Gastrointestinal Bleeding in Cirrhotic Patients with Portal Hypertension. ISRN Hepatol. 2013;2013:541836. [PMID: 27335828 PMCID: PMC4890899 DOI: 10.1155/2013/541836]

Platelet Count to Prothrombin Time: A Noninvasive Predictor of Esophageal Varices in Patients With Chronic Liver Disease

Introduction Esophageal variceal bleeding is a potentially deadly consequence of portal hypertension in patients with cirrhosis. Although upper gastrointestinal endoscopy is still the preferred method for identifying esophageal varices (EV), the present study measured the platelet count to prothrombin time (PLT/PT) ratio for the assessment of portal hypertension and subsequent diagnosis of EVs in patients with chronic liver disease (CLD). Methods This was an observational comparative study conducted in the outpatient department of Patel Hospital, Karachi, Pakistan, using a non-probability consecutive sampling technique. Ethical approval was obtained from the Patel Hospital ethical review committee (PH/IRB/2022/028). An independent sample t-test was used for parametric data, whereas the Mann-Whitney U test was used for non-parametric data. The chi-square test was used to compare the categorical data of patients with and without EV. Receiver operating characteristic (ROC) analysis was performed to evaluate the cutoff values for the PLT/PT ratio, sensitivity, specificity, and area under the curve (AUC). Results The study involved 105 patients with and without EV. Among them, 38 (63.3%) males and 22 (36.7%) females had EV, whereas 30 (66.7%) males and 15 (33.3%) females did not. The platelet (PLT) count was also significantly lower in patients with EV (87.6 ± 59.8) than in those without (176.6 ± 87.7) (p < 0.001). The PLT/PT ratio was significantly lower in patients with EV (median: 5.04, IQR: 3.12-9.21) compared to those without (median: 14.57, IQR: 8.08-20.58) (p < 0.001). The sensitivity and specificity of the PLT/PT ratio for identifying EVs were 97.80% and 83.30%, respectively. Conclusion We found a significantly lower PLT/PT ratio in cases with EV than those without EV. After defining an optimal cutoff, PLT/PT had a high sensitivity in identifying cases with EVs in CLD. Therefore, we conclude that in patients with CLD, the PLT/PT ratio is a noninvasive predictor for the presence of EV.

Factors associated with serious abdominal conditions in geriatric patients visiting the emergency department

BACKGROUND

Abdominal pain occurs in 20% of geriatric patients who visit the emergency department (ED). Geriatric patients usually have more severe conditions and a higher mortality rate. We aimed to determine the factors associated with serious abdominal conditions in geriatric patients who visit the ED with abdominal pain.

METHODS

This retrospective cohort study was conducted from January 1, 2017 to June 30, 2021. The inclusion criteria were patients aged ≥ 65 years and presented at the ED with acute abdominal pain. Significantly associated factors for serious abdominal conditions were examined using univariate and multivariate logistic regression analyses.

RESULTS

A total of 1221 patients were included in this study. Multivariate logistic regression analysis showed that the significant factors associated with serious abdominal conditions were male (adjusted odds ratio [AOR] 2.29, 95% CI:1.3-4.04; p = 0.004), anorexia (AOR 2.16, 95% CI:1.08-4.32; p = 0.03), NEWS 5-6 (AOR 2.96, 95% CI:1.35-6.49; p = 0.007), SBP 100-125 mmHg (AOR 1.5, 95% CI:0.75-2.99; p ≤ 0.001), guarding (AOR 6.92, 95% CI:3.39-14.12; p ≤ 0.001), WBC ≥ 14,000 cells/mm3 (AOR 2.08, 95% CI:1.06-4.09; p = 0.034), ED length of stay (EDLOS) 4-8 h (AOR 2.17, 95% CI:1.08-4.36; p = 0.03), and EDLOS ≥ 8 h (AOR 3.22, 95% CI:1.15-9; p = 0.025).

CONCLUSIONS

The statistically significant factors associated with serious abdominal conditions in geriatric patients were male, anorexia, NEWS 5-6, SBP 100-125 mmHg, guarding, WBC ≥ 14,000 cells/mm3, EDLOS 4-8 h, and EDLOS ≥ 8 h.

