childs Pugh Score (A/B/C), smoking status, laboratory characteristics like hemoglobulin (Hb), TLC, platelets, serum albumin level, cholesterol, alkaline phosphate (ALK), alkaline transaminase (ALT), ascites and presence of oesophageal varices was recorded and analysed using SPSS-21.0.
RESULTS
Out of 167 patients, mean age was 44.86±14.74 years. Eight-nine (53.3%) of the patients were males. The mean duration of cirrhosis was 5.78±1.10 months. Thrombocytopenia was observed in majority (n=130, 77.8%) of the patients. There were 33 (19.8%) patients with Child Pugh score A while Child-Pugh score B and C was found in 67 (40.1%) each. The frequency of oesophageal varices was 141 (84.4%). A significantly higher proportion of oesophageal varices were found among thrombocytopenic patients (p<0.001), ascites (p-0.024), and having "C" Child-Pugh score (p-0.012).
CONCLUSIONS
Oesophageal varices were found in a considerable proportion. Thrombocytopenia, ascites and Child-Pugh class C were found as leading contributing factors to oesophageal varices.
Topics: Male; Humans; Adult; Middle Aged; Young Adult; Female; Esophageal and Gastric Varices; Ascites; Hepacivirus; Cross-Sectional Studies; Liver Cirrhosis; Hepatitis C; Thrombocytopenia
PubMed: 36566409
DOI: 10.55519/JAMC-04-10746