Cohorte descriptiva de pacientes adultos con hipertensión portal en una institución de tercer nivel en Colombia / Descriptive cohort of adult patients with portal hypertension at a tertiary care institution in Colombia

Introducción. La hipertensión portal (HTP) se define como una elevación anormal de la presión venosa en el sistema portal que lleva al desarrollo de vías colaterales para desviar el flujo sanguíneo de la zona. Dentro de su etiología están las relacionadas con la cirrosis hepática y otras causas denominadas no cirróticas. El objetivo de este estudio fue evaluar los principales hallazgos demográficos, clínicos y paraclínicos en un grupo de pacientes con HTP, y determinar el uso de ayudas invasivas y no invasivas, y su disponibilidad para el diagnóstico y seguimiento de los pacientes en los centros que no cuentan con laboratorio de hemodinamia hepática, reflejando la dinámica de múltiples escenarios en Colombia. Metodología. Se realizó un estudio descriptivo de corte transversal, retrospectivo, en pacientes atendidos en una institución de tercer nivel del sur de Colombia, entre enero del año 2015 y diciembre del año 2020. Resultados. Se obtuvo una muestra de 61 pacientes en donde la mayoría de casos correspondían a hombres en la séptima década de la vida, procedentes del área urbana. La principal causa de consulta fue el sangrado digestivo (39,3 %), asociado a la presencia de telangiectasias (arañas vasculares) en el 37,2 %, seguido de circulación colateral (31,3 %) e ictericia (19,7 %). En la ecografía abdominal (realizada en el 57,4 % de los pacientes) predominaron la cirrosis (68 %) y la presencia de esplenomegalia (14,2 %), y en lospacientes con Doppler portal (realizado en el 16,4 %) se encontró hígado cirrótico (80 %) y dilatación portal (40 %). Con respecto a los hallazgos en la esofagogastroduodenoscopia predominó la presencia de várices esofágicas y gastritis crónica. Conclusión. El principal motivo de consulta fue el sangrado digestivo, en tanto que la cirrosis fue el antecedente y el hallazgo imagenológico más frecuente, seguido de las várices esofágicas. Se encontró que el uso de paraclínicos, ecografía abdominal, ecografía con Doppler portal y esofagogastroduodenoscopia fueron los más utilizados en el contexto clínico de los pacientes con el diagnóstico de HTP.

Introduction. Portal hypertension (PHT) is defined as an abnormal elevation of venous pressure in the portal system that leads to the development of collateral pathways to divert blood flow from the area. Within its etiology are those related to liver cirrhosis and other so-called non cirrhotic causes. The aim of this study was to evaluate the main demographic, clinical and paraclinical findings in a group of patients with PHT, and to determine the use of invasive and non-invasive aids, and their availability for the diagnosis and follow-up of patients in centers that do not have a hepatic hemodynamics laboratory, reflecting the dynamics of multiple scenarios in Colombia. Methodology. A descriptive, retrospective, cross-sectional, retrospective study was conducted in patients attended in a third level institution in Southern Colombia, between January 2015 and December 2020. Results. A sample of 61 patients was obtained where the majority of cases corresponded to men in the seventh decade of life, from the urban area. The main cause of consultation was digestive bleeding (39.3%), associated with the presence of telangiectasias (spider veins) in 37.2%, followed by collateral circulation (31.3%) and jaundice (19.7%). In abdominal ultrasound (performed in 57.4% of the patients), cirrhosis (68%) and the presence of splenomegaly (14.2%) predominated, and in patients with portal Doppler (performed in 16.4%), cirrhotic liver (80%) and portal dilatation (40%) were found. With respect to the findings in the esophagogastroduodenoscopy, esophageal varices and chronic gastritis were predominant. Conclusion. The main reason for consultation was gastrointestinal bleeding, while cirrhosis was the most frequent history and imaging finding, followed by esophageal varices. It was found that the use of paraclinics, abdominal ultrasound, ultrasound with portal Doppler and esophagogastroduodenoscopy were the most used in the clinical context of patients diagnosed with PHT.

