Biopsy forceps are useful for measuring esophageal varices in vitro

BACKGROUND To avoid acute variceal bleeding in cirrhosis,current guidelines recommend screening for high-risk esophageal varices(EVs)by determining variceal size and identifying red wale markings.However,visual measurements of EV during routine endoscopy are often inaccurate.AIM To determine whether biopsy forceps(BF)could be used as a reference to improve the accuracy of binary classification of variceal size.METHODS An in vitro self-made EV model with sizes ranging from 2 to 12 mm in diameter was constructed.An online image-based survey comprising 11 endoscopic images of simulated EV without BF and 11 endoscopic images of EV with BF was assembled and sent to 84 endoscopists.The endoscopists were blinded to the actual EV size and evaluated the 22 images in random order.RESULTS The respondents included 48 academic and four private endoscopists.The accuracy of EV size estimation was low in both the visual(13.81%)and BF-based(20.28%)groups.The use of open forceps improved the ability of the endoscopists to correctly classify the varices by size(small≤5 mm,large>5 mm)from 71.85%to 82.17%(P<0.001).CONCLUSION BF may improve the accuracy of EV size assessment,and its use in clinical practice should be investigated.

Non-invasive assessment of esophageal varices:Status of today

With increasing burden of compensated cirrhosis,we desperately need noninvasive methods for assessment of clinically significant portal hypertension.The use of liver and spleen stiffness measurement helps in deferring unnecessary endoscopies for low risk esophageal varices.This would reduce cost and patient discomfort.However,these special techniques may not be feasible at remote areas where still we need only biochemical parameters.More prospective studies validating the non-invasive risk prediction models are definitely needed.

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.

Sonographic gallbladder wall thickness measurement and the prediction of esophageal varices among cirrhotics

Acute variceal bleeding in patients with liver cirrhosis and portal hypertension(PHT) is the most serious emergency complication among those patients and could have catastrophic outcomes if not timely managed. Early screening by esophago-gastro-duodenoscopy(EGD) for the presence of esophageal varices(EVs) is currently recommended by the practice guidelines for all cirrhotic patients. Meanwhile, EGD is not readily accepted or preferred by many patients. The literature is rich in studies to investigate and validate non-invasive markers of EVs prediction aiming at reducing the unneeded endoscopic procedures. Gallbladder(GB) wall thickness(GBWT) measurement has been found promising in many published research articles. We aim to highlight the validity of sonographic GBWT measurement in the prediction of EVs based on the available evidence. We searched databases including Cochrane library, Pub Med, Web of Science and many others for relevant articles. GBWT is associated with the presence of EVs in cirrhotic patients with PHT of different etiologies. The cut-off of GBWT that can predict the presence of EVs varied in the literature and ranges from 3.1 mm to 4.35 mm with variable sensitivities of 46%-90.9% and lower cutoffs in viral cirrhosis compared to non-viral, however GBWT > 4 mm in many studies is associated with acceptable sensitivity up to 90%. Furthermore, a relation was also noticed with the degree of varices and portal hypertensive gastropathy.Among cirrhotics, GBWT > 3.5 mm predicts the presence of advanced(grade Ⅲ-Ⅳ) EVs with a sensitivity of 45%, the sensitivity increased to 92% when a cut-off ≥ 3.95 mm was used in another cohort. Analysis of these results should carefully be revised in the context of ascites, hypoalbuminemia and other intrinsic GB diseases among cirrhotic patients. The sensitivity for prediction of EVs improved upon combining GBWT measurement with other non-invasive predictors, e.g., platelets/GBWT.

Letter to editor‘Non-invasive model for predicting high-risk esophageal varices based on liver and spleen stiffness’

predicting high-risk esophageal varices based on liver and spleen stiffness".Acute bleeding caused by esophageal varices is a life-threatening complication in patients with liver cirrhosis.Due to the discomfort,contraindications,and associated complications of upper gastrointestinal endoscopy screening,it is crucial to identify an imaging-based non-invasive model for predicting high-risk esophageal varices in patients with cirrhosis.

