Diagnosis and treatment of portal hypertension

Nomogram-based prediction of portal vein system thrombosis formation after splenectomy in patients with hepatolenticular degeneration

Objective

Splenectomy is a vital treatment method for hypersplenism with portal hypertension. However, portal venous system thrombosis (PVST) is a serious problem after splenectomy. Therefore, constructing an effective visual risk prediction model is important for preventing, diagnosing, and treating early PVST in hepatolenticular degeneration (HLD) surgical patients.

Methods

Between January 2016 and December 2021, 309 HLD patients were selected. The data were split into a development set (215 cases from January 2016 to December 2019) and a validation set (94 cases from January 2019 to December 2021). Patients' clinical characteristics and laboratory examinations were obtained from electronic medical record system, and PVST was diagnosed using Doppler ultrasound. Univariate and multivariate logistic regression analyses were used to establish the prediction model by variables filtered by LASSO regression, and a nomogram was drawn. The area under the curve (AUC) of receiver operating characteristic (ROC) curve and Hosmer-Lemeshow goodness-of-fit test were used to evaluate the differentiation and calibration of the model. Clinical net benefit was evaluated by using decision curve analysis (DCA). The 36-month survival of PVST was studied as well.

Results

Seven predictive variables were screened out using LASSO regression analysis, including grade, POD14D-dimer (Postoperative day 14 D-dimer), POD7PLT (Postoperative day 7 platelet), PVD (portal vein diameter), PVV (portal vein velocity), PVF (portal vein flow), and SVD (splenic vein diameter). Multivariate logistic regression analysis revealed that all seven predictive variables had predictive values (P < 0.05). According to the prediction variables, the diagnosis model and predictive nomogram of PVST cases were constructed. The AUC under the ROC curve obtained from the prediction model was 0.812 (95% CI: 0.756-0.869) in the development set and 0.839 (95% CI: 0.756-0.921) in the validation set. Hosmer-Lemeshow goodness-of-fit test fitted well (P = 0.858 for development set; P = 0.137 for validation set). The nomogram model was found to be clinically useful by DCA. The 36-month survival rate of three sites of PVST was significantly different from that of one (P = 0.047) and two sites (P = 0.023).

Conclusion

The proposed nomogram-based prediction model can predict postoperative PVST. Meanwhile, an earlier intervention should be performed on three sites of PVST.

Diagnostic validity of serum YKL-40 as a non-invasive diagnostic marker of oesophageal varices in cirrhotic hepatitis C virus patients

Background

Liver cirrhosis is the last phase of chronic hepatitis C virus infection. During the compensated phase, portal pressure is still below the point where varices start to form. On the contrary, decompensated individuals have clinically significant portal hypertension. YKL-40 protein is categorized as an inflammatory protein and is related to various different variables in expressing the severity of hepatic fibrosis, including hepatic venous pressure gradient. The objective of this research was to evaluate the diagnostic validity of serum YKL-40 in cirrhotic hepatitis C virus patients as a predictive non-invasive marker for the diagnosis of oesophageal varices and to compare it to other non-invasive clinical, laboratory, and ultrasonographic parameters, as well as endoscopy with and without treatment modalities.

Results

The present research was done on 80 participants visiting the Tropical Medicine Department at the Main University Hospital in Alexandria; they were divided into four groups, group I (n = 20) cirrhotic patients with no oesophageal varices, group II (n = 20) with small varices, group IIIa (n = 20) with large varices, and group IIIb same patients of group IIIa but after disappearance of varices by band ligation and medical treatment with carvedilol and group IV as apparently healthy control. YKL-40 in serum was evaluated using ELISA. Serum YKL-40 was statistically significantly higher in all cirrhotic patients than healthy controls (p = <0.001). Furthermore, it was statistically significantly greater in patients with small varices compared to those without varices (p = <0.001) and in large varices rather than no varices or small varices (p < 0.001) and (p < 0.001) respectively. However, there was no statistically significant difference between IIIa and IIIb (p = 0.881). In all tested groups, there was no correlation between serum YKL-40 and FIB-4 or APRI. However, only participants in group I exhibited a significant negative correlation between serum YKL-40 and AST/ALT ratio, whereas subjects in groups II and IIIa exhibited no significant correlation.

Conclusion

Serum YKL-40 could be used as a sensitive non-invasive predictor for diagnosis and grading of oesophageal varices but not for follow up after treatment.

