https://aasldpubs.onlinelibrary.wiley.com/doi/pdf/10.1002/hep.24129

Noninvasive assessment of portal hypertension in patients with cirrhosis

SummaryBackground
Several risk scoring systems exist for upper gastrointestinal bleed (UGIB). We hypothesised that a modified Glasgow Blatchford Score (mGBS) that eliminates the subjective components of the GBS might perform as well as current scoring systems.

Aim
To compare the performance of the mGBS to the most widely reported scoring systems for prediction of clinical outcomes in patients presenting with UGIB.

Methods
Prospective cohort study from 9/2010 to 9/2011. Accuracy of the mGBS was compared with the full GBS, full Rockall Score (RS) and clinical RS using area under the receiver operating characterstics-curve (AUC). Primary outcome was need for clinical intervention: blood transfusion, endoscopic, radiological or surgical intervention. Secondary outcome was repeat bleeding or mortality.

Results
One hundred and ninety-nine patients were included. Median age was 56 with 40% women. Thirty-two per cent patients required blood transfusion, 24% endoscopic interventions, 0.5% radiological intervention, 0 surgical interventions, 5% had repeat bleeding and 0.5% mortality. Primary outcome: the mGBS (AUC 0.85) performed as well as the GBS (AUC = 0.86, P = 0.81), and outperformed the full RS (AUC 0.75, P = 0.005) and clinical RS (AUC 0.66, P < 0.0001). Secondary outcome: the mGBS (AUC 0.83) performed as well as the GBS (AUC 0.81, P = 0.38) and full RS (AUC 0.69, and outperformed the clinical RS (AUC 0.59, P = 0.0007).

Conclusions
The modified Glasgow Blatchford Score performed as well as the full Glasgow Blatchford Score while outperforming both Rockall Scores for prediction of clinical outcomes in American patients with upper gastrointestinal bleed. By eliminating the subjective components of the Glasgow Blatchford Score, the modified Glasgow Blatchford Score may be easier to use and therefore more easily implemented into routine clinical practice.

https://onlinelibrary.wiley.com/doi/pdf/10.1111/apt.12029

A modified Glasgow Blatchford Score improves risk stratification in upper gastrointestinal bleed: a prospective comparison of scoring systems.

Portal hypertensive gastropathy (PHG) occurs as a complication of cirrhotic or non-cirrhotic portal hypertension. Although the pathogenesis of PHG is not completely understood, evidence suggests that the key factor for the development of PHG is portal hypertension. PHG is clinically important because it may cause acute (and even) massive or insidious, blood loss. The diagnosis of PHG is (only) made endoscopically; it is most often characterized by an abnormality of the gastric mucosa described as a mosaic-like pattern resembling ‘snake-skin’, with or without red spots and the endoscopic pattern is key its diagnosis. Unfortunately, standardization of the endoscopic diagnostic criteria for PHG is poor and consensus is generally lacking, resulting in a wide range of reported prevalence. Pharmacological therapies, presumably reducing portal pressure and gastric blood flow, have been used to treat acute bleeding; propanolol, a non-selective β-blocker (24–480 mg/day), has been used most frequently. Endoscopic treatment for PHG bleeding plays a small, if any, role in the treatment of PHG. TIPS and shunt surgery have not been extensively analysed as a treatment for acute or chronic PHG bleeding, but they appear to lessen the severity of PHG. Secondary prophylaxis of PHG bleeding with non-selective β-blockers is recommended. There is not enough evidence to support the use of β-blockers in primary prophylaxis of PHG bleeding, even in cases of severe PHG (however, non-selective β-blockers are recommended if varices are present). Further studies are needed to clarify the role of PHG in suspected chronic gastrointestinal bleeding.

https://onlinelibrary.wiley.com/doi/pdf/10.1111/j.1478-3231.2010.02286.x

Portal hypertensive gastropathy: a review.

https://www.liver.theclinics.com/article/S1089-3261(05)00094-2/pdf

Acute Liver Failure in Children

Background & Aims

Combined therapy with endoscopic variceal ligation (EVL) and β-blockers ± isosorbide mononitrate (ISMN) is currently recommended to prevent variceal rebleeding. However, the role of this combined therapy has been challenged by some studies. We performed a systematic review to assess the value of combined therapy with EVL and β-blockers ± ISMN as compared with each treatment alone to prevent rebleeding.



Methods

Databases, references and meeting abstracts were searched to retrieve randomized trials comparing combined therapy with EVL and β-blockers ± ISMN vs either treatment alone, to prevent variceal rebleeding in cirrhosis. Random-effects model was used for meta-analysis.