Correlation of Platelet Count with Grading of Esophageal Varices in Cirrhotic Patients

Background/Aims: Cirrhosis represents a late stage of progressive hepatic fibrosis and is generally considered to be irreversible in its advanced stages. Esophageal varix is a complication of liver cirrhosis and is the consequence of portal hypertension. The aim of this study was to determine the correlation between the severity of thrombocytopenia and the presenting of esophageal varices (EVs) in cirrhotic patient. Patients and Methods: This study was a retrospective, descriptive, analytic and monocentric study, which was carried out at Gastroenterology Department, Khmer Soviet Friendship Hospital, Phnom Penh, Cambodia. It was conducted from 1st September 2020 to 31st January 2021. All patients were diagnosed as liver cirrhosis by clinic, biology and ultrasound. Patients’ data were noted in standardized questionnaire with information such as age, sex, address, laboratory result, and the result of endoscopic finding. All data were registered into a data set and then analyzed by SPSS program version 23. Results: 1445 patients were enrolled for gastroscopy. Only 303 patients (21%) were suggested for variceal screening after the exclusions. Male was predominant with sex ratio F/M (1/2.03). Patients’ age varied between 21 and 80 years old, with the mean age of 55 ± 11 years old. 199 patients (66%) were found with EVs, while EVs grade 1 and 2 without red signs were predominated, accounting to 22.8% and 19.5% respectively. The majority of the patients with platelet count between 50 - 99 giga/l had EVs vs platelet count > 150 giga/l had no EVs (p Conclusion: Thrombocytopenia is a non-invasive parameter with high accuracy for the prediction of EVs in cirrhosis. The severity of thrombocytopenia increased as the grading of EVs increased. Thus, it can assist in triaging cirrhotic patients for endoscopy to identify EVs.

Correlation Between NLRP3 Inflammasome and GP73 Levels and Hepatitis B Cirrhosis with Esophageal Varices Rupture

Objective:To investigate the correlation between NOD-like receptor family protein 3(NLRP3)inflammasome and Golgi protein 73(GP73)levels and hepatitis B cirrhosis with esophageal varices(EV)rupture.Methods:The subjects of this study were 145 patients with hepatitis B cirrhosis and varices who were treated in our hospital in recent years.Endoscopic examination was performed on the patients.The patients were divided into two groups according to whether there was EV rupture:rupture group and non-rupture group.The correlation between plasma NLRP3 and GP73 levels and hepatitis B cirrhosis with EV rupture was analyzed.Results:Through observation,comparing the levels of NLRP3 and GP73 between the two groups,the levels of NLRP3 and GP73 were significantly higher in the rupture group than in the non-rupture group(P<0.05).Logistic regression analysis showed that NLRP3 and GP73 levels and Child-Pugh classification were related risk factors of hepatitis B cirrhosis with EV rupture.Conclusion:NLRP3 inflammasome and GP73 levels are closely related to hepatitis B cirrhosis with EV rupture.The corresponding evaluation aids in predicting EV rupture and bleeding in patients with hepatitis B cirrhosis.

Computed tomography vs liver stiffness measurement and magnetic resonance imaging in evaluating esophageal varices in cirrhotic patients:A systematic review and meta-analysis

BACKGROUND Computed tomography(CT),liver stiffness measurement(LSM),and magnetic resonance imaging(MRI)are non-invasive diagnostic methods for esophageal varices(EV)and for the prediction of high-bleeding-risk EV(HREV)in cirrhotic patients.However,the clinical use of these methods is controversial.AIM To evaluate the accuracy of LSM,CT,and MRI in diagnosing EV and predicting HREV in cirrhotic patients.METHODS We performed literature searches in multiple databases,including Pub Med,Embase,Cochrane,CNKI,and Wanfang databases,for articles that evaluated the accuracy of LSM,CT,and MRI as candidates for the diagnosis of EV and prediction of HREV in cirrhotic patients.Summary sensitivity and specificity,positive likelihood ratio and negative likelihood ratio,diagnostic odds ratio,and the areas under the summary receiver operating characteristic curves were analyzed.The quality of the articles was assessed using the quality assessment of diagnostic accuracy studies-2 tool.Heterogeneity was examined by Q-statistic test and I2 index,and sources of heterogeneity were explored using metaregression and subgroup analysis.Publication bias was evaluated using Deek’s funnel plot.All statistical analyses were conducted using Stata12.0,Meta Disc1.4,and Rev Man5.3.RESULTS Overall,18,17,and 7 relevant articles on the accuracy of LSM,CT,and MRI in evaluating EV and HREV were retrieved.A significant heterogeneity was observed in all analyses(P<0.05).The areas under the summary receiver operating characteristic curves of LSM,CT,and MRI in diagnosing EV and predicting HREV were 0.86(95%confidence interval[CI]:0.83-0.89),0.91(95%CI:0.88-0.93),and 0.86(95%CI:0.83-0.89),and 0.85(95%CI:0.81-0.88),0.94(95%CI:0.91-0.96),and 0.83(95%CI:0.79-0.86),respectively,with sensitivities of 0.84(95%CI:0.78-0.89),0.91(95%CI:0.87-0.94),and 0.81(95%CI:0.76-0.86),and 0.81(95%CI:0.75-0.86),0.88(95%CI:0.82-0.92),and 0.80(95%CI:0.72-0.86),and specificities of 0.71(95%CI:0.60-0.80),0.75(95%CI:0.68-0.82),and 0.82(95%CI:0.70-0.89),and 0.73(95%CI:0.66-0.80),0.87(95%CI:0.81-0.92),and 0.72(95%CI:0.62-0.80),respectively.The corresponding positive likelihood ratios were 2.91,3.67,and 4.44,and 3.04,6.90,and2.83;the negative likelihood ratios were 0.22,0.12,and 0.23,and 0.26,0.14,and 0.28;the diagnostic odds ratios were 13.01,30.98,and 19.58,and 11.93,49.99,and 10.00.CT scanner is the source of heterogeneity.There was no significant difference in diagnostic threshold effects(P>0.05)or publication bias(P>0.05).CONCLUSION Based on the meta-analysis of observational studies,it is suggested that CT imaging,a non-invasive diagnostic method,is the best choice for the diagnosis of EV and prediction of HREV in cirrhotic patients compared with LSM and MRI.

