Diagnostic Accuracy of APRI, AAR, FIB-4, FI, King, Lok, Forns, and FibroIndex Scores in Predicting the Presence of Esophageal Varices in Liver Cirrhosis: A Systematic Review and Meta-Analysis

Establishment and validation of a nomogram for predicting esophagogastric variceal bleeding in patients with liver cirrhosis

BACKGROUND

Patients with decompensated liver cirrhosis suffering from esophagogastric variceal bleeding (EGVB) face high mortality.

AIM

To investigate the risk factors for EGVB in patients with liver cirrhosis and establish a diagnostic nomogram.

METHODS

Patients with liver cirrhosis who met the inclusion criteria were randomly divided into training and validation cohorts in a 6:4 ratio in this retrospective research. Univariate analysis, least absolute shrinkage and selection operator regression, and multivariate analysis were employed to establish the nomogram model. Calibration curve, the area under the receiver operating characteristic curve (AUC), and decision curve analysis (DCA) were applied to assess the discrimination, accuracy, and clinical practicability of the nomogram, respectively.

RESULTS

A total of 1115 patients were enrolled in this study. The nomogram was established based on white blood cells (P < 0.001), hemoglobin (P < 0.001), fibrinogen (P < 0.001), total bilirubin (P = 0.007), activated partial thromboplastin time (P = 0.002), total bile acid (P = 0.012), and ascites (P = 0.006). The calibration curve indicated that the actual observation results were in good agreement with the prediction results of the model. The AUC values of the diagnostic model were 0.861 and 0.859 in the training and validation cohorts, respectively, which were higher than that of the aspartate aminotransferase-to-platelet ratio index, fibrosis index based on 4 factors, and aspartate aminotransferase-to-alanine aminotransferase ratio. Additionally, DCA indicated that the net benefit value of the model was higher than that of the other models.

CONCLUSION

This research constructed and validated a nomogram with perfect performance for predicting EGVB events in patients with liver cirrhosis, which could help clinicians with timely diagnosis, individualized treatment, and follow-up.

Association between Helicobacter pylori infection, MASLD, and liver fibrosis in patients with severe obesity: a single-center experience

BACKGROUND AND METHODS

Our study sought to evaluate if an association exists between Helicobacter pylori (H. pylori), metabolic dysfunction- associated steatotic liver disease (MASLD), and liver fibrosis in patients with severe obesity (BMI > 35). Our retrospective study included 584 patients over the age of 18 years with severe obesity, who underwent preoperative liver transient elastography (VCTE), upper endoscopy, blood work, and intra-operative liver biopsy concurrent with bariatric surgery at a single institution from July 2020 to September 2021. Liver fibrosis scores including FIB-4, APRI, NAFLD fibrosis score, BARD score, AST: ALT ratio, and NAFLD activity score (NAS) were calculated from the laboratory results and liver biopsy findings. The presence or absence of H. pylori was determined based on gastric biopsies obtained during upper endoscopy. Other variables collected included age, gender, mean preoperative weight, BMI, and the presence or absence of comorbidities. Student's t-test and non-parametric testing were used for the analysis of continuous variables and Chi-square analysis was used for categorical data.

RESULTS

Of the 584 patients, 14.7% were H. pylori positive and 85.3% were negative. Liver fibrosis scores including FIB-4, APRI, and NAFLD fibrosis scores were significantly higher in the positive group (p < 0.05), but there was no difference in AST: ALT ratio and BARD score. A significantly higher VCTE steatosis and fibrosis scores were noted in the H. pylori-positive group (p < 0.05). Similarly, a significantly higher NAS (NAFLD activity score) on liver biopsies was noted in the positive group, with all the individual components of NAS (steatosis, lobular inflammation, and hepatocyte ballooning) being significantly higher in the positive group (p < 0.05). A significantly higher incidence of fibrosis on liver biopsies was noted in the positive group overall and across all stages of fibrosis (p < 0.05). There were no significant differences between the groups in relation to gender, mean weight, BMI, presence of comorbidities including Diabetes Mellitus, and laboratory values.

CONCLUSION

Our study demonstrates that H. pylori colonization or infection is associated with a higher risk of development of MASLD and progression to fibrosis. Further, population-based studies are needed to corroborate our findings.

[Not Available]

INTRODUCTION

Esophageal variceal bleeding (EVB) is one of the main causes of mortality and morbidity in cirrhotic patients. Non-invasive tests (NIT) of liver fibrosis have been developed to predict the presence of esophageal varices (EV).

AIM

To evaluate the performance of NIT of liver fibrosis such as liver transient elastography (TE) and serum scores in predicting EV.

METHODS

We conducted a retrospective collecting patients with chronic liver disease. TE and serum scores were evaluated for all patients and correlated with endoscopic data.

RESULTS

One hundred and fifty patients were included with an average age of 58.98 years and a sex ratio of 0.68. Sixty-seven patients were cirrhotic. Viral origin C was found in 72% of cases. Thirty-three patients had EV. NIT of liver fibrosis such as TE and serum scores were statistically correlated to the presence of EV. TE had the better performance for the prediction of EV with a Cut-off of 13.5 Kpa and AUC of 0.855. In multivariate analysis, TE, AST to ALT ratio and platelet count were independent predictors of EV.

CONCLUSION

The performance of TE and serum scores in the diagnosis of EV and LEV was demonstrated. These results suggest that NIT of liver fibrosis make it possible to select patients who are candidates for gastroscopy.

Utility of a score-based approach to liver assessment in heart transplant candidates

Background

While abnormalities of liver function and imaging are common in patients with end-stage heart failure, advanced fibrosis is uncommon. Liver biopsy (LB) is used to identify advanced fibrosis in heart transplant (HT) candidates but can delay or limit access to definitive therapies and cause complications. We sought to develop and determine the utility of a clinical risk score for advanced fibrosis in HT candidates.

Methods

We conducted a retrospective, single-center review of patients evaluated for HT between 2012 and 2019 (n = 1,651) and identified those who underwent LB (n = 137) as well as a matched control cohort (n = 160). Patients with congenital heart disease were excluded. All biopsies were reviewed by a liver pathologist. Univariate logistic modeling was used to identify factors predictive of advanced liver fibrosis. Simulation using synthetic data bootstraps was performed to determine the utility of using a score-based approach to trigger LB. Kaplan-Meier curves were used to assess survival.

Results

We identified 32 (23%) patients with stage 0, 79 (58%) with stage 1 to 2, and 26 (19%) with stage 3 to 4/advanced fibrosis. The factor most associated with pursuit of LB was abnormal liver parenchyma on ultrasound. We found that a score combining severe tricuspid regurgitation, alcohol use, and low-density lipoprotein improved specificity and reduced the number of LBs required. We found no difference in survival at 3 years post-HT based on pre-HT fibrosis stage.

Conclusions

A score composed of noninvasive factors may help reduce the number of patients who require LB for diagnosis of advanced fibrosis. Additional multicenter studies are needed to validate this score.

Non-invasive Fibrosis Markers for Predicting Esophageal Varices: A Potential Alternative to Endoscopic Screening

BACKGROUND

Chronic liver infections and diseases lead to chronic liver injury, which results in fibrosis. Due to this continuous scarring and regeneration, cirrhosis occurs, which is also responsible for several adverse sequelae, including but not limited to esophageal varices. Cirrhosis has resulted in patients' increased morbidity and mortality, especially in low socioeconomic settings such as Pakistan. Endoscopy is the gold standard for measuring the presence or absence of esophageal varices, along with their grade. Currently, some non-invasive markers (aspartate aminotransferase-to-alanine aminotransferase ratio (AAR), fibrosis 4 (FIB-4), AAR to platelet ratio index (AARPRI), aspartate aminotransferase-to-platelet ratio index (APRI), S-index, King's score) are being established that make use of laboratory tests, such as a complete blood profile, liver function profile, and coagulation profile, to estimate the extent of hepatic fibrosis.

OBJECTIVES

The objective of this study is to establish a correlation between non-invasive markers of fibrosis and the presence of esophageal varices and to assess their potential as a substitute for gastrointestinal endoscopy screening. Additionally, the study aims to compare these six scores, thereby generating data on their individual and relative accuracy.

METHODOLOGY

This was a cross-sectional study conducted at the Shalamar Institute of Health Sciences, Lahore, Pakistan. Outpatient (OPD) data were obtained from the Shalamar online portal system from June 2022 to December 2022. Laboratory tests, abdominal ultrasounds, and endoscopy results were accessed and recorded in the questionnaire. The patient's medical records and contact numbers were also noted in case further questions arose. Data were then compiled into a Microsoft Excel spreadsheet (Microsoft Corp., Redmond, WA) and analyzed after computing the non-invasive procedure formulas. It was analyzed using IBM SPSS Statistics for Windows, version 20.0 (IBM Corp., Armonk, NY). P-values were calculated, and conclusions were drawn.

RESULTS

Of the sample size of 100 patients with liver damage and injury, 60% were male and 40% were female. Among males, 15% had a milder (grade 1) degree of esophageal varices, and 45% had a moderate to advanced degree (grades 2-3) of esophageal varices. Among females, 19% had mild (grade 1) varices, while 21% had severe (grade 3) varices. The most common cause of varices in patients who had developed fibrosis and/or cirrhosis was hepatitis C, with a wide margin of other causes. The p-values obtained showed that from the selected list of non-invasive markers of fibrosis, only FIB-4 and AARPRI were statistically significant with p-values of 0.036 and 0.022, respectively.

PRACTICAL IMPLICATIONS

Though endoscopy is currently the gold-standard procedure for detecting the presence or absence and grade of esophageal varices, it is invasive, which makes the patients extremely uncomfortable and apprehensive. It can also lead to post-procedure infection, internal hemorrhages, and trauma due to instrument use. Due to its invasive nature, some patients also tend to refuse this procedure. Non-invasive fibrosis markers can help make a diagnosis without undergoing an endoscopy, which in turn will improve patient compliance and satisfaction.

