Esophageal and Gastric Varices ; etiology ; therapy ; Hemodynamics ; Humans ; Hypertension, Portal ; complications ; therapy ; Liver Cirrhosis ; complications ; therapy ; Portal Vein ; physiopathology

Adult ; Esophageal and Gastric Varices ; drug therapy ; etiology ; physiopathology ; Esophagus ; physiopathology ; Female ; Humans ; Isosorbide Dinitrate ; analogs & derivatives ; therapeutic use ; Liver Cirrhosis ; complications ; physiopathology ; Male ; Manometry ; Vasodilator Agents ; therapeutic use

OBJECTIVE: To investigate the influence of endoscopic variceal ligation (EVL) on liver function and analyze the risk factors of rebleeding after EVL. METHODS: A total of 137 cirrhotic patients with esophageal varices who received EVL were retrospectively analyzed, and divided into group A, B, and C according to the Child-Pugh scores of liver function. We compared the liver function 1 week preoperatively and postoperatively. The patients were further divided into a rebleeding group and a non-rebleeding group after the EVL, and risk factors about rebleeding were analyzed. RESULTS: There was no significant difference on ALT, AST, T-Bil, and D-Bil either preoperatively or postoperatively in group A, B, and C (P>0.05). Thirteen patients (9.49%) rebled after the EVL. The course of disease, liver function, prothrombin time, and mass ascites were the risk factors of rebleeding. CONCLUSION EVL has no obvious effect on liver function, and the course of disease, liver function, prothrombin time and mass ascites are risk factors of rebleeding after EVL.
Adult ; Endoscopy ; methods ; Esophageal and Gastric Varices ; etiology ; surgery ; Female ; Gastrointestinal Hemorrhage ; etiology ; prevention & control ; surgery ; Humans ; Ligation ; methods ; Liver ; physiopathology ; Liver Cirrhosis ; complications ; etiology ; physiopathology ; Logistic Models ; Male ; Middle Aged ; Recurrence ; Risk Factors ; Secondary Prevention

INTRODUCTIONHepatic venous pressure gradient (HVPG) measurement is recommended for prognostic and therapeutic indications in centres with adequate resources and expertise. Our study aimed to evaluate the quality of HVPG measurements at our centre before and after introduction of a standardised protocol, and the clinical relevance of the HVPG to variceal bleeding in cirrhotics.

METHODSHVPG measurements performed at Singapore General Hospital from 2005-2013 were retrospectively reviewed. Criteria for quality HVPG readings were triplicate readings, absence of negative pressure values and variability of ≤ 2 mmHg. The rate of variceal bleeding was compared in cirrhotics who achieved a HVPG response to pharmacotherapy (reduction of the HVPG to < 12 mmHg or by ≥ 20% of baseline) and those who did not.

RESULTS126 HVPG measurements were performed in 105 patients (mean age 54.7 ± 11.4 years; 55.2% men). 80% had liver cirrhosis and 20% had non-cirrhotic portal hypertension (NCPH). The mean overall HVPG was 13.5 ± 7.2 mmHg, with a significant difference between the cirrhosis and NCPH groups (p < 0.001). The proportion of quality readings significantly improved after the protocol was introduced. HVPG response was achieved in 28 (33.3%, n = 84) cirrhotics. Nine had variceal bleeding over a median follow-up of 29 months. The rate of variceal bleeding was significantly lower in HVPG responders compared to nonresponders (p = 0.025).

CONCLUSIONThe quality of HVPG measurements in our centre improved after the introduction of a standardised protocol. A HVPG response can prognosticate the risk of variceal bleeding in cirrhotics.

