Hemodynamic analysis of esophageal varices in patients with liver cirrhosis using color Doppler ultrasound

AIM： To study the portal hemodynamics and their relationship with the size of esophageal varices seen at endoscopy and to evaluate whether these Doppler ultrasound parameters might predict variceal bleeding in patients with liver cirrhosis and portal hypertension. METHODS： One hundred and twenty cirrhotic patients with esophageal varices but without any previous bleeding were enrolled in the prospective study. During a 2-year observation period, 52 patients who had at least one episode of acute esophageal variceal hemorrhage constituted the bleeding group, and the remaining 68 patients without any previous hemorrhage constituted the non-bleeding group. All patients underwent endoscopy before or after color Doppler-ultrasonic examination, and images were interpreted independently by two endoscopists. The control group consisted of 30 healthy subjects, matched to the patient group in age and gender. Measurements of diameter, flow direction and flow velocity in the left gastric vein （LGV） and the portal vein （PV） were done in all patients and controls using color Doppler unit. After baseline measurements, 30 min after oral administration of 75 g glucose in 225 mL, changes of the diameter, flow velocity and direction in the PV and LGV were examined in 60 patients with esophageal varices and 15 healthy controls. RESULTS： The PV and LGV were detected successfully in 115 （96%） and 105 （88%） of 120 cirrhotic patients, respectively, and in 27 （90%） and 21 （70%） of 30 healthy controls, respectively. Among the 120 cirrhotic patients, 37 had F1, 59 had F2, and 24 had F3 grade varices. Compared with the healthy controls, cirrhotic group had a significantly lower velocity in the PV, a significantly greater diameter of the PV and LGV, and a higher velocity in the LGV. In the cirrhotic group, no difference in portal flow velocity and diameter were observed between patients with or without esophageal variceal bleeding （EVB）. However, the diameter and blood flow velocity of the LGV were significantly higher for EVB （＋） group compared with EVB （-） group （P〈0.01）. Diameter of the LGV increased with enlarged size of varices. There were differences between F1 and F2, F1 and F3 varices, but no differences between F2 and F3 varices （P = 0.125）. However, variceal bleeding was more frequent in patients with a diameter of LGV 〉6 mm. The flow velocity in the LGV of healthy controls was 8.70＋1.91 cm/s （n = 21）. In patients with liver cirrhosis, it was 10.3＋2.1 cm/s （n = 12） when the flow was hepatopetal and 13.5＋2.3 cm/s （n = 87） when it was hepatofugal. As the size of varices enlarged, hepatofugal flow velocity increased （P〈0.01） and was significantly different between patients with F1 and F2 varices and between patients with F2 and F3 varices. Variceal bleeding was more frequent in patients with a hepatofugal flow velocity 〉15 cm/s （32 of 52 patients, 61.5%）. Within the bleeding group, the mean LGV blood flow velocity was 16.6＋2.62 cm/s. No correlation was observed between the portal blood flow velocity and EVB. In all healthy controls, the flow direction in the LGV was hepatopetal, toward the PV. In patients with F1 varices, flow direction was hepatopetal in 10 patients, to-and-fro state in 3 patients, and hepatofugal in the remaining 18. The flow was hepatofugal in 91% patients with F2 and all F3 varices. Changes in diameter of the PV and LGV were not significant before and after ingestion of glucose （PV： 1.41＋1.5 cm before and 1.46＋1.6 cm after; LGV： 0.57＋1.7 cm before and 0.60＋1.5 cm after）. Flow direction in the LGV was hepatopetal and to-and-fro in 16 patients and hepatofugal in 44 patients before ingestion of glucose. Flow direction changed to hepatofugal in 9 of 16 patients with hepatopetal and to-and-fro blood flow after ingestion of glucose. In 44 patients with hepatofugal blood flow in the LGV, a significant increase in hepatofugal flow velocity was observed in 38 of 44 patients （86%） with esophageal varices. There was a relationship between the percentage changes in flow velocity and the size of varices. Patients who responded excessively to food ingestion might have a high risk for bleeding. The changes of blood flow velocity in the LGV were greater than those in the PV （LGV： 28.3＋26.1%, PV： 7.2＋13.2%, P〈0.01）, whereas no significant changes in the LGV occurred before and after ingestion of glucose in the control subjects. CONCLUSION： Hemodynamics of the PV is unrelated to the degree of endoscopic abnormalities in patients with liver cirrhosis. The most important combinations are endoscopic findings followed by the LGV hemodynamics. Duplex-Doppler ultrasonography has no value in the identification of patients with cirrhosis at risk of variceal bleeding. Hemodynamics of the LGV appears to be superior to those of the PV in predicting bleeding.

Non-invasive prediction of oesophageal varices in cirrhosis

Non-invasive predictors of varices in cirrhosis would reduce the need for screening endoscopies. Platelet count and spleen size have been shown to be useful parameters, in mixed groups of cirrhotics with different aetiologies. We evaluated this in two homogeneous groups with cirrhosis due to hepatitis C and alcohol. Non-invasive predictors appear promising in the former group, but less so in the latter group.

