Non-invasive diagnosis of esophageal varices in chronic liver diseases

doi:10.1016/S0168-8278(99)80288-8

Journal of Hepatology

Volume 31, Issue 5, November 1999, Pages 867-873

https://doi.org/10.1016/S0168-8278(99)80288-8 Get rights and content

Abstract

Background/Aims: The primary prevention of bleeding from esophageal varices is a major therapeutic issue requiring early screening of esophageal varices. Our aim was to study the diagnostic accuracy of non-endoscopic means for the diagnosis of esophageal varices.

Methods: Sixty-three clinical, biochemical, endoscopic and Doppler ultrasound variables were prospectively recorded in 207 consecutive patients with chronic liver disease. Diagnostic accuracy was evaluated by discriminant analysis, first globally using all variables with diagnostic accuracy≥65% in univariate analysis, then by stepwise regression.

Results: A) whole group (n=207), 1) diagnosis of esophageal varices: diagnostic accuracy was globally 81%, and 81% with 1 variable: irregular liver surface at ultrasound, 2) Diagnosis of large esophageal varices (grades 2+3): diagnostic accuracy was globally 80%, and 79% with 2 variables: prothrombin index, γ-globulins. B) patients with cirrhosis (n=116), 1) diagnosis of esophageal varices: diagnostic accuracy was globally 71%, and 72% with 2 variables: platelet count, prothrombin index, 2) diagnosis of large esophageal varices (grades 2+3): diagnostic accuracy was globally 71%, and 72% with 3 variables: platelet count, prothrombin index, spider naevi. The ROC curve showed that the best threshold for the diagnostic accuracy of platelet count was 160 G/I providing a sensitivity of 80% and a specificity of 58%. Platelet count ≥260 G/I has a negative predictive value ≥91%.

Conclusions: Using a few non-endoscopic criteria, esophageal varices can be correctly diagnosed in 81% of patients with chronic liver disease and in 71% of patients with cirrhosis. These results show that the non-invasive screening of patients who are candidates for the primary prevention of variceal bleeding is possible, but should be improved before being used in a clinical setting.

Section snippets

Patients

The 243 consecutive patients considered for this study were admitted to the hepatogastroenterology unit of the University Hospital in Angers, France, in 1994–5 for alcoholism or alcoholic liver disease, or for chronic hepatitis B or C infection. Patients were included who had drunk at least 50 g of alcohol per day for the past 5 years, who were positive for hepatitis B surface antigen or C serum markers, and who had had persistently elevated serum aminotransferases >1.5 N for at least 6 months

Characteristics of population

Among the 207 patients included, 66% were male and the mean age was 50±12 years. The prevalence of cirrhosis was significantly higher in patients with alcoholic CLD than in patients with viral CLD (60.5 vs 42%, respectively, p<0.05). The distribution of EV was as follows: in the 91 patients with CLD, EV were present in 10%, all grade 1; in the 116 patients with cirrhosis EV were present in 72% with grade 1 in 28%, grade 2 in 42% and grade 3 in 2%. The distribution of Child-Pugh classes in

Discussion

The prevalence of cirrhosis in developed countries ranges between 0.4% in the USA or France 19., 20. and 1.1% in Italy (21). PHT and liver dysfunction are the most frequent complications of cirrhosis. The main consequence of PHT is the development of collateral circulation, including EV which are the most frequent and most dangerous complication. EV and variceal bleeding are an early complication of cirrhosis justifying early screening for EV (4). The usual means of diagnosing EV is upper

Acknowledgements

We thank Pr. Daniel Chappard for his contribution to image analysis and Ms Dale Roche for her contribution.