Esophageal and Gastric Varices ; complications ; physiopathology ; Female ; Follow-Up Studies ; Gastrointestinal Hemorrhage ; etiology ; physiopathology ; prevention & control ; Humans ; Hypertension, Portal ; complications ; physiopathology ; Liver Cirrhosis ; complications ; physiopathology ; Male ; Middle Aged ; Portal Pressure ; physiology ; Prognosis ; Retrospective Studies

BACKGROUND/AIMS: The relationship between portal hemodynamics and fundal varices has not been well documented. The purpose of this study was to understand the pathophysiology of fundal varices and to investigate bleeding risk factors related to the presence of spontaneous portosystemic shunts, and to examine the hepatic venous pressure gradient (HVPG) between fundal varices and other varices. METHODS: In total, 85 patients with cirrhosis who underwent HVPG and gastroscopic examination between July 2009 and March 2011 were included in this study. The interrelationship between HVPG and the types of varices or the presence of spontaneous portosystemic shunts was studied. RESULTS: There was no significant difference in the HVPG between fundal varices (n=12) and esophageal varices and gastroesophageal varices type 1 (GOV1) groups (n=73) (17.1+/-7.7 mm Hg vs 19.7+/-5.3 mm Hg). Additionally, there was no significant difference in the HVPG between varices with spontaneous portosystemic shunts (n=28) and varices without these shunts (n=57) (18.3+/-5.8 mm Hg vs 17.0+/-8.1 mm Hg). Spontaneous portosystemic shunts increased in fundal varices compared with esophageal varices and GOV1 (8/12 patients [66.7%] vs 20/73 patients [27.4%]; p=0.016). CONCLUSIONS: Fundal varices had a high prevalence of spontaneous portosystemic shunts compared with other varices. However, the portal pressure in fundal varices was not different from the pressure in esophageal varices and GOV1.
Adult ; Aged ; Endoscopy, Gastrointestinal ; Esophageal and Gastric Varices/etiology/*physiopathology ; Esophagus ; Female ; Gastric Fundus ; Gastrointestinal Hemorrhage/etiology/*physiopathology ; Humans ; Hypertension, Portal/complications/*physiopathology ; Liver Cirrhosis/complications/*physiopathology ; Male ; Middle Aged ; *Portal Pressure ; *Renal Veins ; Risk Factors ; *Splenic Vein ; Stomach/*blood supply ; Vascular Fistula/complications/*physiopathology

This study sought to determine the value of portal venography with 64-slice MDCT in the evaluation of compensatory circulation resulting from decompensated posthepatitic cirrhosis (PHC), and in the clarification of its anatomic distribution. Thirty-six patients with clinically confirmed compensatory circulations resulting from PHC were enrolled in this study. They underwent thoracicoabdominal triphasic enhancement CT scans with 64-slice MDCT. The data of the portal venous phase acquired were used for obtaining CT-MIP (maximum intensity projection) images of portosystematic collaterals such as gastric fundic and esophageal varices, paraumbilical veins, spleno-renal shunts, and their inflowing and outflowing vessels. On CT-MIP portography, gastric fundic varices were shown in 35 cases (97%) and esophageal varices in 30 cases (83%). The left gastric vein was the common inflowing vessel of the varices in 34 cases (94%); it was mainly originated from splenic vein in 24 cases (67%). With regard to the outflowing vessels, they were commonly azygos vein in 30 cases (83%). As for paraumbilical veins in 7 cases (19%), the inflowing vessel was the left branch of portal vein, and the outflowing vesse was the superficial epigastric vein. Cavernous transformation of the portal vein was seen in 5 cases (14%) and cavernous transformation of splenic vein was seen in 16 cases (44%). CT-MIP venography with 64-row MDCT could be considered as an effective and noninvasive method for detecting the compensatory circulation resulting from decompensated PHC.
Adult ; Aged ; Aged, 80 and over ; Collateral Circulation ; Esophageal and Gastric Varices ; diagnostic imaging ; epidemiology ; Female ; Hepatitis B ; complications ; Humans ; Liver Cirrhosis ; diagnostic imaging ; etiology ; physiopathology ; Male ; Middle Aged ; Portal Vein ; diagnostic imaging ; pathology ; Portography ; methods ; Tomography, Spiral Computed ; methods