MiR-9a-5p regulates proliferation and migration of hepatic stellate cells under pressure through inhibition of Sirt1

AIM: To reveal the functions of microRNAs (miRNAs) with respect to hepatic stellate cells (HSCs) in response to portal hypertension.

METHODS: Primary rat HSCs were exposed to static water pressure (10 mmHg, 1 h) and the pressure-induced miRNA expression profile was detected by next-generation sequencing. Quantitative real-time polymerase chain reaction was used to verify the expression of miRNAs. A potential target of MiR-9a-5p was measured by a luciferase reporter assay and Western blot. CCK-8 assay and Transwell assay were used to detect the proliferation and migration of HSCs under pressure.

RESULTS: According to the profile, the expression of miR-9a-5p was further confirmed to be significantly increased after pressure overload in HSCs (3.70 ± 0.61 vs 0.97 ± 0.15, P = 0.0226), which resulted in the proliferation, migration and activation of HSCs. In vivo, the up-regulation of miR-9a-5p (2.09 ± 0.91 vs 4.27 ± 1.74, P = 0.0025) and the down-regulation of Sirt1 (2.41 ± 0.51 vs 1.13 ± 0.11, P = 0.0006) were observed in rat fibrotic liver with portal hypertension. Sirt1 was a potential target gene of miR-9a-5p. Through restoring the expression of Sirt1 in miR-9a-5p transfected HSCs on pressure overload, we found that overexpression of Sirt1 could partially abrogate the miR-9a-5p mediated suppression of the proliferation, migration and activation of HSCs.

CONCLUSION: Our results suggest that during liver fibrosis, portal hypertension may induce the proliferation, migration and activation of HSCs through the up-regulation of miR-9a-5p, which targets Sirt1.

Identification of differential gene expression profile of HSCs subjected to pressurization by next-generation sequencing

AIM: To identify the gene expression profile of hepatic stellate cells (HSCs) subjected to pressurization by next-generation sequencing.

METHODS: Primary HSCs were isolated and cultured. After cultivation for 14 d, cells were subjected to a pressure of 10 MMHG (millimeters of mercury) for 1 h. Total RNA was then extracted and reverse transcribed into cDNA to screen differential genes between HSCs subjected to pressurization and non-treated HSCs using DEG-Seq.

RESULTS: A total of 979 differentially expressed genes were expressed in HSCs, of which 14 showed the most significant difference, including 10 up-regulated and 4 down-regulated genes. These genes were found to be related to anabolism, immune response, cell apoptosis, etc.

CONCLUSION: Differentially expressed genes could be identified in HSCs subjected to pressurization, indicating that HSCs respond to external pressure stimulation by regulating the expression of these genes.

Oesophageal capsule endoscopy versus oesophago-gastroduodenoscopy for the diagnosis of recurrent varices: a prospective multicentre study

BACKGROUND

Oesophago-gastroduodenoscopy is the standard method for the diagnosis of recurrent oesophago-gastric varices after endoscopic treatment and eradication. The aim of this study was to evaluate the PillCam Eso capsule endoscopy in this setting.

METHODS

Prospective, multicentre study in which patients with history of oesophageal varices treated by band ligation underwent PillCam Eso capsule and oesophago-gastroduodenoscopy. Capsule recordings were blindly read by two endoscopists. Indication for a new prophylactic treatment and patient satisfaction were determined for both procedures.

RESULTS

80 patients (80% males, mean age: 57±12 years) were included, after a median delay of 16 months from last endoscopic treatment. Recurrent oesophageal varices requiring a new prophylactic treatment were detected in 26 patients (32.5%). The mean oesophageal transit time of the capsule was 153 s (range 2-930 s). Capsule sensitivity, specificity, negative and positive predictive values for indication of new prophylactic treatments were 65%, 83%, 83%, and 65%, respectively. Capsule adequately classified 77.5% of the patients for prophylaxis indication. Inter-observer concordance for capsule readings was 88% for the prophylaxis indication.

CONCLUSION

This study demonstrates that accuracy of PillCam Eso capsule for the diagnosis of recurrent oesophageal varices after endoscopic eradication is suboptimal. PillCam Eso capsule might therefore be proposed in patients unable or unwilling to undergo oesophago-gastroduodenoscopy.