Hemorragia digestiva alta / Upper Gastrointestinal Bleeding

Introducción: La hemorragia digestiva alta tiene una elevada morbimortalidad. La endoscopía digestiva alta es el estudio de elección para su diagnóstico y tratamiento. Objetivo: Describir la conducta ante la hemorragia digestiva alta. Métodos: Para la revisión bibliográfica se consultaron artículos científicos indexados en idioma español e inglés, relacionados con la hemorragia digestiva, publicados en las bases de datos PubMed, SciELO, Medline y Cochrane, pertenecientes a autores dedicados al estudio de este tema. Desarrollo: La hemorragia digestiva alta se clasifica, según la etiología de origen, en variceal y no variceal. La mayoría de los pacientes con hemorragia digestiva alta el sangrado se autolimita. La causa más habitual es la úlcera péptica, pero en caso de sangrado masivo la etiología más frecuente es la variceal. El empleo precoz de la terlipresina en los pacientes con hemorragia digestiva alta variceal mejora el control del sangrado y disminuye la mortalidad. Se debe hacer uso de escalas validadas de estratificación del riesgo: escala de riesgo de Rockall (tiene como propósito principal predecir la mortalidad y riesgo de resangrado del paciente) y la escala de Glasgow-Blatchford). Conclusiones: Sospechar la presencia de hemorragia digestiva alta, estratificar su riesgo e instaurar el manejo inicial y apropiado constituye una prioridad para el médico de urgencia(AU)

Introduction: Upper gastrointestinal bleeding presents high morbidity and mortality. Upper gastrointestinal endoscopy is the study of choice for its diagnosis and treatment. Objective: To describe the management of upper gastrointestinal bleeding. Methods: For the bibliographic review, the consultation was carried out of scientific articles indexed in Spanish and English, related to gastrointestinal bleeding, published in the databases PubMed, SciELO, Medline and Cochrane, belonging to authors dedicated to the study of this subject. Development: Upper gastrointestinal bleeding is classified, according to the etiology of origin, into variceal and nonvariceal. In most patients with upper gastrointestinal bleeding the bleeding as such is self-limiting. The most common cause is peptic ulcer; however, in the case of massive bleeding, the most frequent etiology is variceal. Early use of terlipressin in patients with variceal upper gastrointestinal bleeding improves bleeding control and decreases mortality. Validated risk stratification scales should be used: Rockall risk scale (its main purpose is to predict patient mortality and risk of bleeding recurrence) and the Glasgow-Blatchford scale. Conclusions: Suspecting the presence of upper gastrointestinal bleeding, stratifying its risk, as well as instituting initial and appropriate management, are a priority for the emergency physician(AU)

Fatores preditivos de morbidade associada à sangramento de varizes esofágicas em crianças com hipertensão porta / Predictive factors of morbidity associated with esophageal variceal bleeding in children with portal hypertension

ABSTRACT Background: Most data on the natural history of portal hypertension come from studies in adults. The morbidity rate of upper gastrointestinal bleeding (UGIB) in children with portal hypertension has not been systematically characterized. Objective: To describe the morbidity and mortality of UGIB in pediatric patients with portal hypertension and identify predictive factors for the occurrence of its main complications. Methods: This retrospective study included pediatric patients with cirrhotic portal hypertension or with extrahepatic portal vein obstruction (EHPVO). Mortality and UGIB complications within a period of up to 6 weeks of the bleeding were investigated. To determine the predictive factors of morbidity, a multivariate analysis was performed using logistic regression; all results were considered significant at P<0.05. Results: A total of 86 patients (51.2% with EHPVO and 48.8% with cirrhosis) had 174 bleeding events. Ascites was the most common complication (43.1% of all cases), being more prevalent in patients with cirrhosis (P<0.001). Cirrhosis was a predictor of the occurrence of any morbidity (OR 20.3). The need for blood transfusion was predictor of at least one complication (OR 5.8), ascites (OR 7.2) and infections (OR 3.8) in the general group and at least one complication (OR 11.3) and ascites (OR 5.8) in cirrhotic patients. The need for expansion was a predictor of any morbidity (OR 4.6) and infections (OR 3.9) in the general group, in addition to being predictor of infection in cirrhotic patients (OR 5.4). There were no deaths from UGIB in the six weeks post-bleeding. Conclusion: The study showed the relevance of morbidity after UGIB in pediatric patients with portal hypertension, especially in those with cirrhosis. The patients with hemodynamic instability requiring blood transfusion or expansion on admission are at increased risk of complications related to upper gastrointestinal bleeding and should be closely monitored.

