Non-invasive model for predicting high-risk esophageal varices based on liver and spleen stiffness

BACKGROUND Acute bleeding due to esophageal varices(EVs)is a life-threatening complication in patients with cirrhosis.The diagnosis of EVs is mainly through upper gastrointestinal endoscopy,but the discomfort,contraindications and complications of gastrointestinal endoscopic screening reduce patient compliance.According to the bleeding risk of EVs,the Baveno VI consensus divides varices into high bleeding risk EVs(HEVs)and low bleeding risk EVs(LEVs).We sought to identify a non-invasive prediction model based on spleen stiffness measurement(SSM)and liver stiffness measurement(LSM)as an alternative to EVs screening.AIM To develop a safe,simple and non-invasive model to predict HEVs in patients with viral cirrhosis and identify patients who can be exempted from upper gastrointestinal endoscopy.METHODS Data from 200 patients with viral cirrhosis were included in this study,with 140 patients as the modelling group and 60 patients as the external validation group,and the EVs types of patients were determined by upper gastrointestinal endoscopy and the Baveno Ⅵ consensus.Those patients were divided into the HEVs group(66 patients)and the LEVs group(74 patients).The effect of each parameter on HEVs was analyzed by univariate and multivariate analyses,and a noninvasive prediction model was established.Finally,the discrimination ability,calibration ability and clinical efficacy of the new model were verified in the modelling group and the external validation group.RESULTS Univariate and multivariate analyses showed that SSM and LSM were associated with the occurrence of HEVs in patients with viral cirrhosis.On this basis,logistic regression analysis was used to construct a prediction model:Ln[P/(1-P)]=-8.184-0.228×SSM+0.642×LSM.The area under the curve of the new model was 0.965.When the cut-off value was 0.27,the sensitivity,specificity,positive predictive value and negative predictive value of the model for predicting HEVs were 100.00%,82.43%,83.52%,and 100%,respectively.Compared with the four prediction models of liver stiffness-spleen diameter to platelet ratio score,variceal risk index,aspartate aminotransferase to alanine aminotransferase ratio,and Baveno VI,the established model can better predict HEVs in patients with viral cirrhosis.CONCLUSION Based on the SSM and LSM measured by transient elastography,we established a non-invasive prediction model for HEVs.The new model is reliable in predicting HEVs and can be used as an alternative to routine upper gastrointestinal endoscopy screening,which is helpful for clinical decision making.

Prognostic value of risk scoring systems for cirrhotic patients with variceal bleeding

BACKGROUND Acute variceal bleeding is one of the deadliest complications of cirrhosis,with a high risk of in-hospital rebleeding and mortality.Some risk scoring systems to predict clinical outcomes in patients with upper gastrointestinal bleeding have been developed.However,for cirrhotic patients with variceal bleeding,data regarding the predictive value of these prognostic scores in predicting in-hospital outcomes are limited and controversial.AIM To validate and compare the overall performance of selected prognostic scoring systems for predicting in-hospital outcomes in cirrhotic patients with variceal bleeding.METHODS From March 2017 to June 2019,cirrhotic patients with acute variceal bleeding were retrospectively enrolled at the Second Affiliated Hospital of Xi’an Jiaotong University.The clinical Rockall score(CRS),AIMS65 score(AIMS65),Glasgow-Blatchford score(GBS),modified GBS(mGBS),Canada-United Kingdom-Australia score(CANUKA),Child-Turcotte-Pugh score(CTP),model for endstage liver disease(MELD)and MELD-Na were calculated.The overall performance of these prognostic scoring systems was evaluated.RESULTS A total of 330 cirrhotic patients with variceal bleeding were enrolled;the rates of in-hospital rebleeding and mortality were 20.3%and 10.6%,respectively.For inhospital rebleeding,the discriminative ability of the CTP and CRS were clinically acceptable,with area under the receiver operating characteristic curves(AUROCs)of 0.717(0.648-0.787)and 0.716(0.638-0.793),respectively.The other tested scoring systems had poor discriminative ability(AUROCs<0.7).For inhospital mortality,the CRS,CTP,AIMS65,MELD-Na and MELD showed excellent discriminative ability(AUROCs>0.8).The AUROCs of the mGBS,CANUKA and GBS were relatively small,but clinically acceptable(AUROCs>0.7).Furthermore,the calibration of all scoring systems was good for either inhospital rebleeding or death.CONCLUSION For cirrhotic patients with variceal bleeding,in-hospital rebleeding and mortality rates remain high.The CTP and CRS can be used clinically to predict in-hospital rebleeding.The performances of the CRS,CTP,AIMS65,MELD-Na and MELD are excellent at predicting in-hospital mortality.