Liver fibrosis index-based nomograms for identifying esophageal varices in patients with chronic hepatitis B related cirrhosis

BACKGROUND Esophageal varices(EV)are the most fatal complication of chronic hepatitis B(CHB)related cirrhosis.The prognosis is poor,especially after the first upper gastrointestinal hemorrhage.AIM To construct nomograms to predict the risk and severity of EV in patients with CHB related cirrhosis.METHODS Between 2016 and 2018,the patients with CHB related cirrhosis were recruited and divided into a training or validation cohort at The First Affiliated Hospital of Wenzhou Medical University.Clinical and ultrasonic parameters that were closely related to EV risk and severity were screened out by univariate and multivariate logistic regression analyses,and integrated into two nomograms,respectively.Both nomograms were internally and externally validated by calibration,concordance index(C-index),receiver operating characteristic curve,and decision curve analyses(DCA).RESULTS A total of 307 patients with CHB related cirrhosis were recruited.The independent risk factors for EV included Child-Pugh class[odds ratio(OR)=7.705,95%confidence interval(CI)=2.169-27.370,P=0.002],platelet count(OR=0.992,95%CI=0.984-1.000,P=0.044),splenic portal index(SPI)(OR=3.895,95%CI=1.630-9.308,P=0.002),and liver fibrosis index(LFI)(OR=3.603,95%CI=1.336-9.719,P=0.011);those of EV severity included Child-Pugh class(OR=5.436,95%CI=2.112-13.990,P<0.001),mean portal vein velocity(OR=1.479,95%CI=1.043-2.098,P=0.028),portal vein diameter(OR=1.397,95%CI=1.021-1.912,P=0.037),SPI(OR=1.463,95%CI=1.030-2.079,P=0.034),and LFI(OR=3.089,95%CI=1.442-6.617,P=0.004).Two nomograms(predicting EV risk and severity,respectively)were well-calibrated and had a favorable discriminative ability,with C-indexes of 0.916 and 0.846 in the training cohort,respectively,higher than those of other predictive indexes,like LFI(C-indexes=0.781 and 0.738),SPI(C-indexes=0.805 and 0.714),ratio of platelet count to spleen diameter(PSR)(C-indexes=0.822 and 0.726),King’s score(C-indexes=0.694 and 0.609),and Lok index(C-indexes=0.788 and 0.700).The areas under the curves(AUCs)of the two nomograms were 0.916 and 0.846 in the training cohort,respectively,higher than those of LFI(AUCs=0.781 and 0.738),SPI(AUCs=0.805 and 0.714),PSR(AUCs=0.822 and 0.726),King’s score(AUCs=0.694 and 0.609),and Lok index(AUCs=0.788 and 0.700).Better net benefits were shown in the DCA.The results were validated in the validation cohort.CONCLUSION Nomograms incorporating clinical and ultrasonic variables are efficient in noninvasively predicting the risk and severity of EV.

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.

Role of argon plasma coagulation in treatment of esophageal varices

With the development of endoscopic therapy,argon plasma coagulation(APC)has been widely used by endoscopists.It has many advantages,such as simple to operate,low cost,and minimal invasiveness.Because of its capability of lesion ablation and hemostasis,APC has several indications in the gastrointestinal tract.One of them is esophageal varices.The aim of this review is to summarize the research on APC in this field to provide a reference for clinical practice.