CONCLUSION

It was observed that FIB-4 and AARPRI can be used together as reliable markers to assess the presence or absence of esophageal varices.

Correlation of Liver Elastography as a Predictor of Esophageal Varices and Its Comparison With Ultrasound Abdomen and Liver Function Tests in Patients With Chronic Liver Disease

INTRODUCTION

Variceal haemorrhage is a life-threatening complication that occurs in up to 40% of patients with chronic liver disease including cirrhosis. It is associated with a mortality rate of 20% with each episode of variceal bleeding. Esophagogastroduodenoscopy is the gold standard for the detection of esophageal varices but is an invasive procedure and not very cost-effective. Our study was designed to correlate the presence of esophageal varices on endoscopy with the liver stiffness measurement using liver elastography in patients with chronic liver disease. We also compared various non-invasive predictors like laboratory parameters and ultrasound features and correlated them with the presence of varices in patients with chronic liver disease.

METHODOLOGY

This prospective observational study was conducted in a tertiary-care hospital in South India from November 2017 to April 2019. All patients with chronic liver disease were subjected to endoscopy, and the presence of esophageal varices and their grading was noted. The predictive efficacy of ultrasound elastography using Toshiba Aplio 500 ultrasound two-dimensional shear wave elastography (2D-SWE) in predicting esophageal varices was calculated and compared with the efficacy of predicting esophageal varices by other non-invasive parameters like laboratory investigations, abdominal ultrasound, and liver scores like Child-Turcotte-Pugh (CTP) score, model for end-stage liver disease (MELD) score, fibrosis 4 (FIB-4) score, aspartate aminotransferase-to-platelet ratio index (APRI) score, and aspartate aminotransferase/alanine aminotransferase ratio (AAR).

RESULTS

The study included a total of 168 patients out of which 57% (96 patients) had no varices. About 52 patients (72.2%) had F1/Grade I varices, 9 (12.5%) had F2/Grade II varices, and 11 (15.3%) had F3/Grade III varices. The greatest predictive value for esophageal varices was liver stiffness with a diagnostic accuracy of 81.7%. Ultrasound features like coarse echotexture of the liver (66.7%), splenomegaly (67%), dilated portal vein (78.6%), and presence of moderate ascites (66.7%) had a significant statistical association with the presence of esophageal varices. Laboratory parameters like thrombocytopenia of less than 1.5 lakhs/cu.mm (52.8%), albumin <3 g/dL (60.4%), and reversal of albumin/globulin ratio (52.4%) were significant predictors of esophageal varices. The odds ratio for significant scores in predicting oesophageal varices using binary logistic regression was significant in patients whose liver elastography grade was more than F4, CTP score was B, MELD score was >11, and FIB-4 scores was >3.25 and between 1.46 and 3.25.

CONCLUSION

Liver elastography is a non-invasive procedure that can be a useful tool in predicting esophageal varices in chronic liver disease. Other non-invasive predictors like ultrasound abdomen and laboratory parameters can also be considered a replacement for repeated invasive endoscopy, thus facilitating early intervention and avoiding unfavourable outcomes in patients with chronic liver disease.

Automated Multimodal Machine Learning for Esophageal Variceal Bleeding Prediction Based on Endoscopy and Structured Data

Esophageal variceal (EV) bleeding is a severe medical emergency related to cirrhosis. Early identification of cirrhotic patients with at a high risk of EV bleeding is key to improving outcomes and optimizing medical resources. This study aimed to evaluate the feasibility of automated multimodal machine learning (MMML) for predicting EV bleeding by integrating endoscopic images and clinical structured data. This study mainly includes three steps: step 1, developing deep learning (DL) models using EV images by 12-month bleeding on TensorFlow (backbones include ResNet, Xception, EfficientNet, ViT and ConvMixer); step 2, training and internally validating MMML models integrating clinical structured data and DL model outputs to predict 12-month EV bleeding on an H2O-automated machine learning platform (algorithms include DL, XGBoost, GLM, GBM, RF, and stacking); and step 3, externally testing MMML models. Furthermore, existing clinical indices, e.g., the MELD score, Child‒Pugh score, APRI, and FIB-4, were also examined. Five DL models were transfer learning to the binary classification of EV endoscopic images at admission based on the occurrence or absence of bleeding events during the 12-month follow-up. An EfficientNet model achieved the highest accuracy of 0.868 in the validation set. Then, a series of MMML models, integrating clinical structured data and the output of the EfficientNet model, were automatedly trained to predict 12-month EV bleeding. A stacking model showed the highest accuracy (0.932), sensitivity (0.952), and F1-score (0.879) in the test dataset, which was also better than the existing indices. This study is the first to evaluate the feasibility of automated MMML in predicting 12-month EV bleeding based on endoscopic images and clinical variables.

Liver and spleen stiffness for the diagnosis of oesophageal varices in adults with chronic liver disease

This is a protocol for a Cochrane Review (diagnostic). The objectives are as follows:

To assess the diagnostic accuracy of liver stiffness and spleen stiffness, separately or in combination, as measured by vibration‐controlled transient elastography (VCTE) in detection of any oesophageal varices in adults with chronic liver disease. We will regard a combination of tests as positive when at least one is positive.

To compare the diagnostic accuracy of individual tests (liver stiffness and spleen stiffness measured by VCTE) directly and versus the combination of both tests (considering positive when at least one is positive) in detecting any oesophageal varices.

To assess the diagnostic accuracy of liver stiffness and spleen stiffness, separately or in combination, as measured by other elastography techniques (2D‐shear wave elastography (2D‐SWE), point shear wave elastography (pSWE), magnetic resonance elastography (MRE)) in detection of any oesophageal varices in adults with chronic liver disease. We will regard a combination of tests as positive when at least one is positive.

To compare the diagnostic accuracy of liver stiffness and spleen stiffness measured by VCTE with other techniques (pSWE, 2D‐SWE, MRE) in detection of any oesophageal varices in adults with chronic liver disease.

Fontan Hepatopathy - Managing Unknowns

BACKGROUND AND AIMS

How to best monitor Fontan associated liver disease (FALD) remains unclear. We describe results from a prospective liver care pathway in adults (n=84) with a Fontan circulation.

METHODS

Routine assessment of the liver, by acoustic radiation force frequency and ultrasound was undertaken. Results, including liver biochemistry, systemic ventricular function (echocardiography), functional class, medication use and clinical endpoints (varices, hepatocellular carcinoma, heart transplantation and death) were collated.

RESULTS

Most individuals returned a cirrhotic range acoustic radiation force impulse imaging (ARFI) result. ARFI values were greater in the proportion of individuals with hepatic nodularity (p=0.024). Univariate analysis demonstrated moderate correlation with platelet number (Spearmans rho= -0.376, p=0.049). Patients with clinical endpoints had lower platelets (p=0.012) but only a trend to hepatic nodularity (p=0.057). Clinical endpoints were more common in those with ventricular dysfunction (p=0.011). Multivariate analysis revealed that age at Fontan and being on angiotensin converting enzyme inhibitors (ACEI) predicted ARFI score (β=0.06 (95% CI 0.01-0.09), p=0.007 and β=0.53 (95% CI 0.17-0.89), p=0.005, respectively). However, these associations were not significant once adjusted for Fontan type, age at ARFI, systemic ventricle morphology, ventricle function, or Model for End-stage Liver Disease (MELD-XI) excluding international normalised ratio (INR) (p>0.05 for all).

CONCLUSIONS

Ideal FALD monitoring remains unclear. ARFI has utility as a binary non-invasive indicator of cirrhosis, highlighting individuals who may need more frequent ongoing monitoring for hepatocellular carcinoma. However, no definite advantage to serial ARFI, once cirrhotic range ARFI results are present, has been identified.

Novel potential biomarkers for severe alcoholic liver disease

Background

Alcoholic liver disease (ALD) is a leading cause of advanced liver disease; however, minor clinical symptoms in the early stage frequently result in delayed diagnosis and therapy. Invasive liver biopsy, the gold standard for diagnosing ALD, is unsuitable for repetitive analysis. This study aims to identify potential serum biomarkers that could contribute to non-invasive disease screening and monitoring.

Methods

Label-free LC-MS/MS quantitative proteomics analysis was performed to identify differentially expressed proteins in the discovery cohort, followed by bioinformatics analysis based on the KEGG, GO, and String databases. Prioritized proteins were validated subsequently by quantitative assays. The area under the receiver operating characteristic curve (AUROC) was used to assess the diagnosis performance of potential biomarkers.

Results

A total of 161 differentially expressed proteins were identified in the discovery cohort, of which 123 were up-regulated and 38 were down-regulated. B2M, IGFALS, and IGFBP3 were evaluated, and all demonstrated excellent diagnosis performance with AUROCs of over 0.9 when distinguishing patients with severe ALD from healthy controls. The AUROC values of B2M, IGFBP3, and IGFALS were 0.7131, 0.8877, and 0.9896 for differentiating severe ALD from non-severe ALD to indicate disease severity. B2M could distinguish patients with non-severe ALD and HC participants with an AUROC value of 0.8985. The efficiency of multiple combinations of these biomarkers was superior to that of the existing liver fibrosis evaluation indices used to monitor disease progression, with AUROC values of over 0.9. IGFALS showed a positive correlation with ALT/AST (r=0.4648, P=0.0009) and may be developed as a therapeutic target.

Conclusion

This proteomic study identified three novel candidate proteins as promising circulating biomarkers for clinical diagnosis and disease progression and also provided the proteomic atlas for ALD pathophysiological mechanisms.