Laparoscopic splenectomy plus preoperative endoscopic variceal ligation versus splenectomy with pericardial devascularization (Hassab's operation) for control of severe varices due to portal hypertension

BACKGROUND

Our research was conducted to introduce a new, compound surgical method for laparoscopic splenectomy (LS) with preoperative endoscopic variceal ligation (EVL) and compare the new method's efficiency with that of Hassab's operation in patients with severe esophageal varices due to portal hypertension.

METHODS

Between March 2009 and March 2012, 47 patients with liver cirrhosis, portal hypertension, and severe esophageal varices were retrospectively analyzed. Of these patients, 19 received the combined preoperative EVL and LS (minimally invasive surgery, MIS group), and 28 patients received splenectomy with pericardial devascularization (Hassab's operation, H group).

RESULTS

Before surgery, there were no differences in the patient characteristics of the two groups. There were no significant differences in operating time, but significantly less intraoperative blood loss and shorter postoperative hospital stay were found in the MIS group compared with the H group. The mean follow-up periods of the MIS and H groups were 12.1 and 13.6 months, respectively. No deaths were documented during the follow-up period. Generally, hematological parameters and liver function variables eventually revealed considerable improvement in both groups. In the MIS group, the patients with varices improved significantly from severe to mild, and in some cases, the varices disappeared after treatment. Three patients in the H group suffered rebleeding and were treated with repeated EVL. No bleeding or rebleeding occurred in the MIS group.

CONCLUSIONS

The final results suggest that LS with preoperative EVL provides a restorative efficacy equivalent to that of Hassab's operation. Based on the recurrence rate and the rebleeding rate of severe esophageal varices, our surgical strategy (EVL and LS) is a safe and minimally invasive technique that appears satisfactory in comparison to other open procedures.

Clinical outcome and predictors of survival after TIPS insertion in patients with liver cirrhosis

AIM: To determine the clinical outcome and predictors of survival after transjugular intrahepatic portosystemic stent shunt (TIPS) implantation in cirrhotic patients.

METHODS: Eighty-one patients with liver cirrhosis and consequential portal hypertension had TIPS implantation (bare metal) for either refractory ascites (RA) (n = 27) or variceal bleeding (VB) (n = 54). Endpoints for the study were: technical success, stent occlusion and stent stenosis, rebleeding, RA and mortality. Clinical records of patients were collected and analysed. Baseline characteristics [e.g., age, sex, CHILD score and the model for end-stage liver disease score (MELD score), underlying disease] were retrieved. The Kaplan-Meier method was employed to calculate survival from the time of TIPS implantation and comparisons were made by log rank test. A multivariate analysis of factors influencing survival was carried out using the Cox proportional hazards regression model. Results were expressed as medians and ranges. Comparisons between groups were performed by using the Mann-Whitney U-test and the χ² test as appropriate.

RESULTS: No difference could be seen in terms of age, sex, underlying disease or degree of portal pressure gradient (PPG) reduction between the ascites and the bleeding group. The PPG significantly decreased from 23.4 ± 5.3 mmHg (VB) vs 22.1 ± 5.5 mmHg (RA) before TIPS to 11.8 ± 4.0 vs 11.7 ± 4.2 after TIPS implantation (P = 0.001 within each group). There was a tendency towards more patients with stage CHILD A in the bleeding group compared to the ascites group (24 vs 6, P = 0.052). The median survival for the ascites group was 29 mo compared to > 60 mo for the bleeding group (P = 0.009). The number of radiological controls for stent patency was 6.3 for bleeders and 3.8 for ascites patients (P = 0.029). Kaplan-Meier calculation indicated that stent occlusion at first control (P = 0.027), ascites prior to TIPS implantation (P = 0.009), CHILD stage (P = 0.013), MELD score (P = 0.001) and those patients not having undergone liver transplantation (P = 0.024) were significant predictors of survival. In the Cox regression model, stent occlusion (P = 0.022), RA (P = 0.043), CHILD stage (P = 0.015) and MELD score (P = 0.004) turned out to be independent prognostic factors of survival. The anticoagulation management (P = 0.097), the porto-systemic pressure gradient (P = 0.460) and rebleeding episodes (P = 0.765) had no significant effect on the overall survival.

CONCLUSION: RA, stent occlusion, initial CHILD stage and MELD score are independent predictors of survival in patients with TIPS, speaking for a close follow-up in these circumstances.