Can platelet count/spleen diameter ratio be used for cirrhotic children to predict esophageal varices?

AIM To determine the laboratory and radiologic parameters, including the platelet count(PC)-to-spleen diameter(SD) ratio as a non-invasive marker that may predict the presence of esophageal varices(EV) in children with cirrhosis.METHODS Eighty-nine patients with cirrhosis, but without a history of variceal bleeding were prospectively included. The children were grouped into 6-12 and 12-18 years of age groups. These groups were also divided into 2 subgroups(presence and absence of EV). All of the patients underwent a complete biochemical and radiologic evaluation. The PC(n/mm^3)-to-SD(mm) ratio was calculated for each patient. RESULTS Sixty-nine of 98(70.4%) patients had EV. The presence of ascites in all age groups was significantly associatedwith the presence of EV. There were no differences in serum albumin levels, PC, SD and the PC-to-SD ratio between the presence and absence of EV groups in both age groups(P > 0.05). CONCLUSION Laboratory and radiologic parameters, including the PC-to-SD ratio as a non-invasive marker(except for the presence of ascites), was inappropriate for detecting EV in children with cirrhosis.

Post-gastrectomy spleen enlargement and esophageal varices: Distal vs total gastrectomy

AIM: To study the relationship between platelet count-to-spleen diameter ratio and post-gastrectomy esopha-geal varices (EVs) development in patients without liver cirrhosis or hepatitis. METHODS: We retrospectively studied 92 patients who underwent gastrectomy. They were divided into 2 groups on the basis of the surgical treatment: the distal gastrectomy (DG) group and total gastrectomy (TG) group. The incidence of EVs was determined and postoperative platelet counts, spleen diameters, and platelet count-to-spleen diameter ratios were com-pared between the 2 groups. RESULTS: EVs were not detected during the first 6 mo after surgery in either group; however, at 12 mo after surgery, EVs were detected in 2 patients (3%) in the DG group and in 1 patient (3.6%) in the TG group; their mean platelet count-to-spleen diameter ratio was 2628 ± 409, and 2604 ± 360, respectively.CONCLUSION: Endoscopy should be performed to detect EVs when the platelet count-to-spleen diameter ratio is < 2600.

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.

Novel markers of endothelial dysfunction in hepatitis C virus-related cirrhosis: More than a mere prediction of esophageal varices

BACKGROUND Hepatitis C virus(HCV)infection may affect lipid metabolism by enhancing the circulating levels of inflammatory cytokines,together with its impact on endothelial function.AIM To evaluate the potential correlation of changes in lipid profile,carotid intimamedia thickness(CIMT),and ankle-brachial index with the severity of fibrosis,grades of esophageal varices(EVs),and fibrosis indices.METHODS The study included 240 subjects who were divided into 3 groups;group 1(n=90,HCV-related cirrhotic patients with EVs),group 2(n=90,HCV-related cirrhotic patients without EVs),and group 3(n=60,served as the healthy control group).All patients underwent routine laboratory tests,including a lipid profile assay.Low-density lipoproteins(LDL)/platelet count and platelet/splenic diameter ratios were calculated.Abdominal ultrasonography,CIMT by carotid Doppler,bedside ankle-brachial index(ABI),liver stiffness measurement,and upper gastrointestinal endoscopy were performed.RESULTS Multivariate logistic regression revealed that very-low-density lipoprotein(VLDL)(β=0.988,odds ratio 2.5,P=0.001),LDL/platelet count ratio(β=1.178,odds ratio 3.24,P=0.001),CIMT(β=1.37,odds ratio 3.9,P=0.001),and ABI(β=2.3,odds ratio 5.9,P=0.001)were the key variables associated with significant fibrosis,EVs and endothelial dysfunction.CIMT and LDL/platelet count ratio were predictive of advanced fibrosis and EVs at cutoff values of 1.1 mm and 1 mm,respectively,with an area under the curve(AUC)of 0.966 and 0.960(P=0.001),while VLDL and ABI at a cutoff of 16.5 mg/dL and 0.94 were predictive of advanced fibrosis and EVs with an AUC of 0.891 and 0.823,respectively(P=0.001).CONCLUSION CIMT,ABI,VLDL,LDL/platelet count ratio are good non-invasive predictors of advanced fibrosis,presence of EVs,and endothelial dysfunction in liver cirrhosis.