RESUMO Contexto: A maioria dos dados sobre a história natural da hipertensão porta provém de estudos em adultos. A morbidade associada à hemorragia digestiva alta (HDA) em crianças com hipertensão porta ainda não foi sistematicamente estudada. Objetivo: Descrever a morbimortalidade da HDA em pacientes pediátricos com hipertensão porta e identificar fatores preditivos para a ocorrência de suas principais complicações. Métodos: Este estudo retrospectivo incluiu pacientes pediátricos com hipertensão porta cirrótica ou com obstrução extra-hepática da veia porta (OEHVP). A mortalidade e as complicações da HDA foram estudadas até seis semanas após o sangramento. Para determinar os fatores preditivos de morbidade, foi realizada análise multivariada por meio de regressão logística; todos os resultados foram considerados significativos com P<0,05. Resultados: Oitenta e seis pacientes (51,2% com OEHVP e 48,8% com cirrose) tiveram 174 eventos hemorrágicos. A ascite foi a complicação mais comum (43,1% de todos os casos), sendo mais prevalente em pacientes com cirrose (P<0,001). A cirrose foi preditor da ocorrência de pelo menos uma complicação (OR 20,3). A necessidade de transfusão sanguínea foi preditora de pelo menos uma complicação (OR 5,8), ascite (OR 7,2) e infecções (OR 3,8) no grupo geral e pelo menos uma complicação (OR 11,3) e ascite (OR 5,8) nos cirróticos. A necessidade de expansão foi preditor de qualquer morbidade (OR 4,6) e infecções (OR 3,9) no grupo geral, além de ser preditor de infecção em cirróticos (OR 5,4). Não houve óbitos por HDA nas 6 semanas pós-sangramento. Conclusão: O estudo mostrou a relevância da morbidade após HDA em pacientes pediátricos com hipertensão porta, principalmente naqueles com cirrose. Os pacientes com instabilidade hemodinâmica que necessitam de transfusão de sangue ou expansão na admissão têm risco aumentado de complicações relacionadas à hemorragia digestiva alta e devem ser monitorados de perto.

Tolérance et efficacité de la ligature des varices œsophagiennes au Centre Hospitalier Universitaire Andrainjato, Fianarantsoa, Madagascar / Tolerance and efficacy of esophageal varices ligation at the Andrainjato teaching hospital, Fianarantsoa, Madagascar

Introduction: La ligature des varices œsophagiennes constitue un des piliers de la prise en charge de l'hémorragie digestive par rupture des varices œsophagiennes. Cette étude a pour objectif d'analyser la tolérance et l'efficacité de la ligature des varices œsophagiennes dans un échantillon de patients au Centre Hospitalier Universitaire Andrainjato Fianarantsoa, Madagascar. Méthodes: Une étude prospective, observationnelle longitudinale sur une période de 21 mois (mois de janvier 2018 au mois d'août 2019) a été réalisée. Le test de Khi carré a été utilisé pour déterminer les corrélations (SPSS® v22). Résultats : Trente-et-un patients à prédominance masculine (sex ratio 1,5), âgés de 43,0 ± 9,0 ans, ont été retenus et 67 séances de ligatures de varices œsophagiennes ont été effectuées. La prophylaxie secondaire était l'indication de la ligature dans 96,8 % (n = 30) des cas. Les varices œsophagiennes étaient de grade III dans 64,4 % (n = 20) des cas. Toutes les ligatures ont été réalisées sous anesthésie générale. Le nombre de bandes élastiques utilisées était de 3,4 ± 1,1. La bonne tolérance de la ligature élastique était de 97,0 % (n = 65) lors de la procédure et de 58,0 % (n = 39) en post-procédure. La douleur thoracique post-procédure était observée dans 65,7 % (n = 44) des cas. L'éradication était obtenue après 3 séances dans 6,45 % (n = 2) des cas et 58,1 % (n = 18) étaient en cours d'éradication après 1,7 ± 0,9 séances. Conclusion : Cette étude a pu déterminer que la ligature des varices œsophagiennes est une technique bien tolérée et efficace dans la prévention de l'hémorragie digestive par rupture des varices œsophagiennes malgré certains inconvénients postopératoires

Evaluation of the efficacy and safety of endoscopic injection of polidocanol combined with low-dose tissue glue occlusion in the treatment of F3 type esophageal varices in liver cirrhosis / 中国医师杂志