Results

We identified five studies comparing EVL alone or combined with drugs, including a total of 476 patients. Combination therapy reduced overall rebleeding [risk ratios (RR) = 0.44, 95% confidence interval (CI) = 0.28–0.69], and showed a trend towards lower mortality (RR = 0.58, 95% CI = 0.33–1.03), without increasing complications. We identified four trials comparing drugs alone or associated with EVL, including 409 patients. All used β-blockers plus ISMN. Variceal rebleeding decreased with combined therapy (P < 0.01) but rebleeding from oesophageal ulcers increased (P = 0.01). Overall, there was a trend towards lower rebleeding (RR = 0.76, 95% CI = 0.58–1.00) without effect on mortality (RR = 1.24, 95% CI = 0.90–1.70).



Conclusions

The addition of drug therapy to EVL improves the efficacy of EVL alone. However, the addition of EVL to β-blockers and ISMN achieves a non-significant decrease of rebleeding with no effect on mortality. Although combination therapy with EVL plus β-blockers ± ISMN is adequate to prevent rebleeding, β-blockers + ISMN alone may be a valid alternative.

https://onlinelibrary.wiley.com/doi/pdf/10.1111/liv.12452

Drugs plus ligation to prevent rebleeding in cirrhosis: an updated systematic review.

OBJECTIVE To identify hematological, biochemical and ultrasonographic predictors of esophageal varices in patients of cirrhosis. DESIGN Cross-sectional, analytical study. PLACE AND DURATION OF STUDY Department of Gastroenterology, Shaikh Zayed Postgraduate Medical Institute, Lahore, from September 2003 to March 2004. PATIENTS AND METHODS One hundred and one patients with established cirrhosis and no history of variceal bleed underwent physical examination, hematological, biochemical tests and abdominal ultrasound examination. Esophagogastroduodenoscopy (EGD) was carried out in all patients. Presence of varices on EGD was correlated with hematological, biochemical and ultrasonographic variables by regression analysis. RESULTS Esophageal varices were seen in 65 patients while 36 patients had no varices. High grade varices were seen in 15 patients and 50 patients had low grade varices. Serum albumin less than 2.95 g/dl, platelet count less than 88 x 103/muL and portal vein diameter more than 11 mm were associated with presence of varices. High grade varices were predicted by serum albumin 11 mm are more likely to have high grade varices. These patients are candidates for surveillance endoscopy.

Non-endoscopic prediction of presence of esophageal varices in cirrhosis.

OBJECTIVE To validate Rockall scoring system for in-hospital rebleeding and mortality in cirrhotic patients with variceal bleed. STUDY DESIGN Cohort type of case series. PLACE AND DURATION OF STUDY It was carried out at the Department of Gastroenterology and Hepatology, Shaikh Zayed Hospital, Lahore, from March 2005 to March 2006. PATIENTS AND METHODS All cirrhotic patients presenting with upper GI bleeding and later found to have variceal source of bleeding on endoscopy were included. Clinical and endoscopic features were noted to calculate Rockall score. After giving appropriate pharmacological and endoscopic therapy, patients were followed for rebleeding or death till discharge from hospital. Linear regression analysis was used to determine predictive value of score and discrimination was evaluated by calculating the area under the receiver operating characteristic (ROC) curve. RESULTS A total of 402 patients were included. Mean age was 52.57 (+/-11.39) and male to female ratio was 2:1(269/133). Esophageal varices were source of bleeding in 340 (84.5%), gastric fundal varix in 44 (11%) and ectopic duodenal varix in 3 (0.9%) patients. Both esophageal and gastric varices were present in 15 (3.6%) patients. In-hospital mortality was 6.7% while 22 (5.5%) patients had rebleeding. Rockall score was found to have good predictive value for mortality (p-value<0.001 and area under curve AUC 0.834) and in-hospital rebleeding (p-value<0.001 and AUC 0.798). CONCLUSION Rockall scoring system has good predictive and discriminative value for in-hospital rebleeding and mortality in patients with variceal bleeding due to cirrhosis.

Predictive value of Rockall score for rebleeding and mortality in patients with variceal bleeding.