Scoring system for predicting 90-day mortality of in-hospital liver cirrhosis patients at Cipto Mangunkusumo Hospital

BACKGROUND

Liver cirrhosis is the final stage of chronic liver disease. Complications due to progression of liver disease may deteriorate the liver function and worsen prognosis. Previous studies have shown that patients with liver cirrhosis are at increased risk of death within 90-day after hospitalization. It is necessary to identify patients who are at higher risk of early mortality. This study aims to develop a scoring system to predict the 90-day mortality among hospitalized patients with liver cirrhosis that could be used for modification of treatment plan according to the scores that have been obtained. By using this scoring system, crucial care of plans can be taken to reduce the risk of mortality.

METHOD

This prospective cohort study was conducted on hospitalized cirrhotic patients at Cipto Mangunkusumo National General Hospital, Jakarta. Demographic, clinical, and laboratory data were recorded. Patients were monitored for up to 90-day after hospitalization to determine their condition. Cox regression analysis was performed to obtain predictor factors contributing to mortality in liver cirrhosis patients. The scoring system that resulted from this study categorized patients into low, moderate, and high-risk categories based on their predicted mortality rates. The sensitivity and specificity of the scoring system were evaluated using the AUC (area under the curve) metric.

RESULT

The study revealed that liver cirrhosis patients who were hospitalized had a 90-day mortality rate of 42.2%, with contributing factors including Child-Pugh, MELD, and leukocyte levels. The combination of these variables had a good discriminative value with an AUC of 0.921 (95% CI: 0.876-0.967). The scoring system resulted in three risk categories: low risk (score of 0-3) with a 4.1-18.4% probability of death, moderate risk (score of 5-6) with a 40.5-54.2% probability of death, and high risk (score of 8-11) with a 78.1-94.9% probability of death.

CONCLUSION

The scoring system has shown great accuracy in predicting 90-day mortality in hospitalized cirrhosis patients, making it a valuable tool for identifying the necessary care and interventions needed for these patients upon admission.

Influence of non-alcoholic fatty liver disease on non-variceal upper gastrointestinal bleeding: A nationwide analysis

BACKGROUND

Non-alcoholic fatty liver disease (NAFLD) is the leading cause of liver disease globally with an estimated prevalence of 25%, with the clinical and economic burden expected to continue to increase. In the United States, non-variceal upper gastrointestinal bleeding (NVUGIB) has an estimated incidence of 61-78 cases per 100000 people with a mortality rate of 2%-15% based on co-morbidity burden.

AIM

To identify the outcomes of NVUGIB in NAFLD hospitalizations in the United States.

METHODS

We utilized the National Inpatient Sample from 2016-2019 to identify all NVUGIB hospitalizations in the United States. This population was divided based on the presence and absence of NAFLD. Hospitalization characteristics, outcomes and complications were compared.

RESULTS

The total number of hospitalizations for NVUGIB was 799785, of which 6% were found to have NAFLD. NAFLD and GIB was, on average, more common in younger patients, females, and Hispanics than GIB without NAFLD. Interestingly, GIB was less common amongst blacks with NAFLD. Multivariate logistic regression analysis was conducted, controlling for the multiple covariates. The primary outcome of interest, mortality, was found to be significantly higher in patients with NAFLD and GIB [adjusted odds ratio (aOR) = 1.018 (1.013-1.022)]. Secondary outcomes of interest, shock [aOR = 1.015 (1.008-1.022)], acute respiratory failure [aOR = 1.01 (1.005-1.015)] and acute liver failure [aOR = 1.016 (1.013-1.019)] were all more likely to occur in this cohort. Patients with NAFLD were also more likely to incur higher total hospital charges (THC) [$2148 ($1677-$2618)]; however, were less likely to have a longer length of stay [0.27 d (0.17-0.38)]. Interestingly, in our study, the patients with NAFLD were less likely to suffer from acute myocardial infarction [aOR = 0.992 (0.989-0.995)]. Patients with NAFLD were not more likely to suffer acute kidney injury, sepsis, blood transfusion, intubation, or dialysis.

CONCLUSION

NVUGIB in NAFLD hospitalizations had higher inpatient mortality, THC, and complications such as shock, acute respiratory failure, and acute liver failure compared to those without NAFLD.