Noninvasive predictors of clinically significant portal hypertension in NASH cirrhosis: Validation of ANTICIPATE models and development of a lab-based model

Clinically significant portal hypertension (CSPH), defined as hepatic venous pressure gradient (HVPG) ≥ 10 mm Hg, identifies patients with compensated cirrhosis at a high risk of decompensation. However, HVPG is an invasive and nuanced method. The ANTICIPATE models, which include liver stiffness measurements by transient elastography (TE) and platelet count ± body mass index, are robust noninvasive surrogates of CSPH but required external validation in patients with nonalcoholic steatohepatitis (NASH) cirrhosis. Additionally, TE is not widely available worldwide. The aims of the study were: (1) to externally validate the ANTICIPATE models using baseline data from patients with compensated NASH cirrhosis screened/enrolled in a multicenter international randomized controlled trial; and (2) to develop and externally validate a model using only laboratory values. Regarding aim 1, both ANTICIPATE models showed good calibration and discrimination (area under the curve [AUC] > 0.8) in our cohort (n = 222). Regarding aim 2, a new lab-based model using the Fibrosis-4 index (FIB-4 [age, aspartate aminotransferase, alanine aminotransferase, platelet count]) plus serum albumin was developed. The discrimination in the training cohort (n = 309) was good (AUC of 0.78 [95% confidence interval [CI]:0.72-0.83]). It was then externally validated in a separate cohort of 245 patients with compensated NASH cirrhosis (AUC of 0.8 [95% CI: 0.75-0.86]). Given the difference in the prevalence of CSPH between training (74%) and validation (39%) cohorts, the model required an update of the baseline risk to achieve a good calibration. The updated model was named FIB4+. In conclusion, both ANTICIPATE models performed well in predicting the presence of CSPH in NASH cirrhosis. A model using FIB-4 plus albumin (FIB4+) can be used to predict CSPH where TE is not available.

Noninvasive diagnostic value of indocyanine green retention test in patients with esophagogastric varices in liver cirrhosis

OBJECTIVE

This study aimed to evaluate the value of the indocyanine green retention test (ICG-R15) as a noninvasive predictor of gastroesophageal varices (GOV) in cirrhosis.

METHODS

A total of 629 patients with cirrhosis who were admitted to Mengchao Hepatobiliary Hospital of Fujian Medical University between June 2016 and September 2020 (450 in the trial group and 179 in the validation group) were selected. The trial group was divided into a GOV group and a non-GOV group based on gastroscopic findings. The two group's ICG results, clinical hematological, biochemical, and ultrasound parameters were compared. A predictive model for the noninvasive diagnosis of GOV was developed by applying binary logistic regression analysis and compared with previous common noninvasive diagnostic methods, followed by model validation in a validation group.

RESULTS

ICG-R15 is positively correlated with the degree of varicose veins. Univariate and multifactorial logistic regression analyses showed that PLT, PT, ICG-R15, splenic length, splenic vein diameter, and the presence of ascites were independent predictors of GOV. Predictive equation 1 for GOV was constructed based on the above factors: Logistic (Y1) = 1.327 × PLT + 0.691 × PT + 1.110 × ICG-R15 + 0.581 × SVD + 0.815 × SD + 1.130 × presence of ascites - 2.133, which predicted GOV in cirrhosis with an AUC of 0.861, sensitivity 84.5%, and specificity 74.1%. As the internal diameter of the splenic vein and the long diameter of the spleen are influenced by subjective factors and data are not easily available, we removed these two factors and constructed the prediction equation logistic (Y2) = 1.516 × PLT + 0.856 × PT + 1.135 × R15 + 1.297 × presence of ascites - 1.513. AUC for predicting GOV was also high at 0.850, with a sensitivity of 75.3% and a specificity of 83.2%. Similar results were obtained in the validation group. However, the previous GOV prediction models ARPI, AAR, FIB-4, Lok, FI, and King had AUCs of 0.731, 0.643, 0.781, 0.763, 0.735, and 0.730, respectively, in our trial group, with only low-to-moderate diagnostic efficacy.

CONCLUSION

ICG-R15 correlates with the severity of GOV in cirrhosis, and the models based on it can further improve the noninvasive diagnostic efficacy of GOV.

Non-invasive diagnosis and follow-up of portal hypertension

Compensated advanced chronic liver disease (cACLD) describes the spectrum of advanced fibrosis/cirrhosis in asymptomatic patients at risk of developing clinically significant portal hypertension (CSPH, defined by a hepatic venous pressure gradient (HVPG) ≥10 mmHg). Patients with cACLD are at high risk of liver-related morbidity and mortality. In patients at risk of chronic liver disease, cACLD is strongly suggested by a liver stiffness (LSM) value >15 kPa or clinical/biological/radiological signs of portal hypertension, and ruled out by LSM <10 kPa, or Fibrotest® ≤0.58, or Fibrometer® ≤0.786. Patients with chronic liver disease (excluding vascular diseases) with a LSM <10 kPa are at low risk of developing portal hypertension complications. The presence of CSPH can be strongly suspected when LSM is ≥20 kPa. In a patient without clinical, endoscopic or radiological features of portal hypertension, measurement of the HVPG is recommended before major liver or intra-abdominal surgery, before extra-hepatic transplantation and in patients with unexplained ascites. Endoscopic screening for oesophageal varices can be avoided in patients with LSM <20 kPa and a platelet count >150 G/L (favourable Baveno VI criteria) at the time of diagnosis. There is no non-invasive method alternative for oeso-gastroduodenal endoscopy in patients with unfavourable Baveno criteria (liver stiffness ≥20 kPa or platelet count ≤50 G/l). Platelet count and liver stiffness measurements must be performed once a year in patients with cACLD with favourable Baveno VI criteria at the time of diagnosis. A screening oeso-gastroduodenal endoscopy is recommended if Baveno VI criteria become unfavourable.

Indications and methods for measuring portal hypertension in cirrhosis

Background and objectives: Over the last decade our understanding of the pathophysiology of portal hypertension has increased. Novel diagnostic technologies have facilitated and improved the diagnosis and treatment of hepatic fibrosis and cirrhosis. With this review we aim to provide an overview of contemporary diagnostic principles of portal hypertension and indications for measuring portal pressure in cirrhosis.Methods: By review of current literature, we assessed new and old principles of measuring portal hypertension and the diagnostic values of the methods.Results: Invasive measurement of the portal pressure is still the gold standard to quantitate portal hypertension and to assess response to vasoactive treatment. The size of the portal pressure is important to assess since it contains information on the course of the disease and risk of developing hepatic decompensation, hepatocellular carcinoma, and mortality. Reliable non-invasive Elastography techniques are emerging that adequately assess portal pressure, but the available methods are not yet sufficiently accurate.Conclusion: Although elastography techniques provide valuable information and are good monitoring tools, liver vein catheterization remains valuable in diagnosing and monitoring portal hypertension, especially in combination with a trans-jugular liver biopsy.

How effective are APRI, FIB-4, FIB-5 scores in predicting liver fibrosis in chronic hepatitis B patients?

Liver fibrosis is the most important factor in the prognosis and treatment plan of patients with chronic hepatitis B (CHB). Aspartate aminotransferase (AST)-to-platelet ratio index (APRI), fibrosis index based on 4 factors (FIB-4), and fibrosis index based on 5 factors (FIB-5) scores are noninvasive fibrosis markers, and previous comparative studies have shown that they are as effective as liver biopsy in detecting liver fibrosis in different liver diseases. The aim of our study is to investigate whether existing scoring systems are effective in demonstrating fibrosis in CHB patients and to compare the APRI, FIB 4, and FIB 5 scores in differentiating early and advanced fibrosis in 123 patients who underwent liver biopsy for CHB infection. APRI, FIB-4, and FIB-5 scores of patients who underwent liver biopsy due to CHB were calculated by means of calculators and recorded to be compared with liver biopsies in terms of fibrosis scoring. One hundred twenty-three patients who underwent liver biopsy due to chronic hepatitis B were included in the study. APRI (area under the receiver-operating characteristic [ROC] curve 0.728), FIB-4 (area under the ROC curve 0.693) and FIB-5 (area under the ROC curve 0.643) scores were evaluated as significant predictors of advanced fibrosis. The scoring system with the highest positive and negative predictive value was evaluated as FIB-4. APRI, FIB-4, and FIB-5 scoring systems are appropriate scoring systems in the assessment of advanced fibrosis in patients with CHB. Our study is the first to compare APRI, FIB-4, and FIB-5 values in CHB patients, and more comprehensive studies are needed.

Biomarkers in Liver Disease

Symptoms and signs of liver diseases are highly variable depending on the etiology, disease stage, and type of liver involvement. There are different types of liver diseases; causes of liver diseases may be viral, toxic, metabolic, or autoimmune. However, in some cases, liver disease can develop as a result of diseases of other organs or systems. It is almost impossible to differentiate all of these solely on the basis of clinical symptoms and findings. Furthermore, the early stages of liver disease may be completely asymptomatic, or in some cases, the disease may progress with only subtle and non-specific symptoms. Therefore, biomarkers have a critical role in screening, diagnosis, staging, and evaluation of therapeutic response to treatment in liver diseases.

Management of Portal Hypertension

Portal hypertension is the cause of the clinical complications associated with cirrhosis. The primary complications of portal hypertension are ascites, acute variceal bleed, and hepatic encephalopathy. Hepatic venous pressure gradient measurement remains the gold standard test for diagnosing cirrhosis-related portal hypertension. Hepatic venous pressure gradient more than 10 mmHg is associated with an increased risk of complications and is termed clinically significant portal hypertension (CSPH). Clinical, laboratory, and imaging methods can also aid in diagnosing CSPH non-invasively. Recently, deep learning methods have been demonstrated to diagnose CSPH effectively. The management of portal hypertension is always individualized and is dependent on the etiology, the availability of therapies, and the degree of portal hypertension complications. In this review, we discuss the diagnosis and management of cirrhosis-related portal hypertension in detail. Also, we highlight the history of portal hypertension and future research areas in portal hypertension.