Predictive Values of Platelets Count and Spleen Diameter in the Diagnosis of Esophageal Varices in Black African Cirrhotic Patients

Background: Gastrointestinal hemorrhage from ruptured esophageal varices is of concern in Africa where gastrointestinal fibroscopy for diagnosis is lacking. Purpose: To determine the performance of the length of the spleen, of the platelet count in the diagnosis of esophageal varices (OVs) by specifying the diagnostic thresholds in order to facilitate the prophylaxis of varicose hemorrhages in black African cirrhotic patients. Material and Method: This was a prospective study with a descriptive and analytical aim on cirrhotic patients hospitalized at the university hospital of Bouake (Ivory Coast) from 2017 to 2019. The patients included in the study were the cirrhotic of black race hospitalized having carried out an abdominal ultrasound with measurement of the spleen diameter (SD), an eso-gastro-duodenal endoscopy, and a blood count with platelet count (PC). The first primary endpoint was the diagnosis of esophageal varices in cirrhosis. Cirrhosis was retained by the combination of clinical, biological, ultrasound and endoscopic arguments. The OVs were distributed according to size and the presence of red signs. The platelet count, and the measurement of the spleen to calculate the PC/SD ratio were the second endpoint. The secondary endpoints studied were, the viral and ethyl etiologies of the cirrhosis, the Chlid-Pugh prognostic score. Performance was assessed using the ROC curve. The difference was significant for p less than 0.05. Results: The study included 101 patients;they were 79 men (78.2%) and 22 women (21.8%). The mean age of the cirrhotic patients was 48 ± 14. Esophageal varices were present in (n = 93;92%) of cases. The different etiologies were hepatitis B virus (HBV) (n = 65;78.3%), hepatitis C virus (HCV) (n = 21;25, 3%), and alcohol (n = 6;7.2%). Platelet count (PC) < 100,000/mm3 was statistically related to the presence of OV with red signs. Splenomegaly (SD > 130 mm) and PC/SD ratio < 1000 were significantly related to the presence of OVs and large OVs. SD with a cutoff of > 102 mm predicted 75% of OVs (AUROC = 0.797). CP with a cutoff < 131,000/mm3, predicted 100% of OVs (AUROC = 0.756). The PC/SD ratio < 1205 diagnosed 100% of OV (AUROC = 0.801). The PC/SD ratio < 818 and SD > 129 mm predicted large OVs. Conclusion: Platelet count, spleen diamater, and PC/SD ratio were all performant for the diagnosis of OVs in our setting with better diagnostic performance for PC/SD. This report could help initiate prophylactic treatment for OVs rupture in cirrhotic patients in health centers where gastrointestinal endoscopy is lacking.

New Non-Invasive Index for Detecting Esophageal Varices in Patients with Liver Cirrhosis

Introduction: Many studies have shown that clinical, biochemical and ultrasonographic parameter are predictive of the presence and grading of esophageal varices. Aim of Study: Validation of a noninvasive test called P2/MS and its comparison with other noninvasive tests for the detection of high risk esophageal varices. Patients and Methods: We prospectively enrolled 125 consecutive patients with liver cirrhosis. Complete blood count [CBC], Platelet count by direct method, Liver functions [serum bilirubin, AST, ALT, prothrombin time and concentration and serum albumin], kidney functions, hepatitis markers for B & C, abdominal ultrasonography and upper gastrointestinal endoscopy were done for each patient. Calculation of P2/MS [Platelet count)2/{monocyte fraction (%) × segmented neutrophil fraction (%)], API [age-platelet index], APRI [AST-to-platelet ratio index], SPRI [spleen-to-platelet ratio index], ASPRI [age-spleen-to-platelet ratio index] scores and correlating the different scores with the grade of esophageal varices found on upper endoscopy. Results: During processing of our patient’s data, we found certain relation between segmented neutrophils, monocytes, platelet count, total bilirubin and the degree of esophageal varices for the detection of high risk varices and a new equation was formulated and we called it P2/MS-B. In predicting high risk esophageal varices HREV, the area under the curve for this new variable was [0.909, 95% confidence interval 0.858 - 0.961, p = 0.000] which was significantly higher than all the other variables including P2/MS for the detection of HREV. The sensitivity of the new equation for the detection of HREV is 85.3%, the specificity is 83.1%, the positive predictive value is 87.9%, the negative predicative value is 86.0 % and the overall accuracy of the test is 85.6%. Conclusion: A newly detected noninvasive variable for detecting HREV may reliably screen liver cirrhosis patients for HREV and avoid unnecessary endoscopy in low risk patients.