Sociodemographic and medical characteristics of liver cirrhosis deaths in a Ghanaian tertiary hospital

Objective

Cirrhosis is common in Ghana because of its high risk factors prevalence. However, information on cirrhosis in Ghana is lacking. This study aimed to study the clinical, and laboratory characteristics of cirrhotic patients in a tertiary hospital in Ghana.

Design

This was a retrospective study of sociodemographic characteristics, symptoms and signs, biochemical and fibrotic indices, treatments, and complications data of 247 patients with cirrhosis who died on admission.

Setting

This study was carried out at the Gastroenterology Unit of the Korle-Bu Teaching Hospital, Ghana.

Results

Two-thirds (68.0%) of the patients were within 30 to 60 years, with more than half (73.7%) being males. The most common aetiological factors among the patients were Hepatitis B virus infection (53.8%), alcohol use (31.6%) and Hepatitis C virus infection (4.9%). More than half (55.0%) of the patients reported late for admission, and 67.2% died within the first two weeks of admission. The most common clinical feature was abdominal distension (61.1% of patients), and the least was upper-abdominal mass (14.2%). The levels of most liver test parameters were elevated, fibrotic indices were high, and haemoglobin and albumin levels were reduced. More than half (53.8%) of the patients were in Child Pugh class B. The most common complication was hepatic encephalopathy; the least was hepato-renal syndrome. Definite treatment for complications of cirrhosis was lacking.

Conclusion

Deaths from cirrhosis at the hospital were mostly of young males with chronic hepatitis B infection. Implementation of hepatitis B prevention and treatment guidelines can help reduce cirrhosis deaths.

Funding

None declared.

Clinical characteristics and predictors of esophagogastric variceal bleeding among patients with HCV-induced liver cirrhosis: An observational comparative study

OBJECTIVES

To investigate the clinical characteristics, risk factors, and predictors of esophagogastric variceal bleeding in patients with hepatitis C virus (HCV)-induced liver cirrhosis.

METHODS

This comparative observational study was carried out on 100 patients suffering from post hepatitis cirrhosis and portal hypertension who were admitted to the Internal Medicine Department, Al-Azhar University Hospital, Damietta Egypt. Patients were classified into two groups: 50 of them presented with esophagogastric varices with acute variceal bleeding, and 50 patients presented without bleeding. Data were collected, coded, revised, and entered into the Stata software version 16.

RESULTS

The mean age of patients with bleeding was slightly higher than those without bleeding (55.58 ± 5.89 vs. 52.54 ± 9.01 years), p = 0.049. Mild ascites, positive H.Pylori, and Child-Pugh score B and C were an independent predictors of esophagogastric variceal bleeding (OR = 0.036, 95% CI: 0.0004-0.36; p = 0.005), (OR = 7.36, 95% CI: 1.44-37.59; p = 0.016), (OR = 19.0, 95% CI: 2.02-186.3; p = 0.010), and (OR = 40.51, 95% CI: 2.18-751.31; p = 0.013). The sensitivity of this model was 93.88%, specificity was 53.85%, PPV was 88.46%, NPV was 70.0%, correctly classified patients were 85.48%, and AUC was 90.27%. In the second model, pepsinogen level higher than 43.5 μg/l, AST (>54.5), Bilirubin (>1.45), and Hemoglobin (>11.5) were a significant independent predictors of esophagogastric variceal bleeding (OR = 1.18, 95% CI: 1.09-1.27; p<0.001), (OR = 1.14, 95% CI: 1.03-1.27; p = 0.007), (OR = 5.55, 95% CI: 1.21-25.43; p = 0.027), and (OR = 0.05, 95% CI: 0.008-0.32; p = 0.002), respectively. The sensitivity of this model was 92%, specificity was 98%, PPV was 97.87%, NPV was 92.45%, correctly classified patients were 95%, and AUC was 98.68%.

CONCLUSION

The independent predictors of esophagogastric variceal bleeding were ascites, positive H. pylori, Child-Pugh score B and C, pepsinogen level higher than 43.5 μg/l, AST (>54.5), bilirubin (>1.45), and hemoglobin (>11.5). Laboratory investigations are more reliable in predicting variceal bleeding and excluding non-variceal bleeding; however, clinical symptoms should not be neglected, especially H. pylori infection, ascites, and Child-Pugh score.