Objective: To compare the efficacy of propranolol, propranolol with nitrate, band ligation, and band ligation with propranolol and nitrate for the prevention of esophageal variceal rebleeding. Study Design: A prospective randomized trial. Place and Duration of Study: Department of Gastroenterology and Hepatology, Sheikh Zayed Hospital, Lahore, from November 2003 to July 2005. Methodology: One hundred and sixty cirrhotic patients with esophageal variceal bleeding were randomized to four treatment groups (propranolol, propranolol plus isosorbide mononitrate, band ligation, band ligation plus propranolol and nitrate) with 40 patients in each group. Patients were followed for 6 months after the enrolment of last patient. Primary end points were recurrence of esophageal variceal bleeding and death. Treatment complications were noted. Results: Four treatment groups were comparable regarding baseline characteristics. Esophageal variceal rebleeding occurred in 22% patients in band ligation plus drugs group, 26% patients in drug combination group, 31% patients in banding group and 38% patients in propranolol group (p=0.41). Difference in mortality rates was also not significant. Conclusion: There was no significant difference between treatment groups in prevention of esophageal variceal rebleeding.

/pdf/propranolol-isosorbide-mononitrate-and-endoscopic-band-227o21mpw3.pdf

Propranolol, isosorbide mononitrate and endoscopic band ligation - alone or in varying combinations for the prevention of esophageal variceal rebleeding.

OBJECTIVE To determine prognostic indicators for morbidity and mortality in patients with fulminant hepatic failure. DESIGN Observational study. PLACE AND DURATION OF STUDY Department of Gastroenterology and Hepatology, Shaikh Zayed Postgraduate Medical Institute, Lahore, from April 2003 to June 2005. PATIENTS AND METHODS Forty five patients with confirmed diagnosis of fulminant hepatic failure were included in this study. They were investigated for acute viral serology, complete blood count, liver function tests, renal function tests, serum electrolytes, arterial blood gases, initially daily and then on alternate days. Patients were followed in high dependency/ICU at the Shaikh Zayed Postgraduate Medical Institute. Data were analyzed by logistic regression analysis to identify predictors of mortality and morbidity. RESULTS Of the 45 subjects, 31 were males and 14 females. Twenty four patients were positive for acute hepatitis E. Twenty patients recovered fully, whereas 25 died with mortality rate of 55.6 %. Variables i.e. presence of non-A non-B viral hepatitis, serum creatinine > 2.0 mg/dl, serum phosphate > 3.5 mg/dl and sepsis were found to have significant association with mortality on linear correlation. Only serum creatinine more than 2.0 mg/dl, serum phosphate > 3.5 mg/dl and development of sepsis were found to predict the outcome after multivariate analysis. CONCLUSION Patients with serum creatinine > 2.0 mg/dl, serum phosphate > 3.5 mg/dl and sepsis showed adverse prognosis for survival.

Predictors of fatal outcome in fulminant hepatic failure.

Background: Use of endoscopic therapies for esophageal varices has resulted in increased prevalence of fundal varices and severe portal hypertensive gastropathy. This study was meant to compare the effect of band ligation and sclerotherapy on development of fundal varices and portal hypertensive gastropathy. Methods: Patients with esophageal varices presenting in the endoscopy unit of Shiakh Zayed Hospital, with at least one previous endoscopy were included. Patient‘s past record was reviewed for findings and type of treatment given for varices during first endoscopy, number of endoscopies till date, number of esophageal varices band ligation (EVBL) or sclerotherapy sessions. All patients underwent upper GI endoscopy and findings were recorded. Type of treatment patient rendered during first endoscopy either EVBL or sclerotherapy was correlated to the presence of fundal varices and severity of portal hypertensive gastropathy observed on present endoscopy, using Chi square test (χ 2 ). Results: Eighty one patients were included. Mean age of patients was 48.70+ 12.63. Esophageal varices band ligation was carried out during first endoscopy in 49 (60.5%) patients and sclerotherapy in 31 (38.2%) patients. On fresh endoscopy, fundal varices were seen in 25 (30.8%) patients. Severe portal hypertensive gastropathy was found in 26 (32.1%) and mild in 54 (66.7%) patients. Severity of portal hypertensive gastropathy and presence of fundal varices in recent endoscopy was significantly more in patients with EVBL in first endoscopy. Conclusion: Band ligation of esophageal varices is associated with more frequent development of fundal varices and worsening of portal hypertensive gastropathy compared to sclerotherapy. Key Words: Baveno scoring, Esophageal varices band ligation, Portal hypertensive gastropathy,

Irfan Ahmad

Papers

Non-endoscopic prediction of presence of esophageal varices in cirrhosis.

Predictive value of Rockall score for rebleeding and mortality in patients with variceal bleeding.

Propranolol, isosorbide mononitrate and endoscopic band ligation - alone or in varying combinations for the prevention of esophageal variceal rebleeding.

Predictors of fatal outcome in fulminant hepatic failure.

Effect of band ligation on portal hypertensive gastropathy and development of fundal varices