Esophageal Capsule Endoscopy for Screening Esophageal Varices among Japanese Patients with Liver Cirrhosis

Purpose. Although esophageal capsule endoscopy (ECE) is reportedly useful in the diagnosis of esophageal varices (EV), few reports have described the benefits of this technique in Asian countries. The present paper evaluates the usefulness of ECE for diagnosing EV in Japanese patients with cirrhosis. Methods. We examined 29 patients with cirrhosis (20 males and 9 females; mean age 60 years; Child-Pugh classification A/B/C; 14/14/1) using ECE followed by esophagogastroduodenoscopy (EGD). High-risk EV were defined as F2 and/or RC2 and above. Results. The sensitivity and specificity of ECE for the diagnosis of high-risk EV were 92% and 80%, respectively. Conclusions. The findings showed that ECE is a highly sensitive method of diagnosing high-risk EV that requires endoscopic or pharmacological therapy. Thus, ECE might be a useful method for the screening and followup of EV in patients with cirrhosis.

Acrylate glue injection for acutely bleeding oesophageal varices: A prospective cohort study

BACKGROUND

Acrylate glue injection is seldom performed in patients with bleeding oesophageal varices.

AIM

To assess efficacy and safety of acrylate glue injection in patients with bleeding oesophageal varices, as well as the impact of this technique on subsequent variceal ligation.

METHODS

Prospective study on 133 consecutive cirrhotic patients treated by intravariceal injection of undiluted N-butyl-2-cyanoacrylate into the bleeding varix. Outcome measures were initial haemostasis, recurrent bleeding, complications and mortality at 6 weeks.

RESULTS

52 patients were actively bleeding at endoscopy and 81 showed stigmata of recent haemorrhage. Initial haemostasis was achieved in 49/52 active bleeders (94.2% [95% CI 85.1-98.5]). Overall, early recurrent bleeding occurred in 7 patients (5.2% [95% CI 2.3-10.1]). No major procedure-related complication was recorded. At 6 weeks, death occurred in 11 patients, with an overall bleeding-related mortality of 8.2% [95% CI 5.8-15.3]. Mortality was higher in active (15.4% [95% CI 6.9-28.1]) than non-active bleeders (3.7% [95% CI 0.8-10.4], OR 4.7 [95% CI 1.05-28.7], p=0.02). Of those surviving the first bleeding episode, 112 patients subsequently underwent ligation. No technical difficulties were encountered in performing the banding procedure which was successfully completed in all cases.

CONCLUSIONS

Emergency injection of acrylate glue is safe and effective for the treatment of acute bleeding oesophageal varices and does not hamper subsequent variceal ligation.

Blood ammonia levels in liver cirrhosis: a clue for the presence of portosystemic collateral veins

BACKGROUND

Portal hypertension leads to the formation of portosystemic collateral veins in liver cirrhosis. The resulting shunting is responsible for the development of portosystemic encephalopathy. Although ammonia plays a certain role in determining portosystemic encephalopathy, the venous ammonia level has not been found to correlate with the presence or severity of this entity. So, it has become partially obsolete. Realizing the need for non-invasive markers mirroring the presence of esophageal varices in order to reduce the number of endoscopy screening, we came back to determine whether there was a correlation between blood ammonia concentrations and the detection of portosystemic collateral veins, also evaluating splenomegaly, hypersplenism (thrombocytopenia) and the severity of liver cirrhosis.

METHODS

One hundred and fifty three consecutive patients with hepatic cirrhosis of various etiologies were recruited to participate in endoscopic and ultrasonography screening for the presence of portosystemic collaterals mostly esophageal varices, but also portal hypertensive gastropathy and large spontaneous shunts.

RESULTS

Based on Child-Pugh classification, the median level of blood ammonia was 45 mcM/L in 64 patients belonging to class A, 66 mcM/L in 66 patients of class B and 108 mcM/L in 23 patients of class C respectively (p < 0.001).The grade of esophageal varices was concordant with venous ammonia levels (rho 0.43, p < 0.001). The best area under the curve was given by ammonia concentrations, i, e., 0.78, when comparing areas of ammonia levels, platelet count and spleen longitudinal diameter at ultrasonography. Ammonia levels predicted hepatic decompensation and ascites presence (Odds Ratio 1.018, p < 0.001).

CONCLUSION

Identifying cirrhotic patients with high blood ammonia concentrations could be clinically useful, as high levels would lead to suspicion of being in presence of collaterals, in clinical practice of esophageal varices, and pinpoint those patients requiring closer follow-up and endoscopic screening.