Objective:To explore the efficacy and safety of endoscopic injection of polidocanol combined with low-dose tissue glue occlusion in the treatment of F3 esophageal varices in liver cirrhosis.Methods:Retrospective analysis was made on 42 patients with cirrhosis type F3 esophageal varices admitted to the Affiliated Hospital of Zunyi Medical University from January 2020 to June 2021. According to different treatment methods, they were divided into the observation group and the control group, with 21 cases in each group. The observation group received endoscopic injection of polidocanol combined with low-dose tissue glue occlusion, while the control group received endoscopic injection of polidocanol. The differences in the effectiveness (remission rate of varices) and safety (incidence of intraoperative bleeding and postoperative rebleeding, incidence of ectopic embolism, incidence of esophageal ulcer, incidence of esophageal perforation, incidence of esophageal stricture) of the two groups of patients were compared.Results:The total effective rate of relieving esophageal varices in the observation group was significantly better than that in the control group [95.2%(20/21) vs 61.9%(13/21), χ 2=6.929, P=0.008]. There were no cases of ectopic embolism in both groups; The intraoperative bleeding rate in the observation group was 4.8% (1/21), significantly lower than the 38.1% (8/21) in the control group (χ 2=6.929, P=0.008); There was no statistically significant difference in postoperative rebleeding rates between the two groups [33.3%(7/21) vs 23.8%(5/21), χ 2=0.467, P=0.495]; The incidence of esophageal ulcers in the observation group was higher than that in the control group [23.8%(5/21) vs 0, χ 2=5.676, P=0.017], mainly caused by glue discharge ulcers; There were no cases of esophageal perforation and esophageal stricture in both groups. Conclusions:Endoscopic injection of polidocanol combined with low-dose tissue glue occlusion for the treatment of F3 esophageal varices in liver cirrhosis is safe, can greatly reduce the occurrence of intraoperative bleeding, and has a better one-time variceal eradication effect.

Comparative study of the accuracy of Platelet count/ spleen diameter ratio with other non-invasive parameters in predicting large esophageal varices in patients with chronic liver disease

Introduction: Bleeding from esophageal varices causes significant mortality and morbidity in patients with chronic liver disease. With upper GI endoscopy not available in many centers and in rural India, certain noninvasive methods can help to aid in the prediction of the presence of large esophageal varices. Early identification of large varices helps in prophylaxis to prevent bleeding until definitive management is done. Here in this study, we are using platelet count/spleen diameter ratio in predicting the large esophageal varices and comparing its sensitivity and specificity with non-invasive parameters. Study: This is a cross-sectional study (Prospective study) in a tertiary hospital. Methods: Patients admitted to SSIMS & RC, DAVANAGERE between January 2021 and June 2021 with a diagnosis of chronic liver disease were included in the study. Patients were assessed for ascites, splenomegaly, ultrasonographic measurements like splenic size and portal vein diameter, and laboratory parameters like hemoglobin, platelet count, total bilirubin, prothrombin time and serum albumin. The ratio of platelet count with spleen diameter was calculated. Univariate and multivariate analyses were done. Results: Incidence of large varices were seen in 44%. By ultrasonography, 22 were found to have splenomegaly while 28 were found to have normal spleen dimensions. Patients with large esophageal varices had significantly lower platelet counts as compared to those without. Spleen diameter was greater while platelet count/spleen diameter ratio was lower in patients with large esophageal varices. On multivariate analysis, independent predictors for the presence of large varices were palpable spleen, low platelet count, spleen size >13.8 mm, portal vein >13 mm and splenic vein >11.5 mm. The platelet count/ spleen diameter ratio had a sensitivity and specificity of 87 % and 85% respectively which was more than other parameters. Hence platelet count/ spleen diameter ratio can be a reliable indicator for predicting the presence of large esophageal varices than other non-invasive parameters. Conclusion: Platelet count/ spleen diameter ratio is more accurate and a strong predictor of large esophageal varices than any other non-invasive parameters in patients with chronic liver disease which warrant the need for prophylaxis and early intervention to prevent life-threatening hemorrhage.