Use of biochemical parameters for non-invasive screening of oesophageal varices in comparison to elastography-based approach in patients with compensated advanced chronic liver disease

Introduction

Oesophageal varices are routinely diagnosed by esophagogastroduodenoscopy (EGD), and their bleeding has high mortality. We aimed to evaluate diagnostic performance of biochemical tests in comparison to elastography-based approaches, as non-invasive alternatives to EGD, for ruling-out high risk oesophageal varices (HRV).

Material and methods

Retrospective analysis of patients (N = 861) who underwent liver stiffness measurement (LSM) by transient elastography (TE) in a single centre over 5-year period, with available results of EGD (within 3 months from LSM). Only patients with suspicion of compensated advanced chronic liver disease (cACLD) defined by LSM ≥ 10 kPa were included comprising the final cohort of 73 subjects. Original and expanded Baveno VI criteria (B6C), controlled attenuation parameter (CAP), platelet count (PLT), aspartate aminotransferase to PLT ratio index (APRI), Fibrosis-4 index (FIB4), model for end stage liver disease (MELD) score were evaluated against the results of EGD that served as the reference method.

Results

Analysed patients had median age 62 years, 59/73 (0.81) were males, 54/73 (0.74) had alcoholic/non-alcoholic fatty liver disease, and 21/73 (0.29) had HRV. In multivariate logistic regression analysis only LSM and PLT were independently associated with HRV. The best performing tests for ruling-out HRV (% of spared EGD; % of missed HRV) were respectively: LSM < 20 kPa (53.4%; 0%), B6C (38%; 0%), Expanded B6C (47.9%; 4.8%); PLT > 214x10⁹/L (21.9%; 0%); FIB4 ≤ 1.8 (21.4%; 0%), APRI ≤ 0.34 (12.3%; 0%). CAP, MELD = 6 alone or combined with PLT > 150(x10⁹/L) did not show acceptable performance.

Conclusion

The best performing biochemical tests for ruling-out HRV in our cohort of patients were PLT and FIB-4, but they were still outperformed by elastography-based approaches.

Modification of the ALBI-PLT Score for the Prediction of High-risk Varices

BACKGROUND/AIM

A new scoring system [albumin-bilirubin-platelet (ALBI-PLT) score] was reported for identifying cirrhotic patients without high-risk varices (HRV), and patients with ALBI grade 1 (≤-2.60) and a platelet count over 150×109/l were shown to have a low risk of having HRV. The present study modified the cut-off values of the variables in the ALBI-PLT score.

PATIENTS AND METHODS

Among a total of 338 patients with chronic liver diseases, possible cut-off values of the ALBI score and the platelet count were determined by analyzing the first-half group (training cohort: N=169) with the receiver operating characteristic (ROC) method. The utility of the determined values was evaluated in the second-half group (validation cohort: N=169) and total cohort (N=338). In addition, the utility of the modified cut-off values was evaluated in patients with compensated cirrhosis (cirrhotic cohort: N=87).

RESULTS

Possible cut-off values of the ALBI score and platelet count were found to be -2.36 and 114×109/l, respectively. In the training cohort, these cut-off values provided a higher ratio of avoiding esophagogastroduodenoscopy than the original ALBI-PLT score (53.3% vs. 25.4%, p<0.01). Consistent results were observed in the validation cohort (28.4% vs. 15.4%, p<0.01), total cohort (40.8% vs. 20.4%, p<0.01), and cirrhotic cohort (32.2% vs. 11.5%, p<0.01). However, the missing ratio of patients with the HRV was not significantly increased in any cohort studied.

CONCLUSION

Modification of the ALBI-PLT score may be useful for predicting patients without HRV.

[Evaluation of the Validity of ROI Setting in CEI Used for the Assessment of Liver]

PURPOSE

The enhancement effect ratio using ethoxybenzyl (EOB) contrast is useful in the assessment of liver fibrosis. Since the enhancement effect ratio is calculated by setting a region of interest (ROI) in the liver, the ROI setting method may affect the enhancement effect ratio. One of the methods of setting the ROI in liver fibrosis evaluation is by placing the ROI in each Quinault segment, but this method requires considerable time. Therefore, it is necessary to consider a reproducible ROI setting method in contrast to the method of placing ROIs in each Quinault segment.

METHOD

In contrast to the method of placing one ROI in each Quinault segment, we examined the method of setting four ROIs (two in the right lobe and two in the left lobe) and two ROIs (one in the right lobe and one in the left lobe). The size of the ROI was set to 1 cm², 4 cm², and the maximum area that fits within each placement area.

CONCLUSION

In the ROI setting method for CEI calculation, reproducibility can be maintained by setting the number of ROIs in four locations and by setting ROIs of 4 cm² or more.

Derivation of "Egyptian varices prediction (EVP) index": A novel noninvasive index for diagnosing esophageal varices in HCV Patients

•

Esophageal Varices is one complication of chronic liver disease that leads to deaths globally due to hemorrhage.

•

The prediction of presence the Esophageal Varices is essential to avoid bleeding for patients.

•

Now the only diagnostic method for Esophageal Varices by the upper gastrointestinal endoscopy but it has many disadvantages.

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Only ten variables are the most significant for diagnosing the varices: PLT, Stiffness, PC, liver texture, spleen, HCV-RNA, Albumin, gender, Total bilirubin, and PV diameter.

•

We Evaluated the effectiveness of several noninvasive markers for predicting Varices.

•

We Introduced a novel (EVP) index with acceptable performance for diagnosing Varices and compared with the exist, it could save operating the upper endoscopic by nearly 46.5%.

Introduction

Esophageal Varices (EVs) is one of the major dangerous complications of liver fibrosis. Upper Gastrointestinal (UGI) Endoscopy is necessary for its diagnosis. Repeated examinations for EVs screening severely burden endoscopic units in terms of cost and other side implications; moreover, the lack of public health resources in rural areas and primary hospitals should be considered, particularly in developing countries. So, an accurate noninvasive marker for EV is highly needed for liver disease patients.

Objectives

This study sought to evaluate the values of several indices to determine how adequate are they in predicting EV and build a novel accurate prediction index.

Methods

Five thousand and thirteen patients were enrolled. The laboratory tests, abdominal ultrasonography, liver stiffness measurement using Fibro-scan, and UGI endoscopy were performed. Ten common indices: Fib-4 score, AST-to-platelet ratio index, Fibrosis index, AST/ALT ratio Varices Prediction Rule, Baveno VI, APRI-Fib4 Combo, King score, “Model for End-Stage Liver Disease”, and Lok Score were calculated. The significant predictors for EVs were identified by using “P-value Correlation-based Filter Selection” method, where a novel Egyptian Varices Prediction (EVP) index was developed using binary logistic regression. The diagnostic performance was evaluated by some parameters and the Area Under Curve (AUC).

Results

EVP Index was correlated to EVs at 0.5; it achieved higher performance (AUC 0.788, accuracy 73.3%, and sensitivity 78%) than the other indices at a cutoff point of 0.423.

Conclusion

EVP Index was a good noninvasive predictor. It had an acceptable performance for diagnosing EVs and it was only required regular laboratory tests and imaging data. It can provide a tool for classifying or arranging the patients according to the degree pre-emptive for selective endoscopy and the degree of severity. Also, it will enable clinicians to concentrate on one marker instead of a wide set of parameters.

Value of Liver Function Tests in Cirrhosis

The liver comprises both parenchymal and non-parenchymal cells with varying functions. Cirrhosis is often complicated by the development of portal hypertension and its associated complications. Hence, assessment of liver in cirrhosis should include assessment of its structural, function of both hepatic and non-hepatic tissue and haemodynamic assessment of portal hypertension. There is no single test that can evaluate all functions of liver and assess prevalence and severity of portal hypertension. Commonly available tests like serum bilirubin, liver enzymes (alanine [ALT] and aspartate aminotransferase [AST], serum alkaline phosphatase [ALP], gamma glutamyl transpeptidase [GGT]), serum albumin and prothrombin time for assessment of liver functions partly assess liver functions. quantitative liver functions like indocyanine clearance tests [ICG-K], methacetin breath test [MBT] were developed to assess dynamic status of liver but has its own limitation and availability. Imaging based assessment of liver by transient elastography, MRI based 99 mTc-coupled asialoglycoprotein mebrofenin scan help the clinician to assess liver function, functional volume of liver left after surgery and portal hypertension [PH]. Hepatic venous pressure gradient still remains the gold standard for the assessment of portal hypertension but is invasive and not available in all centres. Combinations of blood parameters in form of various indices like fibrosis score of 4 [FIB-4], Lok index, scores like model for end stage liver disease (MELD) and Child-Turcotte Pugh score are commonly used for assessing liver function in clinical practice.