Meta-analysis of capsule endoscopy in patients diagnosed or suspected with esophageal varices

AIM: To review the literature on capsule endoscopy (CE) for detecting esophageal varices using conventional esophagogastroduodenoscopy (EGD) as the standard.

METHODS: A strict literature search of studies comparing the yield of CE and EGD in patients diagnosed or suspected as having esophageal varices was conducted by both computer search and manual search. Data were extracted to estimate the pooled diagnostic sensitivity and specificity.

RESULTS: There were seven studies appropriate for meta-analysis in our study, involving 446 patients. The pooled sensitivity and specificity of CE for detecting esophageal varices were 85.8% and 80.5%, respectively. In subgroup analysis, the pooled sensitivity and specificity were 82.7% and 54.8% in screened patients, and 87.3% and 84.7% in the screened/patients under surveillance, respectively.

CONCLUSION: CE appears to have acceptable sensitivity and specificity in detecting esophageal varices. However, data are insufficient to determine the accurate diagnostic value of CE in the screen/surveillance of patients alone.

Esophageal varices: noninvasive diagnosis with duplex Doppler US in patients with compensated cirrhosis

PURPOSE

To prospectively develop and evaluate the accuracy of a duplex Doppler ultrasonographic (US) index for predicting the presence or absence of esophageal varices in patients with compensated cirrhosis (Child-Pugh class A) by using endoscopy as the reference standard.

MATERIALS AND METHODS

The study had institutional review board approval; all participants gave informed consent. Data in a total of 383 prospectively enrolled patients who underwent duplex Doppler US and screening endoscopy were divided into training (n = 240) and validation (n = 143) sets. Duplex Doppler US indexes, including mean portal vein velocity (PVV), hepatic impedance indexes, splenic impedance indexes, and the splenic index were evaluated with univariate and multivariate logistic regression analyses to find the independent factors predictive of the presence of esophageal varices. Receiver operating characteristic (ROC) curves were constructed for these factors to evaluate diagnostic accuracy in the training set and reproducibility in the validation set.

RESULTS

Multivariate logistic regression analysis showed that splenic index and mean PVV were predictive of the presence of esophageal varices in the training set. A splenoportal index (SPI) was calculated as the splenic index divided by mean PVV to amplify the opposite effects on esophageal varices. Areas under ROC curves for SPI were significantly higher than those for the splenic index (0.93 vs 0.90, P = .02) and mean PVV (0.93 vs 0.67, P < .001) in the training set and in the validation set (0.96 vs 0.91 for splenic index, P = .01; 0.93 vs 0.80 for mean PVV, P < .001). An SPI threshold of 3.0 had 92% sensitivity, 93% specificity, 91% positive predictive value, and 94% negative predictive value for esophageal varices. Applying this cutoff value correctly predicted the presence or absence of esophageal varices in 92% of the patients without screening endoscopy.

CONCLUSION

SPI can serve as a useful noninvasive index to predict the presence or absence of esophageal varices.

Nitric oxide levels in chronic liver disease patients with and without oesophageal varices

Introduction Patients with chronic liver disease ultimately progress to develop cirrhosis and portal hypertension. Recently it seems well established that nitric oxide disturbances play a key role in the pathogenesis of chronic liver disease and portal hypertension. The aim of this work was to clarify the correlation between chronic liver disease stages, liver function status, esophageal varices presence and nitric oxide disturbances. Subjects and methods All subjects (n = 120) in the present study were classified into; group I which included 15 age and sex matched healthy volunteers (taken as control), group II which included 20 patients with chronic active hepatitis, and group III which included 85 patients with hepatic cirrhosis. All subjects included were subjected to full clinical assessment, routine laboratory investigations, serum nitrate level determination using colorimetric method, abdominal ultrasonography and upper endoscopy. Results Increased serum nitrate level could not be detected in patients with chronic active hepatitis as well as those with early cirrhosis (Child’s class A). Progressive and significant increase of serum nitrate levels were detected in more advanced stages of cirrhosis (Child’s class B & C). The best non-invasive predictor for the presence of oesophageal varices was a combination of platelet count <150.000/mm³, splenomegaly >18 cm, Child’s class B or C and serum nitrate ≥38 μmol/l, with 93.3% sensitivity and 100% specificity. Conclusion Serum nitrate level can be used as a non-invasive predictor for progression of chronic liver disease as well as for the presence of oesophageal varices.