Cola de cianoacrilato para varizes gastroesofágicas: uma única experiência central no norte da Índia / Cyanoacrylate glue for gastroesophageal varices: a single centre experience from north india

ABSTRACT Background: In natural history of cirrhosis, variceal bleeding is one of the earliest decompensations to happen, and, if adequately managed, survival is improved. Gastric varices have challenges in management due to their location, size and propensity to bleed. The N-butyl 2-cyanoacrylate (NBC) glue application has emerged as definitive therapy in bleeding gastric varices. Here we present our experience with use of NBC in management of gastric and difficult cases of esophageal varices. Methods: A total of 75 patients underwent NBC glue application for varices which included 69 patients with gastric varices and six patients with esophageal varices. All the procedures were done with flexible endoscope and sclerotherapy needle after due precautionary measures. Results: Hemostasis was varices in all patients after endotherapy. The average quantity of glue used was 2.75±0.95 mL. Complete obliteration with single session of NBC application was achieved in 55 patients. Re-bleeding occurred in five patients within 5 days of index event. 20 patients had in-hospital mortality but none was related to gastrointestinal bleeding. 6-week all-cause mortality was 26 (35%). Conclusion: Glue therapy with NBC is a life saving therapy in patients with bleeding gastric varices and esophageal varices not amenable to endoscopic variceal ligation or sclerotherapy.

RESUMO Contexto: Na história natural da cirrose, o sangramento de varizes é uma das primeiras descompensações a acontecer e, se adequadamente controlada, a sobrevivência é melhorada. Varizes gástricas têm desafios na sua gestão devido à sua localização, tamanho e propensão a sangrar. A aplicação de cola N butil 2-cianoacrilato (NBC) surgiu como terapia definitiva em varizes gástricas sangrantes. Apresentamos nossa experiência com o uso da NBC na gestão de casos gástricos e difíceis de varizes esofágicas. Métodos: Um total de 75 pacientes foram submetidos à aplicação de cola NBC para varizes que incluiu 69 pacientes com varizes gástricas e seis pacientes com varizes de esôfago. Todos os procedimentos foram feitos com endoscópio flexível e agulha de escleroterapia após as devidas medidas de precaução. Resultados: A hemostasia foi alcançada em todos os pacientes após a endoterapia. A quantidade média de cola utilizada foi de 2,75+0,95 mL. A obliteração completa com sessão única de aplicação da NBC foi alcançada em 55 pacientes. O reexame ocorreu em cinco pacientes dentro de 5 dias após o evento de índice. 20 pacientes tiveram mortalidade hospitalar, mas nenhum foi relacionado com o sangramento gastrointestinal. A mortalidade após 6 semanas foi de 26 (35%). Conclusão: A terapia de cola com a NBC é uma terapia que salva vidas em pacientes com varizes gástricas hemorrágicas e varizes esofágicas não condizíveis à ligadura endoscópica ou escleroterapia.

Guías para el diagnóstico y seguimiento de niños y adolescentes portadores de hipertensión portal / Guidelines for diagnosis and follow-up of children and adolescents with portal hypertension

La hipertensión portal es un síndrome complejo producido por un aumento de la resistencia al flujo venoso esplácnico a nivel de la vena porta o sus ramas, con una circulación sistémica hiperdinámica caracterizada por vasodilatación periférica y aumento del gasto cardíaco. El sitio de obstrucción al flujo portal puede ser prehepático (hígado normal), intrahepático (como en la cirrosis) o posthepático (síndrome de BuddChiari). En los pacientes pediátricos, las causas prehepáticas e intrahepáticas se reparten en proporciones casi iguales (aproximadamente el 50 % cada una). La expresión clínica y el impacto individual son muy variados, pero en todos los casos expresan un deterioro en la salud de los pacientes y la necesidad de corregir el problema, tanto en sus consecuencias como, idealmente, en sus causas.

Portal hypertension is a complex syndrome caused by increased resistance to the splachnic venous flow at the portal vein level, with a hyperdynamic systemic circulation characterized by peripheral vasodilation and high cardiac output. Portal flow can be obstructed at prehepatic (¨normal liver¨), intrahepatic (as in cirrhosis), or post-hepatic level (as in Budd-Chiari syndrome). In pediatric patients, prehepatic and intrahepatic causes are almost equally distributed (nearly 50% each). Clinical presentation and individual impact are heterogeneous, but in each case, it is the expression of a worsening condition and the need to solve the problem, either by treating its consequences or (ideally) its causes.