Assessment of Non-invasive Markers for the Prediction of Esophageal Variceal Hemorrhage

Background: Esophageal variceal (EV) hemorrhage is a life-threatening consequence of portal hypertension in cirrhotic patients. Screening upper endoscopy and endoscopic variceal ligation to identify and treat EVs have contraindications, complications, and high costs. We sought to identify non-invasive tests (NITs) as alternatives to endoscopic EV screening. Methods: In this case-control study, we retrospectively analyzed 286 cirrhotic patients treated for EVs at the Second People's Hospital of Fuyang City, China from January to December 2019. We applied ROC curve analysis to assess the accuracy of various NITs in predicting EV hemorrhage. Results: There were significant differences between the hemorrhage and non-hemorrhage groups in median serum albumin (ALB) (p < 0.001), median bilirubin (TBIL) (p < 0.046), prothrombin (PT) time (p < 0.001), Golgi protein 73 (GP73; p = 0.012) and Child-Pugh (C-P) scores (p < 0.001). For ALB (cutoff <33.2g/L), PT time (cutoff > 14.2 seconds), GP73 (cutoff > 126.4 ng/ml), and C-P scores, the areas under the ROC curves (AUCs) were 73.4% (95% CI: 67.5-79.2), 68.6% (95% CI: 62.4-74.8), 62.2% (95% CI: 52.8-71.5) and 69.8% (95%CI: 63.8-75.8), respectively, with corresponding sensitives of 71.5, 59.8, 69.8, and 92.2% and specificities of 65.6%, 70.1%, 56.5%, and 38.6%. When ALB was combined with GP73, the AUC was 74.3% (95% CI: 66.1-82.5) with a sensitivity of 65.1% and specificity of 76.5%. When ALB, PT, and C-P scores were combined, the AUC was 76.5% (95% CI: 70.9-82.1) with a sensitivity of 79.5% and specificity of 64.3%. When ALB, PT, GP73, and C-P scores were combined, the AUC was 75.2% (95% CI: 67.3-83.1) with a sensitivity of 54.0% and specificity of 86.9%. Conclusion: ALB, TBIL, GP73, and C-P scores, may be used to predict EV hemorrhage in cirrhotic patients. The combination of multiple NITs is better than a single index and can increase diagnostic performance.

Protective Effects of Statin Therapy in Cirrhosis Are Limited by a Common SLCO1B1 Transporter Variant

Complications of cirrhosis and portal hypertension (PH) can be reduced by statin therapy. The common loss-of-function variant p.V174A in the solute carrier organic anion transporter gene 1B1 (SLCO1B1) gene encoding the organic anion transporting polypeptide 1B1 results in decreased hepatic uptake of statins. Our specific aim was to assess the impact of this variant in patients with cirrhosis and statin treatment while controlling for the stage of cirrhosis and other potential confounders with propensity score matching (PSM), availing of a large cohort of genotyped study patients. In total, from 1,088 patients with cirrhosis in two German academic medical centers, PSM yielded 154 patients taking statins and 154 matched controls. The effect on PH was assessed by the liver stiffness-spleen size-to-platelet score (LSPS), and complications of cirrhosis were retrospectively recorded applying consensus criteria. As hypothesized, patients on statin treatment presented less frequently with signs of PH: Esophageal varices (41% vs. 62%; P < 0.001) were less common, and LSPS (4.8 ± 11.5 vs. 5.6 ± 6.4; P = 0.01) was reduced. Correspondingly, decompensation events were also reduced in patients on statins (odds ratio [OR] = 0.54, 95% confidence interval [CI] 0.32-0.90; P = 0.02). When the variant in SLCO1B1 was present in patients on statins, esophageal varices (OR = 2.68, 95% CI 1.24-5.81; P = 0.01) and bacterial infections (OR = 2.50, 95% CI 1.14-5.47; P = 0.02) were more common as compared with wild type carriers on statins. Conclusion: In this cohort, signs and complications of PH were reduced in patients with cirrhosis treated with statins. Notably, this effect was diminished by the common loss-of-function variant in SLCO1B1. Further prospective studies in independent cohorts are warranted to confirm these genotype-specific observations.

A vein-viewing application enabled detecting abdominal wall varices related to the presence of non-treated gastroesophageal varices: a cross-sectional study

BACKGROUND

Gastroesophageal varices (GOV) are a life-threatening complication in chronic liver disease. A method for non-invasively predicting GOV is crucial for management. This study aimed to determine whether a vein-viewing application can detect abdominal wall varices (AWV) and elucidate the relationship between AWV and GOV.

METHODS

One-hundred patients with chronic liver diseases were prospectively enrolled. All the patients underwent esophagogastroduodenoscopy within three months of the enrollment. Unmanipulated images (UI) and vein-weighted images (VWI) were taken for assessing AWV by a vein-viewing application on iPhone. Two doctors independently evaluated both image types. We defined the grading of both UI and AWV as grade 0 (non-detectable), grade 1 (slightly detectable), and grade 2 (distinct).

RESULTS

The causes of liver diseases among the 71 men and 29 women (median age, 70.5 yr) included Hepatitis B (n = 19), Hepatitis C (n = 21), alcoholism (n = 33), primary biliary cholangitis (n = 3), autoimmune hepatitis (n = 4) and others (n = 20). GOV was indicated in 60 patients, and half of them had not been treated previously (non-treated). VWI could significantly visualize AWV than UI (72% vs. 24%, p = 0.0005). The presence of cirrhosis (chronic hepatitis vs. cirrhosis = 64.6% vs. 91.4%, p = 0.004) and GOV (52.3% vs. 74.3%, p = 0.032) were significantly higher in the VWI-AWV grade 2 group. Multivariate analysis demonstrated that VWI-AWV grade 2 was an independent factor related to the presence of non-treated GOV [OR = 3.05 (1.24-7.53), p = 0.016].

CONCLUSIONS

The vein-viewing application non-invasively detected AWV related to the presence of cirrhosis and GOV, and VWI-AWV grade 2 was an independent factor related to the presence of non-treated GOV.

Métodos diagnósticos en hipertensión portal

La hipertensión portal es un síndrome caracterizado por el incremento en el gradiente de presión portal, definido por la diferencia entre la presión de la porta y la vena cava inferior. Esta presión depende del flujo venoso y la resistencia vascular. En los pacientes cirróticos estas dos variables están alteradas de manera suprafisiológica, inicialmente por la lesión estructural dependiente de fibrosis y los nódulos de regeneración y posteriormente por cambios dinámicos vasculares que causan vasoconstricción intrahepática y vasodilatación esplácnica, lo cual explica las manifestaciones sistémicas de la cirrosis. La importancia de la hipertensión portal radica en la frecuencia y severidad de las complicaciones asociadas, especialmente la hemorragia variceal y otras como ascitis, peritonitis bacteriana espontanea, síndrome hepatorrenal y encefalopatía hepática. El objetivo de este artículo es realizar una revisión actualizada sobre el uso de las pruebas diagnósticas invasivas y no invasivas disponibles para el estudio de la hipertensión portal y su aplicación en la práctica clínica.

Development and validation of a radiomics signature as a non-invasive complementary predictor of gastroesophageal varices and high-risk varices in compensated advanced chronic liver disease: A multicenter study

BACKGROUND AND AIM

Gastroesophageal varices (GEV) present in compensated advanced chronic liver disease (cACLD) and can develop into high-risk varices (HRV). The gold standard for diagnosing GEV is esophagogastroduodenoscopy (EGD). However, EGD is invasive and less tolerant. This study aimed to develop and validate radiomics signatures based on noncontrast-enhanced computed tomography (CT) images for non-invasive diagnosis of GEV and HRV in patients with cACLD.

METHODS

The multicenter trial enrolled 161 patients with cACLD from six university hospitals in China between January 2015 and September 2019, who underwent both EGD and noncontrast-enhanced CT examination within 14 days prior to the endoscopy. Two radiomics signatures, termed rGEV and rHRV, respectively, were built based on CT images in a training cohort of 129 patients and validated in a prospective validation cohort of 32 patients (ClinicalTrials. gov identifier: NCT03749954).

RESULTS

In the training cohort, both rGEV and rHRV exhibited high discriminative abilities on determining the existence of GEV and HRV with the area under receiver operating characteristic curve (AUC) of 0.941 (95% confidence interval [CI] 0.904-0.978) and 0.836 (95% CI 0.766-0.905), respectively. In validation cohort, rGEV and rHRV showed high discriminative abilities with AUCs of 0.871 (95% CI 0.739-1.000) and 0.831 (95% CI 0.685-0.978), respectively.

CONCLUSIONS

This study demonstrated that rGEV and rHRV could serve as the satisfying auxiliary parameters for detection of GEV and HRV with good diagnostic performance.

Non-invasive laboratory, imaging and elastography markers in predicting varices with high risk of bleeding in cirrhotic patients

Introduction. Upper digestive tract endoscopy remains the gold-standard for detecting esophageal or gastric varices and assessment of bleeding risk, but this method is invasive. The aim of the study was to identify non-invasive factors that could be incorporated into an algorithm for estimating the risk of variceal bleeding.Methods. A prospective study was performed on 130 cirrhotic patients. Tests were performed on all patients which included liver enzymes, complete blood count and coagulation parameters, abdominal ultrasound, elastography of both the liver and the spleen. Upper gastrointestinal endoscopy was performed in all patients included in the study and the results were classified, in accordance with Baveno VI into 2 outcome groups: Group 1 - patients with low bleeding risk and Group 2 - patients with varices needing treatment.Results. The study lot (130 patients) was divided into: Group I (low bleeding risk - 102 patients), and Group II (high bleeding risk - 28 patients). Parameters found to have significant differences in univariate analysis were transaminases, platelet count, spleen size, INR, portal vein diameter and both liver and spleen elastography. Calculating AUROC for each parameter identifies spleen elastography as having the best result, followed by INR, AST and platelet count. Liver elastography had the worst AUROC. Independent variables identified by logistic regression included spleen elastography, INR, platelet count, spleen diameter, ALT, age, and gender.Conclusions. Spleen stiffness is the best single parameter predicting the presence of high-risk esophageal varices.

Evaluation of Non-invasive Fibrosis Markers in Predicting Esophageal Variceal Bleeding

BACKGROUND/AIMS

Esophageal variceal bleeding (EVB) is an important cause of mortality and morbidity in liver cirrhosis. In this study, we aimed to predict the possibility of EVB in patients with cirrhosis using a non-invasive score.