BACKGROUND/AIMS: Bleeding from esophageal varices (EV) is a major cause of death in patients with liver cirrhosis. Endoscopic screening is recommended for diagnosing EV, but various noninvasive parameters can also be used to predict EV. The liver stiffness measurement (LSM), a noninvasive technique for estimating liver fibrosis, was recently reported to be strongly correlated with the hepatic venous pressure gradient. This study evaluated the usefulness of LSM for predicting the presence and size of EV in patients with cirrhosis. METHODS: The relationships of LSM with the presence and size of EV were analyzed in 112 patients with liver cirrhosis. Liver cirrhosis was diagnosed histologically or clinically. The presence and size of EV were assessed by endoscopy, and LSM was determined by the Fibroscan(R) technique. RESULTS: LSM was strongly correlated with the presence of EV (P<0.0001): the LSM value was 42.7+/-21.9 kPa (mean+/-standard deviation) in patients with EV (n=82) and 19.1+/-12.6 kPa in patients without EV (n=30). The area under the receiver operating characteristic curve was 0.818 (95% CI, 0.732-0.904) for predicting the presence of EV, and an LSM value of 19.7 kPa was predictive of the presence of EV with a sensitivity of 87%, a specificity of 70%, a PPV of 89%, and a NPV of 66%. However, there was a weak correlation between LSM and the size of EV. CONCLUSIONS: LSM is useful for predicting the presence of EV in patients with cirrhosis but not their size.
Adult ; Aged ; Elasticity ; Esophageal and Gastric Varices/etiology/*ultrasonography ; Female ; Hepatic Veins ; Humans ; Liver/*ultrasonography ; Liver Cirrhosis/*complications/physiopathology ; Male ; Middle Aged ; Portal Pressure ; Predictive Value of Tests ; ROC Curve ; Severity of Illness Index

Adult ; Aged ; Blood Flow Velocity ; Esophageal and Gastric Varices ; complications ; physiopathology ; Female ; Gastrointestinal Hemorrhage ; diagnostic imaging ; etiology ; physiopathology ; Hemodynamics ; Humans ; Hypertension, Portal ; diagnostic imaging ; etiology ; physiopathology ; Liver Cirrhosis ; complications ; Liver Diseases ; complications ; Male ; Middle Aged ; Portal System ; diagnostic imaging ; physiopathology ; Spleen ; diagnostic imaging ; physiopathology ; Ultrasonography, Doppler, Color

INTRODUCTIONLarge, recent population-based data for evaluating the predictors of oesophageal variceal bleeding (OVB) among cirrhotic patients is still lacking. This study aimed to determine the cumulative incidence of OVB among cirrhotic patients and identify the predictors of OVB occurrence.

METHODSPatient information on 38,172 cirrhotic patients without a history of OVB, who were discharged between 1 January 2007 and 31 December 2007, was obtained from the Taiwan National Health Insurance Database for this study. All patients were followed up for three years. Death was the competing risk when calculating the cumulative incidences and hazard ratios (HRs) of OVB.

RESULTSOVB was present in 2,609 patients (OVB group) and absent in 35,563 patients (non-OVB group) at hospitalisation. During the three-year follow-up period, the cumulative incidence of OVB was 44.5% and 11.3% in the OVB and non-OVB group, respectively (p < 0.001). Modified Cox regression analysis showed that the HR of OVB history was 4.42 for OVB occurrence (95% confidence interval [CI] 4.13-4.74). Other predictors for OVB occurrence included hepatocellular carcinoma (HR 1.16, 95% CI 1.09-1.24), young age (HR 0.98, 95% CI 0.98-0.98), ascites (HR 1.46, 95% CI 1.37-1.56), alcohol-related disorders (HR 1.20, 95% CI 1.12-1.28), peptic ulcer bleeding (HR 1.26, 95% CI 1.13-1.41) and diabetes mellitus (HR 1.14, 95% CI 1.06-1.23).

CONCLUSIONCirrhotic patients have a fourfold increased risk of future OVB following the first incidence of OVB.

Adult ; Aged ; Alcoholism ; complications ; Ascites ; complications ; Carcinoma, Hepatocellular ; complications ; Databases, Factual ; Diabetes Complications ; Esophageal and Gastric Varices ; epidemiology ; etiology ; Female ; Gastrointestinal Hemorrhage ; epidemiology ; etiology ; Humans ; Incidence ; Liver Cirrhosis ; complications ; physiopathology ; Liver Neoplasms ; complications ; Male ; Middle Aged ; Peptic Ulcer ; complications ; Proportional Hazards Models ; Recurrence ; Retrospective Studies ; Risk ; Taiwan