A randomized control trial of balloon compression-assisted endoscopic injection sclerotherapy for esophageal varices / 中华消化内镜杂志

Objective:To investigate the clinical efficacy and safety of balloon compression-assisted endoscopic injection sclerotherapy (bc-EIS) for esophageal varices in patients with cirrhosis.Methods:From December 2020 to April 2021, cirrhotic patients with esophageal varices who planned to receive endoscopic treatment in the Department of Gastroenterology of the First Affiliated Hospital of Anhui Medical University were selected and randomly divided into the trial group (treated with bc-EIS) and the control group [treated with endoscopic variceal ligation (EVL)] through computer randomization. The varices eradication rate, rebleeding rate and postoperative adverse reactions in the two groups were studied.Results:During the study, 93 cases were initially included according to inclusion criteria, among which 9 cases were excluded by exclusion criteria. Finally, 84 cases were included for data analysis, with 42 cases in each group. The esophageal varices eradication rate after the first treatment in the trial group was 88.10% (37/42), which was significantly higher than that in the control group [33.33% (14/42)] ( χ2=26.40, P<0.001). The esophageal varices eradication rate after 1 to 2 times and 1 to 3 times of treatment in the trial group were both significantly higher than those in the control group [97.62% (41/42) VS 40.48% (17/42), χ2=29.47, P<0.001; 100.00% (42/42) VS 45.24% (19/42), P<0.001]. The maximum follow-up period was 6 months, and none of the patients had rebleeding in the trial group, and the rebleeding rate in the control group was 4.76% (2/42) ( P=0.494). The incidence of thoracic and abdominal discomfort, nausea and vomiting, and abdominal distension in the trial group and control group were 26.19% (11/42) and 35.71% (15/42) ( χ2=0.51, P=0.474), 2.38% (1/42) and 7.14% (3/42) ( χ2=0.26, P=0.608), and 4.76% (2/42) and 11.90% (5/42) ( χ2=0.62, P=0.430), respectively. No other adverse events such as infection, dysphagia, perforation, esophageal tracheal fistula, esophageal stenosis, or ectopic embolism occurred in any group. Conclusion:Bc-EIS is effective and safe for the treatment of esophageal varices in patients with cirrhosis, with a one-time varices eradication rate of more than 85%, and can be completely eradicated after 1 to 3 times of treatment.

Clinical evaluation of different modalities in emergency endoscopic treatment of esophageal variceal bleeding / 中国医师杂志

Objective:This study aimed to evaluate the rebleeding risk and prognosis of patients being treated after acute esophageal varices bleeding by two different treatment strategies: sclerosing agent combined with tissue glue injection, esophageal varices ligation (EVL), through comparing the therapeutic effects and securities.Methods:A total of 76 patients who underwent endoscopy and received treatment in Zhongshan Hospital Affiliated to Fudan University due to acute esophageal variceal bleeding were included retrospectively. 6 patients with active bleeding and 70 patients with thrombus in esophagus varices under gastroscopy. Among them, 21 cases were treated with sclerosing agent combined with tissue glue injection (sclerosing tissue glue group), and 55 cases were treated with EVL (EVL group). The emergency endoscopic diagnosis and treatment of the two groups were compared, and the risk factors of rebleeding 6 months after endoscopic treatment were analyzed by univariate and multivariate analysis.Results:All patients received endoscopic treatment successfully. During the follow-up period of 6 months after endoscopic treatment, rebleeding occurred in 13 cases. Kaplan Meier analysis showed that the 6-month rebleeding rate in the sclerosing tissue glue group was significantly higher than that in the EVL group (41.6% vs 12.3%, P=0.011). There were 8 deaths in total. Kaplan Meier analysis showed that there was no significant difference in 6-month mortality between the two groups (17.5% vs 10.1%, P=0.616). Multivariate analysis further showed that malignant tumor ( HR=3.700, 95% CI: 1.187-11.536, P=0.024) and treatment mode of esophageal variceal bleeding ( HR=4.834, 95% CI: 1.443-16.193, P=0.011) were independent risk factors for rebleeding 6 months after endoscopic treatment of acute esophageal variceal bleeding. Conclusions:This study found that EVL and the combining injection of lauromacrogol and cyanoacrylate could be used in emergent hemostatic treatment for acute esophageal varices bleeding. Moreover, EVL is the prioritized approach in endoscopic emergency treatment with a lower rebleeding rate and fewer complications. Sclerotherapy combined with tissue glue can be used as one of the measures of emergency treatment, which is not better than ligation.