Endoscopic findings in patients with upper gastrointestinal bleeding clinically classified into three risk groups prior to endoscopy

AIM: To investigate in a prospective study whether a simplifi ed clinical score prior to endoscopy in upper gastrointestinal bleeding (UGIB) patients was able to predict endoscopic findings at urgent endoscopy. METHODS: All consecutive UGIB patients referred to a single endoscopic center during a 16 mo period were enrolled. Before endoscopy patients were strati- fied according to a simple clinical score (T-score), including T1 (high-risk), T2 (intermediate-risk) and T3 (low-risk). Endoscopy was performed in all cases within 2 h, and high-risk stigmata were considered for further analysis. RESULTS: Out of the 436 patients included into the study, 126 (29%) resulted to be T1, 135 (31%) T2, and 175 (40%) T3. Overall, stigmata of recent haem-orrhage (SRH) were detected in 118 cases (27%). SRH occurred more frequently in T1 patients than in T2/T3 cases (85% vs 3.2%; χ2 = 304.5309, P < 0.001). Older age (t=3.311; P < 0.01) and presence of comor-bidities (χ2 = 14.7458; P < 0.01) were more frequently detected in T1 than in T2/T3 patients. CONCLUSION: Our simplifi ed clinical score appeared to be associated with the detection of endoscopic findings which may deserve urgent endoscopy. A further,randomised study is needed to assess its accuracy in safely scheduling endoscopy in UGIB patients.

Right liver lobe/albumin ratio:Contribution to non-invasive assessment of portal hypertension

AIM： To study the value of biochemical and ultrasonographic parameters in prediction of presence and size of esophageal varices.METHODS： The study includes selected cirrhotic patients who underwent a complete biochemical workup, upper digestive endoscopic and ultrasonographic examinations. Albumin/right liver lobe diameter and platelet count/spleen diameter ratios were calculated. The correlation between calculated ratio and the presence and degree of esophageal varices was evaluated.RESULTS： Ninety-four subjects （62 males, 32 females）, with a mean age of 52.32 ± 13.60 years, were studied. Child-Pugh class A accounted for 42.6%, class 13 37.2%, whereas class C 20.2%. Esophageal varices （OE） were not demonstrated by upper digestive endoscopy in 24.5%, while OE grade Iwas found in 22.3% patients, grade Ⅱ in 33.0%, grade m in 16.0%, and grade iV in 4.3%. The mean value of right liver lobe diameter/ albumin ratio was 5.51± 1.82 （range from 2.76 to 11.44）, while the mean platelet count/spleen diameter ratio was 1017.75 ± 729.36 （range from 117.39 to 3362.50）, respectively. Statistically significant correlation was proved by Spearman＇s test between OE grade and calculated ratios. The P values were 0.481 and -0.686, respectively.CONCLUSION： The right liver lobe diameter/albumin and platelet count/spleen diameter ratios are noninvasive parameters providing accurate information pertinent to determination of presence of esophageal varices, and their grading in patients with liver cirrhosis.

Esophageal capsule endoscopy

Capsule endoscopy is now considered as the first imaging tool for small bowel examination. Recently, new capsule endoscopy applications have been developed, such as esophageal capsule endoscopy and colon capsule endoscopy. Esophageal capsule endoscopy in patients with suspected esophageal disorders is feasible and safe, and could be also an alternative procedure in those patients refusing upper endoscopy. Although large-scale studies are needed to confirm its utility in GERD and cirrhotic patients, current results are encouraging and open a new era in esophageal examination.

Cost saving by reloading the multiband ligator in endoscopic esophageal variceal ligation: A proposal for developing countries

AIM:To assess the cost savings of reloading the multiband ligator in endoscopic esophageal variceal ligation (EVL) used on the same patient for subsequent sessions. METHODS:This single centre retrospective descriptive study analysed patients undergoing variceal ligation at a tertiary care centre between 1st January, 2003 and 30th June, 2006. The multiband ligator was reloaded with six hemorrhoidal bands using hemorrhoidal ligator for the second and subsequent sessions. Analysis of cost saving was done for the number of follow-up sessions for the variceal eradication. RESULTS:A total of 261 patients underwent at least one session of endoscopic esophageal variceal ligation between January 2003 and June 2006. Out of 261, 108 patients (males 67) agreed to follow the eradication program and underwent repeated sessions. A total of 304 sessions was performed with 2.81 sessions per patient on average. Thirty-two patients could not complete the programm. In 76 patients (70%), variceal obliteration was achieved. The ratio of the costs for the session with reloaded ligator versus a session with a new ligator was 1:2.37. Among the patients who completed esophageal varices eradication, cost saving with reloaded ligator was 58%. CONCLUSION:EVL using reloaded multiband ligators for the follow-up sessions on patients undergoing variceal eradication is a cost saving procedure. Reloading the ligator thus is recommended especially for developing countries where most of the patients are not health insured.