Liver cirrhosis

Cirrhosis is defined as the histological development of regenerative nodules surrounded by fibrous bands in response to chronic liver injury, which leads to portal hypertension and end-stage liver disease. Recent advances in the understanding of the natural history and pathophysiology of cirrhosis, and in treatment of its complications, have resulted in improved management, quality of life, and life expectancy of patients. Liver transplantation remains the only curative option for a selected group of patients, but pharmacological treatments that can halt progression to decompensated cirrhosis or even reverse cirrhosis are currently being developed. This Seminar focuses on the diagnosis, complications, and management of cirrhosis, and new clinical and scientific developments.

Liver cirrhosis

Cirrhosis is defined as the histological development of regenerative nodules surrounded by fibrous bands in response to chronic liver injury, which leads to portal hypertension and end-stage liver disease. Recent advances in the understanding of the natural history and pathophysiology of cirrhosis, and in treatment of its complications, have resulted in improved management, quality of life, and life expectancy of patients. Liver transplantation remains the only curative option for a selected group of patients, but pharmacological treatments that can halt progression to decompensated cirrhosis or even reverse cirrhosis are currently being developed. This Seminar focuses on the diagnosis, complications, and management of cirrhosis, and new clinical and scientific developments.

Contrast-enhanced ultrasound to evaluate the severity of chronic hepatitis C

BACKGROUND

Non-invasive techniques are being developed to assess the severity of liver disease. Haemodynamic changes in the hepatic circulation during the development of liver disease can be evaluated with contrast-enhanced ultrasound.

AIM

To evaluate the possible correlation between ultrasound contrast-agent transit times and different stages of chronic hepatitis C.

PATIENTS

Sixteen patients with clinically evident hepatitis C virus-related cirrhosis, 22 non-cirrhotic patients with chronic hepatitis C and 14 controls with no clinical evidence of liver disease were studied.

METHODS

Contrast-enhanced hepatic ultrasonography was performed with a sulphur hexafluoride-filled microbubble contrast agent, and time curves of hepatic vein signal intensity were analysed to determine the time of enhancement onset (hepatic vein arrival time) and peak enhancement (hepatic vein peak enhancement).

RESULTS

Hepatic vein arrival time in cirrhotic patients was significantly shorter (p<0.001) than in non-cirrhotic patients and controls. Within the group with chronic hepatitis C, METAVIR scores of fibrosis and necro-inflammatory changes had no significant effect on hepatic vein arrival times.

CONCLUSION

Analysis of the time of onset of ultrasound contrast enhancement of the hepatic vein appears to be a simple, non-invasive method for reliably excluding cirrhosis with signs of portal hypertension, but not for assessing the severity of either chronic hepatitis C or cirrhosis.

Noncirrhotic portal fibrosis/idiopathic portal hypertension: APASL recommendations for diagnosis and treatment

The Asian Pacific Association for the Study of the Liver (APASL) Working Party on Portal Hypertension has developed consensus guidelines on the disease profile, diagnosis, and management of noncirrhotic portal fibrosis and idiopathic portal hypertension. The consensus statements, prepared and deliberated at length by the experts in this field, were presented at the annual meeting of the APASL at Kyoto in March 2007. This article includes the statements approved by the APASL along with brief backgrounds of various aspects of the disease.

Splenectomy with endoscopic variceal ligation is superior to splenectomy with pericardial devascularization in treatment of portal hypertension

AIM: To investigate the therapeutic efficacy and complications of splenectomy with endoscopic variceal ligation (EVL) and splenectomy with pericardial devascularization (i.e. Hassab’s operation) in patients with portal hypertension.

METHODS: A total of 103 patients with liver cirrhosis and portal hypertension were randomly selected to receive either splenectomy with EVL (n = 53, group A) or Hassab’s operation (n = 50, group B).

RESULTS: The portal blood flow volume, the presence of portal vein thrombosis, gastric emptying time and free portal venous pressure (FPP) before and after the operation were determined. Patients were followed up for up to 64 mo with an average of 45 mo, and the Dagradi classification of variceal veins and the grading of portal hypertension gastropathy (PHG) were evaluated. It was found that all esophageal varices were occluded or decreased to grade II or less in both groups. There was little difference in the recurrence rate of esophageal varices (11.9% vs 13.2%) and the re-bleeding rate (7.1% vs 5.3%) between groups A and B. The incidence of complications and the percentage of patients with severe PHG after the operation were significantly higher in group B (60.0% and 52.0%) than in group A (32.1% and 20.8%, P < 0.05). No patients died of operation-related complications. There was no significant difference in gastric emptying time, FPP and portal blood flow volume between the two groups.