Diagnostic performance of platelet count/spleen diameter ratio to detect esophageal varices in patients with cirrhosis / Rendimiento diagnóstico del índice de recuento de plaquetas/diámetro del bazo para detectar várices esofágicas en pacientes con cirrosis

Abstract Introduction: The platelet count/spleen diameter (PC/SD) ratio is a noninvasive method for the diagnosis of esophageal varices (EV) used as an alternative to endoscopy in patients with cirrhosis. Objective: To evaluate the diagnostic performance of the PC/SD ratio (cut-off point <909) to detect EV in patients with cirrhosis treated at a tertiary referral hospital in Bogotá D.C., Colombia. Materials and methods: A prospective diagnostic test accuracy study was conducted in 66 patients with cirrhosis treated at the Hospital Universitario de La Samaritana between July and December 2018. A descriptive analysis of the data was performed. In addition, the diagnostic performance of the PC/SD ratio (cut-off point <909) for the detection of EV was compared with the findings reported in the esophagogastroduodenoscopy (gold standard), calculating its sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), positive likelihood ratio (LR+), and negative likelihood ratio (LR-). A significance level of p<0.05 was considered. Results: The mean age of the participants was 65.5 years, 53.03% were female, and the most common causes of cirrhosis were alcohol consumption (40.90%) and autoimmune hepatitis (22.72%). EV was diagnosed in 48 patients (72.72%). The PC/SC ratio showed sensitivity of 60%, specificity of 78%, PPV of 0.88, NPV of 0.42, LR+ of 2.73, and LR- of 0.51. Conclusion: The low sensitivity, specificity, and NPV found in the present study suggest that the PC/SD ratio (cut-off point <909) may not be a useful diagnostic test for detecting EV in patients with cirrhosis.

Resumen Introducción. El índice de recuento de plaquetas/diámetro del bazo (RP/DB) es un método no invasivo para el diagnóstico de varices esofágicas (VE) que se usa como alternativa a la endoscopia en pacientes con cirrosis. Objetivo. Evaluar el rendimiento diagnóstico del índice RP/DM (punto de corte <909) para detectar VE en pacientes cirróticos atendidos en un hospital de tercer nivel de Bogotá D.C., Colombia. Materiales y métodos. Estudio prospectivo de validez de prueba diagnóstica realizado en 66 pacientes cirróticos atendidos en el Hospital Universitario de La Samaritana entre julio y diciembre de 2018. Se realizó un análisis descriptivo de los datos. Además, el rendimiento diagnóstico del índice RP/DM (punto de corte <909) para la detección de VE se comparó con los hallazgos de la esofagogastroduodenoscopia (prueba de oro), calculándose su sensibilidad, especificidad, valor predictivo positivo (VPP), valor predictivo negativo (VPN), razón de probabilidad positiva (LR+) y razón de probabilidad negativa (LR-). Se consideró un nivel de significancia de p<0.05. Resultados. La edad promedio de los participantes fue 65.5 años, 53.03% eran mujeres y las causas más comunes de cirrosis fueron consumo de alcohol (40.90%) y hepatitis autoinmune (22.72%). Las VE fueron diagnosticadas en 48 pacientes (72.72%). El índice RP/DM tuvo una sensibilidad de 60%, una especificidad de 78%, un VPP de 0.88, un VPN de 0.42, una LR+ de 2.73 y una LR- de 0.51. Conclusión. La baja sensibilidad, especificidad y VPN encontrados en el presente estudio sugieren que el índice RP/DM (punto de corte <909) podría no ser una prueba diagnóstica útil para detectar VE en pacientes cirróticos.

Endoscopic prophylaxis and factors associated with bleeding in children with extrahepatic portal vein obstruction / Profilaxia endoscópica e fatores associados ao sangramento em crianças com obstrução extra-hepática da veia porta

Abstract Objectives: This study aimed to evaluate factors associated with upper digestive hemorrhage and primary and secondary endoscopic prophylaxis outcomes in children with extrahepatic portal vein obstruction. Methods: This observational and prospective study included 72 children with extrahepatic portal vein obstruction who were followed from 2005 to 2017. Risk factors associated with upper digestive hemorrhage and the results of primary and secondary prophylaxis of these patients were evaluated. Results: Fifty patients (69.4%) had one or more episodes of bleeding during follow-up, with a median age at first hemorrhage of 4.81 years. The multivariate analysis showed that medium- to large-caliber esophageal varices were associated with an 18-fold risk of upper digestive hemorrhage (95% CI: 4.33-74.76; p < 0.0001). Primary prophylaxis was administered to 14 patients, with eradication in 85.7%; however, 14.3% of these patients had hemorrhages during the follow-up period and 41.7% had a relapse of varices. Secondary prophylaxis was administered to 41 patients. Esophageal varices were eradicated in 90.2% of patients. There were relapse and re-bleeding of esophageal varices in 45.9% and 34.1% of the children, respectively. Conclusion: Primary and secondary endoscopic prophylaxes showed high rates of esophageal varix eradication, but with significant relapses. Eradication of esophageal varices cannot definitively prevent recurrent upper digestive hemorrhage, since bleeding from alternate sites can occur. Medium- and large-caliber esophageal varices were associated with upper digestive hemorrhage in patients with extrahepatic portal vein obstruction. To the best of the authors' knowledge, this study is the first to evaluate bleeding risk factors in children with extrahepatic portal vein obstruction.