METHODS

A total of 359 patients with cirrhosis were divided into two groups based on the presence or absence of EVB. ChildTurcotte-Pugh (CTP) score, a model for end-stage liver disease, aspartate aminotransferase to alanine aminotransferase ratio, aspartate aminotransferase to platelet ratio index (APRI), fibrosis-4-index (FIB-4), aspartate aminotransferase to alanine aminotransferase ratio/platelet ratio index (AARPRI), and S-index were measured for all participants. Receiver operating characteristic curves were obtained for all parameters, and the optimal cut-off value was determined in predicting EVB.

RESULTS

In patients with EVB, the number of platelets (PLT) were low (p<0.001) and APRI, AARPRI, FIB-4, and S-index were significantly higher than those in patients without EBV. APRI, AARPRI, FIB-4, PLT, and S-index were statistically significant predictors of EVB (p<0.05).

CONCLUSION

FIB-4 and AARPRI, which are non-invasive markers of fibrosis, can be used to predict EVB. In addition, the 66.5 109/L cut-off value for PLT is important for EVB.

Diagnostic accuracy of the attenuation value in abdominal contrast enhanced dynamic multi-detector-row computed tomography for esophageal varices in patients with liver cirrhosis

Purpose

To investigate whether the attenuation value obtained by subtracting the CT value obtained from abdominal dynamic contrast enhanced (ADCE)-MDCT imaging of the equilibrium phase from the value obtained from that of the portal phase in hepatic parenchyma is useful in distinguishing normal liver from liver cirrhosis (LC) and to predict the development of esophageal varices (EVs) in patients with LC.

Materials and methods

We assigned 72 outpatients to group A (n = 45; normal liver) and group B (n = 27; LC), who underwent ADCE-MDCT. The attenuation value and CT value of the hepatic parenchymal portal and equilibrium phase were compared, and the correlation between attenuation value and biomarkers (ALB, T-bil, PLT, FIB-4, APRI, and AAR) was investigated. Furthermore, we investigated differences in the attenuation value, FIB-4, APRI, and AAR between the two subgroups of group B [without EVs (group a) and with EVs (group b)]. We performed receiver operating characteristic (ROC) analysis of the attenuation value, FIB-4, APRI, and, AAR for subgroup a vs b and evaluated the diagnostic accuracy.

Results

Significant differences were observed between groups A and B in all items. The attenuation value correlated with ALB, T-bil, PLT, FIB-4, and APRI. Only attenuation value showed a significant difference between groups a and b. The best cut-off attenuation value, FIB-4, APRI, and AAR for predicting EVs, according to ROC analysis was 13.4 HU, 6.8, 1.9, and 1.5.

Conclusions

Attenuation value can be useful to quantitatively classify normal liver and LC and to predict EVs in patients with LC.

Noninvasive Detection of Clinically Significant Portal Hypertension in Compensated Advanced Chronic Liver Disease

Patients with compensated advanced chronic liver disease have different prognoses depending on the presence of portal hypertension. Current non-invasive diagnostic methods allow identification of clinically significant portal hypertension. Portosystemic collaterals on imaging or liver stiffness of more than 20 to 25 kPa by using transient elastography identifies patients with clinically significant portal hypertension. Patients with liver stiffness of less than 20 kPa and platelet count of greater than 150 g/L can avoid endoscopy. This rule could be expanded using spleen stiffness. Methods to risk stratify for portal hypertension in compensated advanced chronic liver disease and successfully treated chronic hepatitis C and B are subject of research.

Mac-2 Binding Protein Glycosylation Isomer for Screening High-Risk Esophageal Varices in Liver Cirrhotic Patient

Background: Esophageal varices occur at middle to advanced stages of cirrhosis and are associated with increased mortality due to their potential for rupture and bleeding. The aim of this study is to examine the accuracy of a surrogate marker, Mac-2 binding protein glycosylation isomer (M2BPGi), for screening high-risk esophageal varices in cirrhotic patients. Methods: Ninety-four cirrhotic patients who underwent endoscopy screening at Cipto Mangunkusumo Hospital, Jakarta, Indonesia were included. Patients with a history of ligation, portal vein thrombosis, or hepatocellular carcinoma were excluded. All enrolled patients underwent ultrasonography, transient elastography, and laboratory tests. The HISCL-5000 Sysmex analyzer was used to measure M2BPGi levels. Results: Of these 94 patients, 27 had high-risk esophageal varices and 67 had non-high-risk esophageal varices. M2BPGi levels were higher in patients with high-risk esophageal varices compared with those with non-high-risk esophageal varices (cutoff index (COI) of 11.4 vs. 3.7, p < 0.001). The sensitivity, specificity, positive predictive value, and negative predictive value of M2BPGi with a cutoff value of 5 COI was 92.6%, 70.1%, 55.6%, and 95.9%, respectively. Conclusions: M2BPGi could be used as a non-invasive surrogate marker for ruling out high-risk esophageal varices in cirrhotic patients. This method is cheap and non-invasive and could be used as a screening tool in resource-limited settings.

Clinical and novel application of FibroScan, FIB-4 and aspartate aminotransferase-to-platelet ratio index in liver fibrosis evaluation in patients with hepatocellular carcinoma and their roles in oesophageal variceal prediction

BACKGROUND

Non-invasive techniques for liver fibrosis diagnosis are very important for clinician especially in high-risk patients for liver biopsy. We further explored the diagnostic accuracy of FibroScan, FIB-4 and aminotransferase-to-platelet ratio index (APRI) in identifying liver fibrosis and assess their predictive role for oesophageal varices in patients with hepatocellular carcinoma (HCC).

METHODS

In total, 380 patients who underwent surgery for HCC were included based on retrospective study design. Liver fibrosis was pathologically diagnosed using the Ishak scoring system. Liver stiffness parameters were measured using FibroScan. APRI and FIB-4 were calculated. Among those, 121 patients who received oesophagogastroduodenoscopic examination underwent variceal evaluation.

RESULTS

For liver cirrhosis diagnosis with FibroScan, the optimal cut-off values for the patients with HCC overall, left HCC and right HCC were 8.85, 11.75 and 8.70 kPa (the accuracy were 78.7%, 78.4% and 79.2%, respectively). They had high areas under the receiver operating characteristic curve of 0.84, 0.84 and 0.85. The combined FibroScan, APRI and FIB-4 had very high specificity (more than 92%) for cirrhosis diagnosis. The optimal cut-off liver stiffness values for the diagnosis of varices were all 11.2 kPa. For predicting varices, the optimal cut-off values of FIB-4 and APRI were 2.64 and 0.71, their accuracy were 64.3%-78.4%, 69.4% and 72.7%, respectively.

CONCLUSIONS

FibroScan, FIB-4 and APRI have moderate accuracy for liver fibrosis diagnosis and oesophageal varices prediction in patients with hepatoma. This is a study of these non-invasive techniques applied in specific hepatoma patients and with inevitable limitations and need future more studies for validation.

Approaches to the Diagnosis of Portal Hypertension: Non-Invasive or Invasive Tests?

Portal hypertension is the main driver of complications in patients with advanced chronic liver disease (ACLD) and is defined by values of hepatic venous pressure gradient measurement (HVPG) >5 mmHg. Values of HVPG ≥10 mmHg determine the presence of clinically significant portal hypertension (CSPH), the main predictor of the risk of variceal bleeding, hepatic decompensation, and mortality. However, its measurement is invasive and requires high expertise, so its routine use outside third level centers or clinical trials is limited. In the last decades, several non-invasive tests (NITs) have been developed and validated for the diagnosis of portal hypertension. Among these, liver (LSM) and spleen stiffness measurement (SSM) are the most promising tools available, as they have been proven accurate to predict CSPH, high-risk esophageal varices, decompensation, and mortality in patients with ACLD. In the last Baveno VI Consensus proceedings, LSM evaluation was recommended for the first time for diagnosis of CSPH (LSM >20-25 kPa) and the screening of patients with a low probability of having high-risk varices (LSM <20 kPa and platelet count >150.000/mm³). In this review, we aimed to summarize the growing evidence supporting the use of non-invasive tests for the evaluation of portal hypertension in patients with chronic liver disease.

Optimal diagnostic tool for surveillance of oesophageal varices during COVID-19 pandemic

AIM

To study the diagnostic accuracy and utility of triphasic abdominal computed tomography (CT) in the diagnosis and grading of oesophageal varices (OVs) as an alternative to endoscopy during the COVID-19 pandemic.

MATERIALS AND METHODS

A prospective analysis was undertaken of retrospective data from cirrhotic patients who underwent oesophago-gastro-duodenoscopy (OGD) and a triphasic abdominal CT from January to December 2019. Endoscopists and radiologists provided their respective independent assessment of OV grading after being blinded to the clinical details. Performance of CT grading of OVs was compared with the reference standard endoscopic grading using weighted kappa (k). Non-invasive scores such, as aspartate transaminase (AST)-to-platelet ratio index (APRI), Fibrosis-4 (FIB-4) Index, platelet: spleen (PS) ratio were correlated between the two techniques.

RESULTS

OV grading between endoscopists and radiologists showed 81.73% agreement (85 out of 104 patients) in the comparative analysis of 104 cirrhotic patients, of which no varices (57.1%, n=4), small (85.1%, n=23), medium (72.2%%, n=26), and large varices (94.1%, n=32) with a weighted k score of 0.88 (95% confidence interval 0.82-0.94). Overall, the sensitivity of CT in the diagnosis of no, small, medium, and large OVs was 66.6%, 79.3%, 89.6%, and 94.1%, respectively, with an area under the receiver operating curve (AUROC) score of 0.775, 0.887, 0.839, and 0.914. Performance of APRI, FIB-4, and PS ratio correlated well with the severity of OVs with no difference between OGD and CT grading.