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Transient elastography and platelet count as noninvasive predictors of gastroesophageal varices in patients with compensated hepatitis C virus–related liver cirrhosis
2023, Medical Journal Armed Forces India
Early detection of esophageal varices (EV) before the first attack of bleeding is crucial for primary prophylaxis. The current work aims to investigate the use of a combination of FibroScan and platelet count as noninvasive means to identify EV in patients with compensated cirrhosis.
Sixty-two patients with compensated hepatitis C virus (HCV)-related cirrhosis were divided into two groups with and without EV. All patients were exposed to complete history, physical examination, laboratory, and endoscopic evaluation. FibroScan was performed for all patients, and the two groups were compared.
A statistically significant higher mean liver stiffness measurement (LSM) (KPa), lower mean platelet count to splenic diameter ratio (PSR), and higher mean fibrosis-4 (FIB4) score were noticed in those with EV with P < 0.0005. A cutoff value of ≥23.1 for LSM, ≥3.71 for FIB4, and ≥130 mm for splenic diameter have a sensitivity of 94%, 97%, and 97% and a specificity of 81%, 81%, and 68%, respectively, in the detection of varices. Platelet count of ≥112,500 (×10³/dl) and of ≥771.33 for PSR have a sensitivity of 84% and 77% and a specificity of 87% and 90%, respectively, to rule out the presence of varices. LSM, FIB4 score, and splenic diameter are predictors of the presence of varices where platelet count and PSR are negative predictors.
The combination of LSM by transient elastography (TE), PSR, or platelet count can be used to detect a relevant category of patients with compensated cirrhosis who have a very low possibility of EV where endoscopy can be avoided.
Novel albumin, bilirubin and platelet criteria for the exclusion of high-risk varices in compensated advanced chronic liver disease: A validation study
2021, Clinics and Research in Hepatology and Gastroenterology
Availability of transient elastography (TE) limits the application of Baveno-VI criteria. In a derivation study, the ABP criteria (Albumin >40 g/l, Bilirubin <22 μmol/l and Platelet >114,000/μl) had been shown to perform well in identifying compensated advanced chronic liver disease (cACLD) patients without high-risk varices (HRV). We aim to externally validate this novel ABP criteria for the exclusion of HRVs among cACLD patients.
Data was retrospectively collected from consecutive cACLD patients with paired TE and esophagogastroduodenoscopy (EGD) performed between 2011 and 2017 in Changi General Hospital, Singapore. We estimate the discriminative ability of ABP criteria in validation cohort using AUROC and calibration-in-the-large. We subsequently compare the performance between ABP and Baveno-VI criteria in the validation cohort.
Among 314 patients included in our validation cohort, 32 (10.2%) had HRV on screening EGD. Application of ABP criteria within this validation cohort has increased discriminative ability than the derivation cohort. The AUROC of validation and derivation cohort were 0.68 (0.60–0.76) and 0.66 (0.60–0.76), respectively. The mean and standard error for calibration-in-the-large and calibration slope were −0.08 (0.22) and 0.93 (0.26) respectively. The ABP criteria had excellent performance in excluding HRV and will spare more screening EGDs than the Baveno-VI criteria (39.2% vs 27.4%, p < 0.001), without missing more HRVs.
We validated the performance of ABP criteria for the exclusion of HRVs in cACLD patients. ABP criteria is superior to Baveno-VI criteria by sparing more screening EGD without the need of TE.
Evaluation of three “beyond Baveno VI” criteria to safely spare endoscopies in compensated advanced chronic liver disease
2019, Digestive and Liver Disease
Liver stiffness measurement (LSM) <20 kPa and platelet count >150,000/mm³ exclude varices needing treatment (VNT) in viral compensated advanced chronic liver disease (cACLD), saving-up to 20–25% endoscopies (Baveno VI criteria). Refinements of such criteria to further reduce endoscopies and an approach without LSM (Platelet 150/MELD 6) were later proposed.
To assess LSM 25/platelet 125, LSM 25/platelet 110 (Expanded-Baveno VI) and Platelet 150/MELD 6 accuracy versus Baveno VI criteria, and the impact of platelet count variability on criteria accuracy in all-etiologies cACLD.
cACLD patients undergoing screening endoscopy with laboratory data within 6 months and LSM within one year.
Of 442 patients, 31% had varices (7% with VNT). Baveno VI criteria had 100% sensitivity (Se) and negative predictive value (NPV) and spared 19.5% endoscopies. “LSM 25/platelet 125” and “Expanded-Baveno VI” criteria maintained such accuracy, sparing 15% and 24% more endoscopies, respectively (p < 0.001). Platelet 150/MELD 6 was less accurate, misclassifying 10% VNT. Platelet count variability exceeded 8% and one VNT patient was misclassified with both “Expanded-Baveno VI” and “LSM 25/platelet 125” criteria considering the previous platelet count.
Both “Expanded-Baveno VI” and “LSM 25/platelet 125” criteria are accurate in cACLD, but the former are more advantageous. Platelet 150/MELD 6 proved inadequate.
The noninvasive diagnosis of esophageal varices and its application in clinical practice
2018, Clinics and Research in Hepatology and Gastroenterology