Non-invasive prediction model for high-risk esophageal varices in the Chinese population

BACKGROUND There are two types of esophageal varices(EVs):high-risk EVs(HEVs)and lowrisk EVs,and HEVs pose a greater threat to patient life than low-risk EVs.The diagnosis of EVs is mainly conducted by gastroscopy,which can cause discomfort to patients,or by non-invasive prediction models.A number of noninvasive models for predicting EVs have been reported;however,those that are based on the formula for calculation of liver and spleen volume in HEVs have not been reported.AIM To establish a non-invasive prediction model based on the formula for liver and spleen volume for predicting HEVs in patients with viral cirrhosis.METHODS Data from 86 EV patients with viral cirrhosis were collected.Actual liver and spleen volumes of the patients were determined by computed tomography,and their calculated liver and spleen volumes were calculated by standard formulas.Other imaging and biochemical data were determined.The impact of each parameter on HEVs was analyzed by univariate and multivariate analyses,the data from which were employed to establish a non-invasive prediction model.Then the established prediction model was compared with other previous prediction models.Finally,the discriminating ability,calibration ability,and clinical efficacy of the new model was verified in both the modeling group and the external validation group.RESULTS Data from univariate and multivariate analyses indicated that the liver-spleen volume ratio,spleen volume change rate,and aspartate aminotransferase were correlated with HEVs.These indexes were successfully used to establish the noninvasive prediction model.The comparison of the models showed that the established model could better predict HEVs compared with previous models.The discriminating ability,calibration ability,and clinical efficacy of the new model were affirmed.CONCLUSION The non-invasive prediction model for predicting HEVs in patients with viral cirrhosis was successfully established.The new model is reliable for predicting HEVs and has clinical applicability.

Predictive value of alarm symptoms in patients with Rome IV dyspepsia: A cross-sectional study

BACKGROUND No studies have evaluated the predictive value of alarm symptoms for organic dyspepsia and organic upper gastrointestinal(GI)diseases based on Rome IV criteria in the Chinese population.AIM To evaluate the predictive value of alarm symptoms for dyspeptic patients based on Rome IV criteria.METHODS We performed a cross-sectional study of dyspepsia patients who met the inclusion and exclusion criteria at two academic urban tertiary-care centers from March 2018 to January 2019.Basic demographic data,dyspeptic information,alarm symptoms,lifestyle,examination results,family history and outpatient cost information were collected.Dyspepsia patients with normal findings on upper GI endoscopy,epigastric ultrasound and laboratory examination and without Helicobacter pylori-associated dyspepsia were classified as functional dyspepsia.RESULTS A total of 381 patients were enrolled in the study,including 266 functional dyspepsia patients and 115 organic dyspepsia patients.There were 24 patients with organic upper GI disease among patients with organic dyspepsia.We found that based on the Rome IV criteria,alarm symptoms were of limited value in differentiating organic dyspepsia and organic upper GI diseases from functional dyspepsia.Age(odds ratio(OR)=1.056,P=0.012),smoking(OR=4.714,P=0.006)and anemia(OR=88.270,P<0.001)were independent predictors for organic upper GI diseases.For the comparison of epigastric pain syndrome,postprandial distress syndrome and epigastric pain syndrome combined with postprandial distress syndrome,the results showed that there were statistically significant differences in anorexia(P=0.021)and previous visits(P=0.012).The ClinicalTrials.gov number is NCT 03479528.CONCLUSION Most alarm symptoms had poor predictive value for organic dyspepsia and organic upper GI diseases based on Rome IV criteria.Gastroscopic screening should not be based solely on alarm symptoms.

Association of proton pump inhibitors with risk of hepatic encephalopathy in advanced liver disease: A meta-analysis

BACKGROUND Several studies have explored the association between the use of proton pump inhibitors (PPIs) and the risk of developing hepatic encephalopathy (HE) in patients with advanced liver disease. However, the evidence-based conclusions are controversial. We hypothesized that using PPIs may increase the risk of HE in patients with advanced liver disease. If confirmed, clinicians must strictly adhere to the indications for PPI treatment in this population. AIM To evaluate the pooled risk of HE in patients with advanced liver disease who use PPIs. METHODS Three electronic databases (PubMed, EMBASE, and the Cochrane Library) were searched from the date of database inception through January 8, 2019 to identify comparative studies evaluating the association between PPI use and the risk of HE. Data from the included studies were extracted. The random-effects model was used for pooling risk estimates and the corresponding 95% confidence intervals (CIs). Subgroup and sensitivity analyses were also performed. RESULTS In total, 4342 patients from five case-control studies and 188053 patients from four cohort studies were included in this analysis. In patients with advanced liver disease, PPI use was associated with an elevated risk of developing HE, with significant heterogeneity. The pooled odds ratio for case-control studies was 2.58 (95%CI: 1.68-3.94, I2 = 72%). The pooled RR for cohort studies was 1.67 (95%CI: 1.30-2.14, I2 = 67%). The results of the subgroup analyses suggested that the heterogeneity may be the result of differences in the study designs and the definitions of PPI use. The sensitivity and subgroup analyses did not alter our findings. CONCLUSION In patients with advanced liver disease, PPI use is associated with an elevated risk of HE. Future large prospective studies are needed to confirm this association.