Coagulation in chronic liver disease and the use of prothrombin complex concentrate for an emergent procedure: a case report and review of literature

Synthetic dysfunction observed in cirrhosis results in altered production of procoagulants and anticoagulants that can lead to both bleeding and thrombotic events, respectively. In patients with decompensated cirrhosis, frequent hospital visits often require bedside procedures such as diagnostic paracenteses, thoracenteses and endoscopy. It can be difficult to determine at what coagulation threshold procedures can safely be performed. Currently, the most common therapies given pre-procedurally include fresh frozen plasma (FFP) and vitamin K. The effectiveness of these treatments is estimated by international normalized ratio (INR), an imprecise measure of coagulation in the setting of cirrhosis. Transfusion with FFP may lead to detrimental side effects, including worsening volume overload and increased portal hypertension. We present a case of a 60-year-old patient intubated for acute hypoxic respiratory failure secondary to volume overload who subsequently developed bilateral pneumothoraces, requiring immediate chest tube placement. In this case, the patient had ongoing hepatic decompensation with volume overload and acute worsening of coagulopathy with an INR of 4.2. In this setting, 4-Factor Prothrombin Complex Concentrate (4F-PCC) was chosen to correct coagulation parameters with a low infusion volume. One hour following administration, INR was 1.5. Chest tubes were placed bilaterally and oxygenation improved without bleeding complications. While the data is still lacking, 4F-PCC may be considered for urgent and emergency situations in cirrhotic patients.

Value of FibroScan and aspartate aminotransferase-to-platelet ratio index, alone or in combination, in predicting esophagogastric variceal bleeding in patients with liver cirrhosis

AIM

To investigate the value of FibroScan and aspartate aminotransferase-to-platelet ratio index (APRI), alone or in combination, in predicting the risk of esophagogastric variceal bleeding in patients with liver cirrhosis.

METHODS

Two hundred and ten patients with posthepatitic cirrhosis were divided into a non-bleeding group (n = 153) and a bleeding group (n = 57) according to the presence of esophagogastric variceal bleeding or not. FibroScan values (LSM values) and APRI values were obtained within a week and compared between the two groups using t-tests. Receiver operating characteristic curve (ROC) analysis was used to assess the accuracy of LSM alone, APRI alone, and LSM + APRI in predicting the risk of esophagogastric variceal bleeding.

RESULTS

The LSM values of the patients with and without bleeding were 28.49 kPa ± 9.46 kPa and 22.87 kPa ± 6.95 kPa, respectively, and the APRI values were 2.99 ± 1.11 and 2.13 ± 1.01, respectively, both of which showed a significant difference between the two groups. The AUCs of LSM alone, APRI alone, and LSM + APRI in predicting the risk of bleeding were 0.669, 0.727 and 0.722, respectively, suggesting that APRI alone and LSM + APRI had good diagnostic value in esophagogastric variceal bleeding.

CONCLUSION

APRI alone and FibroScan combined with APRI have good predictive value for the risk of esophageal variceal bleeding in patients with liver cirrhosis.

Management of variceal and nonvariceal upper gastrointestinal bleeding in patients with cirrhosis

Acute upper gastrointestinal haemorrhage remains the most common medical emergency managed by gastroenterologists. Causes of upper gastrointestinal bleeding (UGIB) in patients with liver cirrhosis can be grouped into two categories: the first includes lesions that arise by virtue of portal hypertension, namely gastroesophageal varices and portal hypertensive gastropathy; and the second includes lesions seen in the general population (peptic ulcer, erosive gastritis, reflux esophagitis, Mallory-Weiss syndrome, tumors, etc.). Emergency upper gastrointestinal endoscopy is the standard procedure recommended for both diagnosis and treatment of UGIB. The endoscopic treatment of choice for esophageal variceal bleeding is band ligation of varices. Bleeding from gastric varices is treated by injection with cyanoacrylate. Treatment with vasoactive drugs as well as antibiotic treatment is started before or at the same time as endoscopy. Bleeding from portal hypertensive gastropathy is less frequent, usually chronic and treatment options include β-blocker therapy, injection therapy and interventional radiology. The standard of care of UGIB in patients with cirrhosis includes careful resuscitation, preferably in an intensive care setting, medical and endoscopic therapy, early consideration for placement of transjugular intrahepatic portosystemic shunt and, sometimes, surgical therapy or hepatic transplant.