Here, we review recent improvements made to different noninvasive tests used for the diagnosis of esophageal varices (EV) in the light of the recent Baveno VI recommendation and with an emphasis on clinical application. Like for fibrosis tests, these noninvasive EV tests can be classified as direct markers when they provide a visualization of EV (including all imaging procedures like endoscopy or radiology) and as indirect markers when they do not (blood markers or elastometry). Clinical descriptors expressed as percentages, especially the spared endoscopy rate and the missed high-risk esophageal varices (HREV) rate, are more eloquent in this setting than classical statistical descriptors like accuracy. Single biomarkers are insufficient, generally due to a missed HREV rate exceeding the acceptable limit of 5% indicated in the Baveno VI consensus. Thus, biomarker combinations are currently garnering the most interest. The Baveno VI recommendation states that in alcoholic and viral cirrhoses, screening endoscopy can be safely set aside for patients with liver stiffness < 20 kPa and platelets > 150 G/L. The Baveno rule's mean missed HREV rate is < 5% but its spared endoscopy rate is < 20%. New combinations or stepwise algorithms show promise but must be validated. Going forward, the Baveno rule provides a simple noninvasive method to rule out HREV in clinical practice but the need for further research continues. The noninvasive diagnosis of HREV will be significantly improved by new, simple and affordable combinations.
Non-invasive Diagnosis of Oesophageal Varices Using Systemic Haemodynamic Measurements by Finometry: Comparison with Other Non-invasive Predictive Scores
2016, Journal of Clinical and Experimental Hepatology
Citation Excerpt :
As increasing numbers of patients require endoscopic surveillance for varices, increasing interest is being shown in the non-invasive diagnosis of oesophageal varices, due to the cost and burden this places on endoscopy units and the requirement for repeated surveillance over many years. Multiple studies have been performed assessing parameters relating to liver function, liver fibrosis, portal hypertension and hypersplenism, and combining modalities to produce predictive scores, but to date none of these have proved accurate enough to replace the current gold standard of gastroscopy.9–20 Portal hypertension is the force that drives the development of oesophageal varices in cirrhotic patients.
Cirrhosis and portal hypertension are characterised by a hyperdynamic circulation, which is independently associated with variceal size. Non-invasive techniques for measurement of systemic haemodynamics are now available.
The aim of the study was to prospectively assess the accuracy of systemic haemodynamics measured non-invasively for the detection of oesophageal varices in cirrhotic patients as compared to other currently available non-invasive methods.
In a study of 29 cirrhotic patients, systemic haemodynamics were studied non-invasively using the Finometer^® (mean arterial pressure (MAP), cardiac output (CO)/index, heart rate (HR), peripheral vascular resistance) and portal pressure was assessed by hepatic venous pressure gradient. Sensitivity, specificity, predictive values and area under the receiver operating characteristic (ROC) curves were assessed for predicting presence of varices and large oesophageal varices. Results were compared to child's classification, platelet/spleen ratio and ALT/AST ratios as predictors of the presence of large varices.
Using finometry large oesophageal varices were correctly predicted in 83% of patients compared to other non-invasive techniques (range 66–76%).
Non-invasive assessment of systemic haemodynamics using finometry could aid the identification of patients who do not immediately require variceal surveillance reducing the numbers of endoscopies and ensuring services are provided to those most likely to benefit.
Incidence and predictors of rebleeding after band ligation of oesophageal varices
2014, Arab Journal of Gastroenterology
Variceal bleeding is a severe complication in patients with portal hypertension. Early rebleeding occurs frequently in the first few weeks after band ligation, and the mortality associated with each bleeding episode ranges from 30% to 50%. Our aims were to study the rate of early rebleeding oesophageal varices after band ligation in the Sohag University Hospital, Egypt, and to assess different clinical, biochemical, ultrasonographic, and endoscopic parameters that may predict the risk factors of rebleeding.
In the period from December 2011 to December 2012, we performed endoscopic variceal ligation (EVL) for 146 cirrhotic patients (105 male and 41 female) with a mean age of 51.77 ± 10.47 years; the patients were divided into rebleeding and non-rebleeding groups. Complete history taking, clinical examination, laboratory investigations, abdominal ultrasound (US), and upper gastrointestinal (GI) endoscopy were performed for all patients.
The incidence of early rebleeding after EVL was 20.54%, and it was significantly associated with male gender (p = 0.013), older age (p = 0.009), infection with spontaneous bacterial peritonitis (SBP) (p < 0.0007), reduced liver size (p = 0.017), a coarser echo pattern (p = 0.03), the presence of hepatic focal lesions (p < 0.001), splenomegaly (p = 0.02), the presence of portosystemic collaterals (p = 0.006), a low haemoglobin (HB) level (p < 0.0001), prothrombin concentration (p = 0.017), high aspartate aminotransferase (AST) level (p = 0.01), Child–Pugh B and C (p = 0.02, 0.003), large oesophageal varices F3 in the two endoscopies (p = 0.002; p < 0.0001), varices extending to the superior third Ls (p < 0.001), and the presence of massive red colour signs (RC+++) (p < 0.0001). By multivariate analysis, SBP and low HB level were found to be independent predictors of rebleeding.
The following conclusions were drawn from this study: (1) The incidence of rebleeding after EVL in our centre is about 20%. (2) Early rebleeding after EVL is affected by many clinical, laboratory, ultrasonographic, and endoscopic parameters. The most prominent of them are SBP, splenomegaly, the presence of collaterals, anaemia, more decompensated cirrhosis, and the presence of large varices with red signs. (3) SBP and low HB level were found to be independent predictors of rebleeding.