CONCLUSION

Triphasic abdominal CT can be an invaluable tool in the diagnosis and grading of OVs during the COVID-19 pandemic.

Plateletcrit and Mean Platelet Volume in the Evaluation of Alcoholic Liver Cirrhosis and Nonalcoholic Fatty Liver Disease Patients

Platelet (PLT) indices have been proposed as potential markers in the assessment of liver fibrosis and exacerbation of liver failure. The aim of our study was to verify mean platelet volume (MPV), platelet distribution width (PDW), and plateletcrit (PCT) in alcohol-related liver cirrhosis (ALC) and nonalcoholic fatty liver disease (NAFLD) patients. One hundred forty-two patients with ALC, 92 with NAFLD, and 68 in control group were enrolled in this study. Hematological indices (MPV, PCT, and PDW) and serological (indirect and direct) markers of liver fibrosis (AAR, APRI, FIB-4, GPR, PICP, PIIINP, TGF-α, PDGF-AB, laminin) were measured in each participant. MELD score in ALC patients and NAFLD fibrosis score (NFS) together with BARD score in the NAFLD group were also obtained. Results were compared between research and control groups. Then, a correlation between evaluated indices was performed in study groups. Receiver operating characteristic curves (ROCs) and area under the curve (AUC) values were applied to assess the diagnostic accuracy of measured indices. Significant increase in PDW and decrease in PCT in comparison to controls were noted in examined ALC (60.4% vs. 51.2% and 0.1% vs. 0.21%, respectively, p < 0.0001) and NAFLD (54.75% vs. 51.2% and 0.19 vs. 0.21%, respectively, p < 0.01) patients. Decreased level of MPV was observed in NAFLD group (7.85 fl vs. 8.90 fl, p < 0.0001). Additionally, PCT correlated with NFS (p < 0.0001). Evaluated PLT indices correlated with MELD score (MPV and PDW, p < 0.001; PCT, p < 0.05). They correlated with indirect and direct markers of liver fibrosis in the whole research group, too. PCT was the parameter with the greatest diagnostic accuracy in ALC patients (AUC = 0,839 for cutoff < 0.17%); in NAFLD group, it was MPV (AUC = 0,808 for cutoff < 7.9 fl). PCT in ALC and MPV in NAFLD can be perceived as potential diagnostic markers.

Serum ammonia as a non-invasive marker for early prediction of esophageal varices

INTRODUCTION

There is a growing need for identification of non-endoscopic, non-invasive methods that can accurately predict esophageal varices (EV). Previous studies found an inconclusive correlation between blood ammonia level and the presence and size of EV.

AIM

We aimed at assessing the value of serum ammonia as a non-invasive method for early prediction of EV.

PATIENT AND METHODS

The study included 204 patients with HCV-related cirrhosis. The selected patients were categorized into two groups: patients with EV and those without, also patients with no or small EV and with large EV group. All patients underwent a complete biochemical workup, ultrasound and upper GI endoscopy. Child-Pugh class, Model of End-Stage Liver Disease (MELD) score and platelet count/splenic diameter ratio, and serum ammonia level.

RESULTS

There was a statistical difference between the two groups of patients regarding the following parameters: serum ammonia, international normalized ratio, portal vein diameter, spleen diameter, Child-Pugh class, MELD score, platelet count/splenic diameter ratio, aspartate aminotransferase-to-platelet ratio index, alanine aminotransferase-to-aspartate aminotransferase ratio, Forns index, FIB-4 and King's score. Serum ammonia could predict the presence of EV using a cutoff value of 82 (µmol/L) with a sensitivity of 92.3%, specificity 92%. In addition, a cutoff of 95.5 (µmol/L) could predict large EV with a sensitivity of 92.7% and a specificity of 92.3%. Serum Ammonia in cirrhosis with large EV was 143 ± 39 µmol/L and in cirrhosis with small/without EV was 80.7 ± 9.7 µmol/L (P < 0.0001). Platelet/spleen ratio was 555.9 ± 187.3 in cirrhosis with EV and 694.4 ± 74.2 in cirrhosis without EV (P < 0.0001). Platelet/spleen ratio was 407.7 ± 107.1 in cirrhosis with large EV and 690.4 ± 103.7 in cirrhosis with small/without EV (P < 0.0001).

CONCLUSION

Serum ammonia can accurately predict the presence and the size of EV in patients with liver cirrhosis with high sensitivity and specificity.

Noninvasive markers for esophageal varices in children with cirrhosis

BACKGROUND

The diagnosis of esophageal varices (EV) is based on the findings of esophagogastroduodenoscopy (EGD), biopsy, and serum markers. Thus, noninvasive cost-effective tests through which high-risk EV children can be diagnosed are needed.

PURPOSE

This cross-sectional study aimed to identify the noninvasive markers for EV in children with liver cirrhosis.

METHODS

A total of 98 children with liver cirrhosis were evaluated in this study. The spleen size, platelet count, serum albumin, liver function test results, and risk scores were evaluated prior to endoscopy. The endoscopic investigations aimed to identify the presence of EV and red signs, and determine varices sizes.

RESULTS

Endoscopy revealed varices in 43 subjects (43.9%). The spleen size, platelet count, international normalized ratio, aspartate aminotransferase to platelet ratio index (APRI), platelet count to spleen size ratio, and risk score differed significantly between patients with and without EV on univariate analysis; however, the logistic regression analysis showed no differences, indicating that none of these parameters were independently associated with the presence of EV.

CONCLUSION

Platelet count, risk score, platelet count to spleen size, and APRI can be useful tools for the identification of highrisk patients with EV and might reduce the need for invasive methods like EGD.

Detachable string magnetically controlled capsule endoscopy for detecting high-risk varices in compensated advanced chronic liver disease (CHESS1801): A prospective multicenter study

BACKGROUND

Gastroesophageal varices is a serious complication of compensated advanced chronic liver disease (cACLD). Primary prophylaxis to reduce the risk of variceal hemorrhage is recommended if high-risk varices (HRV) are detected. We performed this study to compare the accuracy, patients' satisfaction and safety of detection of HRV by detachable string magnetically controlled capsule endoscopy (DS-MCCE) with esophagogastroduodenoscopy (EGD) as the reference.

METHODS

We prospectively recruited participants with cACLD from 12 university hospitals (11 in China and one in the United Kingdom) between November 2018 and December 2019 (ClinicalTrials.gov, NCT03749954). All participants underwent DS-MCCE, followed by EGD within a week in a blinded fashion. Following endoscopy, and on the same day, participants were asked to fill in a satisfaction questionnaire regarding their experience.

FINDINGS

A total of 105 eligible participants were enrolled. With EGD as the reference standard, the concordance index, sensitivity, specificity, positive predictive value, negative predictive value, positive likelihood ratio, and negative likelihood ratio of DS-MCCE in diagnosis of HRV were 0•90 (95% confidence interval [CI]: 0•83-0•95), 92% (95% CI: 78-98%), 88% (95% CI: 78-95%), 80% (95% CI: 70-92%), 95% (95% CI: 90-100%), 7•91 (95% CI: 4•10-15•30), and 0•09 (95% CI: 0•03-0•30), respectively. The kappa score of 0•78 (95% CI: 0•65-0•90) suggested substantial agreement between DS-MCCE and EGD. Moreover, in participants undergoing EGD without sedation, the satisfaction of DS-MCCE was significantly better than that of EGD (p < 0•0001, d = 1•15 [95%CI: 0•88-1•42]). All participants confirmed the excretion of the capsule, and no adverse events occurred.

INTERPRETATION

DS-MCCE is an accurate alternative to EGD for detecting HRV in cACLD, which is safe and associated with better satisfaction.

FUNDING

A full list of funding can be found in the Funding Support section.

Overall clinical and economic impact of non-alcoholic fatty liver disease

OBJECTIVES

to establish the clinical and economic consequences (resource utilization and healthcare costs) of non-alcoholic fatty liver in the setting of the usual clinical practice in Spain.

PATIENTS AND METHODS

an observational, retrospective study was performed based on a review of the medical records of adult patients ≥ 18 years of age who sought medical care from 2017 to 2018. Patients were categorized into two groups according to fibrosis stage (estimation method: FIB-4): a) F0-F2; and b) F3-F4 (advanced fibrosis). Follow-up lasted one year. Primary endpoints included comorbidity, concomitant medication, resource utilization and costs. Results were analyzed using a multivariate approach with p < 0.05.

RESULTS

a total of 8,151 patients were recruited with a mean age of 61.1 years and 51.5 % were male. By group: a) mild fibrosis n = 7,127, 87.4 %; and b) advanced fibrosis n = 1,024, 12.6 % (6.8 % with liver cirrhosis). The most common comorbidities included 63 % dyslipidemia, 52 % obesity, 52 % hypertension and 35 % diabetes. The average number of drugs used was 2.1 per patient. Patients with advanced fibrosis (F3-F4) had a higher average number of concomitant medications (2.5 vs 2.1; p < 0.001) and a higher AST/ALT ratio (1.1 vs 0.8; p < 0.001). The average cost (patient-year) for subjects with advanced fibrosis, corrected for covariates, was higher (€1,812 vs €1,128, p < 0.001). Age, morbidity, concomitant medication, fibrosis stage and total costs were higher in patients with diabetes.

CONCLUSIONS

patients with advanced fibrosis were associated with more comorbidity and concomitant medications, which resulted in higher healthcare costs for the National Health System.