Suspected cerebrovascular air embolism during endoscopic esophageal varices ligation under sedation with fatal outcome: A case report

BACKGROUND Air embolism is a very rare,yet serious and potentially fatal complication of digestive endoscopic treatment.Air embolism is the result of air directly entering the arteries or veins.However,to recognize neurological dysfunction under sedation can be difficult.Therefore,it is extremely important to identify high-risk groups and take preventive measures.CASE SUMMARY Herein,we report a 74-year-old female patient with esophageal varices who suffered from consciousness disturbance after the third endoscopic ligation of esophageal varices under sedation.Combined with the patient’s imaging examination results and medical history,we highly suspected that the patient had developed paradoxical cerebral air embolism during endoscopic ligation.We learned that the patient died at a later follow-up.In order to be able to identify and prevent the occurrence of air embolism early,we summarize and analyze the risk factors,pathogenesis,clinical manifestations,prevention and treatment options of gastrointestinal endoscopy complicated by cerebral air embolism.CONCLUSION Electroencephalographic monitoring helps to recognize the occurrence of air embolism in time and increase the patient's chance of survival.

Transparent cap adjusted the stent placed for stenosis after endoscopic injection of esophageal varices:A case report

BACKGROUND The stent embedded in the esophageal mucosa is one of the complications after stenting for esophageal stricture.We present a case of stent adjustment with the aid of a transparent cap after endoscopic injection of an esophageal varices stent.CASE SUMMARY A 61-year-old male patient came to the hospital with discomfort of the chest after the stent implanted for the stenosis because of endoscopic injection of esophageal varices.The gastroscopy was performed,and the stent embedded into the esophageal mucosa.At first,we pulled the recycling line for shrinking the stent,however,the mucosa could not be removed from the stent.Then a forceps was performed to remove the mucosa in the stent,nevertheless,the bleeding form the mucosa was obvious.And then,we used a transparent cap to scrape the mucosa along the stent,and the mucosa were removed successfully without bleeding.CONCLUSION A transparent cap helps gastroscopy to remove the mucosa embedded in the stent after endoscopic injection of the esophageal varices stent.

Effectiveness of antibiotic prophylaxis for acute esophageal variceal bleeding in patients with band ligation: A large observational study

BACKGROUND Esophageal variceal bleeding is a severe complication associated with liver cirrhosis and typically necessitates endoscopic hemostasis.The current standard treatment is endoscopic variceal ligation(EVL),and Western guidelines recom-mend antibiotic prophylaxis following hemostasis.However,given the impro-vements in prognosis for variceal bleeding due to advancements in the management of bleeding and treatments of liver cirrhosis and the global concerns regarding the emergence of multidrug-resistant bacteria,there is a need to reassess the use of routine antibiotic prophylaxis after hemostasis.AIM To evaluate the effectiveness of antibiotic prophylaxis in patients treated for EVL.METHODS We conducted a 13-year observational study using the Tokushukai medical database across 46 hospitals.Patients were divided into the prophylaxis group(received antibiotics on admission or the next day)and the non-prophylaxis group(did not receive antibiotics within one day of admission).The primary outcome was composed of 6-wk mortality,4-wk rebleeding,and 4-wk spontaneous bacterial peritonitis(SBP).The secondary outcomes were each individual result and in-hospital mortality.A logistic regression with inverse probability of treatment weighting was used.A subgroup analysis was conducted based on the Child-Pugh classification to determine its influence on the primary outcome measures,while sensitivity analyses for antibiotic type and duration were also performed.RESULTS Among 980 patients,790 were included(prophylaxis:232,non-prophylaxis:558).Most patients were males under the age of 65 years with a median Child-Pugh score of 8.The composite primary outcomes occurred in 11.2%of patients in the prophylaxis group and 9.5%in the non-prophylaxis group.No significant differences in outcomes were observed between the groups(adjusted odds ratio,1.11;95%confidence interval,0.61-1.99;P=0.74).Individual outcomes such as 6-wk mortality,4-wk rebleeding,4-wk onset of SBP,and in-hospital mortality were not significantly different between the groups.The primary outcome did not differ between the Child-Pugh subgroups.Similar results were observed in the sensitivity analyses.CONCLUSION No significant benefit to antibiotic prophylaxis for esophageal variceal bleeding treated with EVL was detected in this study.Global reassessment of routine antibiotic prophylaxis is imperative.