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Non-invasive diagnosis of esophageal varices in chronic liver diseases

Abstract

Section snippets

Patients

Characteristics of population

Discussion

Acknowledgements

Gastrointest Endosc

Gastroenterology

Gastroenterology

J Hepatol

Gastroenterology

Gastroenterology

Gastrointest Endosc

Gastroenterology

Hepatology

J Hepatol

J Hepatol

Main causes of death in cirrhosis

Scand J Gastroenterol

Histoire naturelle des varices œsophagiennes au cours de la cirrhose (de la naissance à la rupture)

Gastroenterol Clin Biol

Beta-adrenergicantagonist drugs in the prevention of gastrointestinal bleeding in patients with cirrhosis and esophageal varices

N Engl J Med

Incidence of large esophageal varices in patients with cirrhosis. Application to prophylaxis of first bleeding

Gut

Predicting esophageal varices in patients with primary biliary cirrhosis (PBC)

Gastroenterology

Serum laminin Pl levels do not reflect critically elevated portal pressure in patients with liver cirrhosis

Hepato-Gastroenterology

Portal hypertensive gastric mucosa: an endoscopic study

Gut

Gastric lesions in portal hypertension: inflammatory gastritis or congestive gastropathy

Gut

Frequency of upper gastrointestinal lesions in patients with liver cirrhosis

Dig Dis Sci