Non-invasive model for predicting esophageal varices based on liver and spleen volume

BACKGROUND Upper endoscopy is the gold standard for predicting esophageal varices in China.Guidelines and consensus suggest that patients with liver cirrhosis should undergo periodic upper endoscopy,most patients undergo their first upper endoscopy when esophageal variceal bleeds.Therefore,it is important to develop a non-invasive model to early diagnose esophageal varices.AIM To develop a non-invasive predictive model for esophageal varices based on liver and spleen volume in viral cirrhosis patients.METHODS We conducted a cross-sectional study based on viral cirrhosis crowd in the Second Affiliated Hospital of Xi'an Jiaotong University.By collecting the basic information and clinical data of the participants,we derived the independent risk factors and established the prediction model of esophageal varices.The established model was compared with other models.Area under the receiver operating characteristic curve,calibration plot and decision curve analysis were used to test the discriminating ability,calibration ability and clinical practicability in both the internal and external validation.RESULTS The portal vein diameter,the liver and spleen volume,and volume change rate were the independent risk factors of esophageal varices.We successfully used the factors to establish the predictive model[area under the curve(AUC)0.87,95%CI:0.80-0.95],which showed better predictive value than other models.The model showed good discriminating ability,calibration ability and the clinical practicability in both modelling group and external validation group.CONCLUSION The developed non-invasive predictive model can be used as an effective tool for predicting esophageal varices in viral cirrhosis patients.

Predictive value of alarm symptoms in Rome IV irritable bowel syndrome:A multicenter cross-sectional study

BACKGROUND Irritable bowel syndrome(IBS)is a common functional bowel disease that shares features with many organic diseases and cannot be accurately diagnosed by symptom-based criteria.Alarm symptoms have long been applied in the clinical diagnosis of IBS.However,no study has explored the predictive value of alarm symptoms in suspected IBS patients based on the latest Rome IV criteria.AIM To investigate the predictive value of alarm symptoms in suspected IBS patients based on the Rome IV criteria.METHODS In this multicenter cross-sectional study,we collected data from 730 suspected IBS patients evaluated at 3 tertiary care centers from August 2018 to August 2019.Patients with IBS-like symptoms who completed colonoscopy during the study period were initially identified by investigators through medical records.Eligible patients completed questionnaires,underwent laboratory tests,and were assigned to the IBS or organic disease group according to colonoscopy findings and pathology results(if a biopsy was taken).Independent risk factors for organic disease were explored by logistic regression analysis,and the positive predictive value(PPV)and missed diagnosis rate were calculated.RESULTS The incidence of alarm symptoms in suspected IBS patients was 75.34%.Anemia[odds ratio(OR)=2.825,95%confidence interval(CI):1.273-6.267,P=0.011],fecal occult blood[OR=1.940(95%CI:1.041-3.613),P=0.037],unintended weight loss(P=0.009),female sex[OR=0.560(95%CI:0.330-0.949),P=0.031]and marital status(P=0.030)were independently correlated with organic disease.The prevalence of organic disease was 10.41%in suspected IBS patients.The PPV of alarm symptoms for organic disease was highest for anemia(22.92%),fecal occult blood(19.35%)and unintended weight loss(16.48%),and it was 100%when these three factors were combined.The PPV and missed diagnosis rate for diagnosing IBS were 91.67%and 74.77%when all alarm symptoms were combined with Rome IV and 92.09%and 34.10%when only fecal occult blood,unintended weight loss and anemia were combined with Rome IV,respectively.CONCLUSION Anemia,fecal occult blood and unintended weight loss have high predictive value for organic disease in suspected IBS patients and can help identify patients requiring further examination but are not recommended as exclusion criteria for IBS.

Overtube-assisted technique for insertion of linear endoscopic ultrasonography

Introduction Over the last three decades,endoscopic ultrasonography(EUS)and EUS-guided fine-needle aspiration(EUS-FNA)have gradually become established tools for the diagnosis,staging and treatment of benign or malignant gastrointestinal diseases and pulmonary disorders[1].Compared with standard upper endoscope,EUS uses a dedicated echoendoscope that has a more rigid tip and a longer nonflexible segment at the most distal end of the device.On the other hand,most currently available linear echoendoscopes are side-viewing instruments.Both the unique mechanical and optical features of EUS scopes make manipulations difficult;even skilled EUS operators occasionally encounter difficulty when inserting,which may be more likely to cause severe complications[2].One of the most frequent complications is gastrointestinal perforation,which can take place in the hypopharynx,hiatal hernia,tip of the duodenal bulb and rectosigmoidal junction[3].The incidence rate of pharyngoesophageal perforations resulting from gastrointestinal endoscopes is approximately 0.01%[2].For EUS,a higher risk of perforation has been reported[4].Hypopharyngeal perforation can lead to lethal complications(e.g.mediastinitis,mediastinal pneumothorax and fistulas)and these complications are associated with a mortality rate of 2%–36%[5].Therefore,it is necessary to explore some techniques to avoid these complications to the utmost extent.