Accuracy of Fibrosis-4 Index in Identification of Patients with Cirrhosis Who Could Potentially Avoid Variceal Screening Endoscopy

A potential restriction of the Baveno VI consensus, which helps to avoid unnecessary endoscopies, is the limited availability of FibroScan. We aimed to identify serum fibrosis indices that might aid in ruling out the presence of high-risk varices in cirrhotic patients. This retrospective study included 541 consecutive patients with cirrhosis who underwent endoscopy and had data available for nine serum fibrosis indices, including platelet count, hyaluronic acid, 7S fragment of type 4 collagen, procollagen type III N-terminal peptide, tissue inhibitor of metalloproteinases 1, Mac-2 binding protein glycosylation isomer, fibrosis index based on four factors (FIB-4), aspartate transaminase/platelet ratio index and enhanced liver fibrosis score. Optimal index cutoffs for predicting high-risk varices were calculated in an estimation cohort (n = 127) and evaluated in a validation cohort (n = 351). The diagnostic performance of the indices was assessed by receiver operating characteristic curve analysis. In the estimation cohort, a FIB-4 cutoff of 2.78 provided the greatest diagnostic accuracy in predicting both all-grade and high-risk varices. FIB-4 had a negative predictive value of 1.00 for high-risk varices in both cohorts, and 21.3% (27/127) and 14.8% (52/351) of the estimation and validation cohorts, respectively, avoided esophagogastroduodenoscopy; no high-risk varices were missed in either cohort. FIB-4 correctly identifies the absence of high-risk varices in patients with cirrhosis. Therefore, those with a FIB-4 of ≥2.78 should undergo esophagogastroduodenoscopy, and FIB-4 determination should be recommended every 6-12 months concurrently with the other blood tests until the index value reaches 2.78 in those with a FIB-4 of <2.78.

Fibrosis index predicts variceal bleeding and reduces need for nonselective beta-blocker in compensated cirrhosis with initial small esophageal varices without red-color sign

BACKGROUND

Various non-invasive markers predicting hepatic fibrosis are poor predictors of esophageal variceal bleeding (EVB). Elastography performs well but resource-limited. Controversy for small EV prevention also exists. We aim to investigate if a non-invasive marker could predict subsequent EVB within 1 and 2 years in patients with compensated liver cirrhosis (CLC), initial small EV without red-color sign (RCS), without use of non-selective beta-blockers (NSBB) and endoscopic variceal ligation (EVL). This marker would also be tested if it could help reduce use of NSBB, thereby avoiding potential side effects and saving medical costs.

METHODS

In this retrospective cohort study, 6,803 CLC patients fulfilling the inclusion-exclusion criteria were enrolled between 2001 and 2018, and were followed-up for 1 year, 2 years. The primary outcomes were subsequent EVB within 1 and 2 years of enrollment. Another 281 CLC patients with NSBB use were compared for additional outcome analysis.

RESULTS

In total, 539 patients and 710 patients experienced EVB within 1 year and 2 years, respectively. The fibrosis index (FI) with cut-off value of 3.95 showed a negative predictive value (NPV) of 94.3% and an area under receiver operating characteristic (AUROC) of 62.95% for predicting subsequent EVB within 1 year. The EVB and mortality of patients with FI <3.95 and not taking NSBB were significantly lower than those of the other 3 groups. Similar results were demonstrated within 2 years.

CONCLUSIONS

In CLC patients with initial small EV and no RCS, low FI scores showed a high NPV and moderate AUROC in predicting subsequent EVB and mortalities, signifying clinically non-significant portal hypertension. Patients with low FI scores and not taking NSBB had significantly lowest EVB and mortality. The medical cost savings for cutting NSBB in these patients would be estimated at least $3 million per year in the U.S. Further randomized control trial study needed to validate this screening tool.

Validation of albumin, bilirubin, and platelet criteria for avoiding screening endoscopy in patients with advanced fibrosis

AIM

The albumin, bilirubin, and platelet (ABP) criteria was proposed to avoid screening endoscopy for detecting high-risk varices (HRV) and it has high diagnostic accuracy. We carried out a retrospective cross-sectional study to verify the diagnostic accuracy.

METHODS

A total of 610 patients with advanced fibrosis were enrolled in the study. ABP criteria are defined as follows: albumin >4.0 g/dL, bilirubin <22 μmol/L, and platelets >114 000/μL.

RESULTS

Background liver disease were hepatitis C/hepatitis B/non-alcoholic fatty liver disease/others:405 (66.4%)/67 (10.5%)/78 (12.8%)/60 (10.3%). A total of 105 patients (17.2%) had HRV. In multivariate analysis, serum bilirubin <22 μmol/L (HR 2.00, 95% CI 1.2-3.4), albumin >4.0 g/dL (HR 2.56, 95% CI 1.7-3.8), and platelets >114 000/μL (HR 3.52, 95% CI 2.1-5.8) levels were independently associated with no presence of HRV. When the ABP criteria were examined, 200 patients (32.8%) fulfilled the criteria, and 194 patients had no HRV (positive predictive value 97.0%) When classified by etiologies (hepatitis C/hepatitis B/non-alcoholic fatty liver disease), positive predictive value were 97.7/100/92.0%, respectively.

CONCLUSIONS

The ABP criteria are easy to examine, because they use only standard laboratory tests, and they are available for screening patients who might avoid endoscopy regardless of etiologies.

Red cell distribution width-to-lymphocyte ratio: A novel predictor for HBV-related liver cirrhosis

To evaluate the diagnostic power of red cell distribution width-to-lymphocyte ratio (RLR) for HBV-related liver cirrhosis via a retrospective cohort study.Seven hundred fifty healthy controls, 327 chronic hepatitis B (CHB) patients, and 410 patients with HBV-related liver cirrhosis (HBV-LC) were enrolled in this study. RLR, lymphocyte-to-monocyte ratio (LMR), neutrophil-to-lymphocyte ratio (NLR), red cell distribution width (RDW), AST to platelet ratio index (APRI), and fibrosis index based on the 4 factors (FIB-4) were compared between the 3 groups. The predictive powers of RLR and RDW for HBV-related liver cirrhosis and patient prognosis were evaluated using AUROC.Patients with HBV-related liver cirrhosis had higher RLR, FIB-4, NLR, RDW, APRI, and lower LMR compared with the control and CHB groups. RLR in the HBV-LC group was significantly higher than both CHB and control groups (both P < .05). While RLR in the CHB group was also higher than the control group, the difference was not statistically significant (P > .05). The AUROC of RLR for predicting HBV-related liver cirrhosis was 0.87, and was superior to RDW (0.81), FIB-4 (0.79), and APRI (0.60). With an optimized cut-off value (10.87), RLR had the highest sensitivity (0.88) and specificity (0.72), and was superior to RDW (0.86, 0.64), FIB-4 (0.80, 0.65), and APRI (0.85, 0.48) as a biomarker. For all 3 groups, RLR was negatively correlated (all P < .05) with serum platelet (PLT) and was positively correlated (all P < .05) with FIB-4 and APRI. There was no significant statistical difference in RLR for patients in HBV-LC group who had different prognosis (P > .05).The RLR, a routinely available, inexpensive, and easily calculated measure, can be used as a predictor of HBV-related liver cirrhosis, but not as a predictor of prognosis for patients with liver cirrhosis. Use of RLR may reduce the need for frequent liver biopsies in CHB patients.

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 PubMed, 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 I 2 index, and sources of heterogeneity were explored using meta-regression and subgroup analysis. Publication bias was evaluated using Deek's funnel plot. All statistical analyses were conducted using Stata12.0, MetaDisc1.4, and RevMan5.3.

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.

Clinical Implications of Thrombocytopenia for the Cirrhotic Patient

Thrombocytopenia is a frequent complication in patients with cirrhosis. As many as 84% of patients with cirrhosis have thrombocytopenia, and it is an independent variable indicative of advanced disease and poor prognosis. Although there is great concern that it may aggravate bleeding during surgical procedures, there is limited evidence to inform decisions regarding the treatment of cirrhotic patients with thrombocytopenia undergoing invasive procedures. Finally, there is evidence that platelets play a significant role in liver regeneration. In this report, the clinical implications of thrombocytopenia in cirrhotic patients are reviewed. The utility of platelet counts in the prognosis of cirrhosis and relationship to complications of advanced liver disease, including portal hypertension, esophageal varices, and hepatocellular carcinoma. The impact of low platelet counts on bleeding complications during invasive procedures is outlined. Finally, the role of platelets and potential adverse impact in liver regeneration is reviewed.

Use of the Serum Wisteria floribunda Agglutinin-Positive Mac2 Binding Protein as a Marker of Gastroesophageal Varices and Liver-Related Events in Chronic Hepatitis C Patients

BACKGROUND

A test to narrow down patients who require esophagogastroduodenoscopy (EGD) with a high probability of having gastroesophageal varices (GEV) and a high-risk of liver-related events is an unmet need.

METHODS

The measurement of serum fibrosis markers and EGD was performed in 166 consecutive chronic hepatitis C patients. The correlation between the grades of GEV and fibrosis markers and the subsequent occurrence of liver-related and fibrosis markers were examined.

RESULTS

Wisteria floribunda agglutinin-positive human Mac-2 binding protein (WFA⁺-M2BP) levels increased according to the grade of GEV (3.4 (0.2-18.6) for no GEV, 7.9 (1.8-20.0) for small GEV, and 11.4 (4.0-20.0) for large GEV; p < 0.001). The diagnostic accuracy of the WFA⁺-M2BP was superior compared to other serum fibrosis markers, and WFA⁺-M2BP was an independent predictor of GEV in the multivariate analysis. Furthermore, the cumulative incidence of liver-related events at one year was 2.3% in patients with WFA⁺-M2BP levels ≤ 7.0 and 37.5% in patients with WFA⁺-M2BP levels > 7.0 (p < 0.001). WFA⁺-M2BP > 7.0 was a significant predictive factor for liver-related events (Hazard ratio 6.7, p = 0.004) independent of Child-Pughclass.

CONCLUSIONS

WFA⁺-M2BP could be used to estimate the presence and grade of GEV and is linked to liver-related events in chronic hepatitis C patients.