CONCLUSION: The results suggest that splenectomy with EVL achieves similar therapeutic efficacy to that of Hassab’s operation in terms of the recurrence rate of esophageal varices and the re-bleeding rate, but the former results in fewer and milder complications.

Natural history of a randomized trial comparing distal spleno-renal shunt with endoscopic sclerotherapy in the prevention of variceal rebleeding: A lesson from the past

AIM: To compare endoscopic sclerotherapy (ES) with distal splenorenal shunt (DSRS) in the prevention of recurrent variceal bleeding in cirrhotic patients during a long-term follow-up period.

METHODS: In 1984 we started a prospective, controlled study of patients with liver cirrhosis. Long-term follow-up presents a natural history of liver cirrhosis complicated by advanced portal hypertension. In this study the effects of 2 types of treatment, DSRS or ES, were evaluated. The study population included 80 patients with cirrhosis and portal hypertension referred to our department from October 1984 to March 1991. These patients were drawn from a pool of 282 patients who underwent either elective surgery or ES during the same period of time. Patients were assigned to one of the 2 groups according to a random number table: 40 to DSRS and 40 to ES using polidocanol.

RESULTS: During the postoperative period, no DSRS patient died, while one ES patient died of uncontrolled hemorrhage. One DSRS patient had mild recurrent variceal hemorrhage despite an angiographically patent DSRS and another patient suffered duodenal ulcer rebleeding. Eight ES patients suffered at least one episode of gastrointestinal bleeding: 4 from varices and 4 from esophageal ulcerations. Eight ES patients developed transitory dysphagia. Long-term follow-up was completed in all patients except for 5 cases (2 DSRS and 3 ES patients). Five-year survival rates for shunt (73%) and ES (56%) groups were statistically different: in this follow-up period and in subsequent follow-ups this difference decreased and ceased to be of statistical relevance. The primary cause of death became hepatocellular carcinoma (HCC). Four DSRS patients rebled due to duodenal ulcer, while eleven ES patients had recurrent bleeding from esophago-gastric sources (seven from varices, three from hypertensive gastropathy, one from esophageal ulcerations) and two from unknown sources. Nine DSRS and 2 ES patients developed a chronic encephalopathy; 13 DSRS and 5 ES patients suffered at least one episode of acute encephalopathy. Five ES patients had esophageal stenoses, which were successfully dilated.

CONCLUSION: In a subgroup of patients with good liver function, DSRS with a correct portal-azygos disconnection more effectively prevents variceal rebleeding than ES. However, this positive effect did not influence the long-term survival because other factors (e.g. HCC) were more important in deciding the fate of the cirrhotic patients with portal hypertension.

Application of the platelet count/spleen diameter ratio to rule out the presence of oesophageal varices in patients with cirrhosis: a validation study based on follow-up

BACKGROUND

Screening for oesophageal varices represents an important part of the diagnostic work-up of cirrhotic patients. We have previously shown that the platelet count/spleen diameter ratio is a parameter that can rule out the presence of oesophageal varices safely and in a cost-effective fashion.

AIM

To evaluate the prognostic and diagnostic accuracy of the platelet count/spleen diameter ratio for ruling out the presence of oesophageal varices in the follow-up of a cohort of cirrhotic patients without oesophageal varices at inclusion.

METHODS

After initial endoscopy, the 106 cirrhotic patients without oesophageal varices who participated in our previous study were followed-up with annual or biannual surveillance endoscopy. Patients were censored at the time of diagnosis of oesophageal varices or at their last visit, and at that time platelet count and spleen diameter were recorded. Sixty-eight patients made up the study cohort after excluding patients who were lost to follow-up or died before undergoing control endoscopy.

RESULTS

During the follow-up, 27 patients (40%) developed oesophageal varices. Patients with higher baseline platelet count/spleen diameter ratios (p<0.0001) as well as a ratio above 909 were less likely to develop oesophageal varices (p<0.0005). At follow-up, a platelet count/spleen diameter ratio < or = 909 had 100% negative predictive value and 84% efficiency in identifying the presence of oesophageal varices.

CONCLUSIONS

The use of the platelet count/spleen diameter ratio proved to be an effective means for ruling out the presence of oesophageal varices even in the longitudinal follow-up of patients.