Resumo Objetivos: Este estudo visou avaliar fatores associados à hemorragia digestiva alta e resultados da profilaxia endoscópica primária e secundária em crianças com obstrução extra-hepática da veia porta. Métodos: Este estudo observacional e prospectivo incluiu 72 crianças com obstrução extra-hepática da veia porta acompanhadas de 2005 a 2017. Os fatores de risco associados à hemorragia digestiva alta e os resultados da profilaxia primária e secundária desses pacientes foram avaliados. Resultados: Dos pacientes, 50 (69,4%) apresentaram ≥ 1 episódio de sangramento durante o acompanhamento, com idade média da primeira hemorragia de 4,81 anos. A análise multivariada mostrou que varizes esofágicas de médio a grande calibre estavam associadas a um risco 18 vezes maior de hemorragia digestiva alta (IC de 95% 4,33-74,76; p < 0,0001). Foi administrada profilaxia primária em 14 pacientes, com erradicação em 85,7%; contudo, 14,3% desses pacientes apresentaram hemorragias durante o período de acompanhamento e 41,7% apresentaram recidiva de varizes. Foi administrada profilaxia secundária em 41 pacientes. As varizes esofágicas foram erradicadas em 90,2% dos pacientes. Houve recidiva e novos sangramentos de varizes esofágicas em 45,9% e 34,1% das crianças, respectivamente. Conclusão: As profilaxias esofágicas primárias e secundárias apresentaram altas taxas de erradicação de varizes esofágicas, porém com recidivas significativas. A erradicação de varizes esofágicas não pode prevenir de forma definitiva a hemorragia digestiva alta recorrente, pois pode ocorrer sangramento de outros locais. Varizes esofágicas de médio e grande calibre estavam associadas à hemorragia digestiva alta em pacientes com obstrução extra-hepática da veia porta. No melhor de nosso conhecimento, nosso estudo é o primeiro a avaliar os fatores de risco de sangramento em crianças com obstrução extra-hepática da veia porta.

Hipertensión portal secundario a trombosis de la vena porta y várices esofágicas / Secondary portal hypertension to portal venous thrombosis and esophageal varices

Resumen La hipertensión portal se define como la alteración patológica en el gradiente de presión a nivel del sistema portal, es decir, la diferencia entre la presión de la vena porta y la vena cava inferior. El valor normal es entre 1-5 mm Hg y se considera hipertensión cuando es mayor de 10 mm Hg. En este artículo, se describe el caso de una paciente de 5 años con un cuadro de hipertensión portal secundario a várices esofágicas y trombosis de la vena porta, confirmado por endoscopia de vías digestivas alta y angioresonancia magnética. La paciente fue atendida en la Fundación Clínica Infantil Club Noel de la ciudad de Cali, Colombia, entre los meses de diciembre del 2018 y febrero del 2019.

Abstract Portal hypertension is defined as the pathological increase in the portal pressure gradient, which is the difference between the pressure of the portal vein and the inferior vena cava. Normally portal vein pressure ranges between 1-5 mmHg and is considered hypertension when it is higher than 10 mmHg. In this study the case of a 5-year-old patient that suffers from secondary portal hypertension to portal venous thrombosis and esophageal varices is presented. The diagnostic is confirmed by an endoscopy of the upper gastrointestinal tract and by a magnetic angioresonance. The patient was treated at the Fundacion Clinica Infantil Club Noel located in Cali, Colombia, between the months of December 2018 and February 2019.

Sugiura modificado: una alternativa para pacientes no cirróticos con trombosis de la vena porta extrahepática y sangrado variceal recurrente / Modified sugiura procedure: an alternative for non-cirrhotic patients with extrahepatic portal vein thrombosis and recurrent variceal bleeding

Resumen Una de las consecuencias más graves de la trombosis de la vena porta extrahepática es la hipertensión portal con sangrado variceal recurrente. Una vez falla la ligadura endoscópica de las várices y el eje esplenoportal no se encuentra permeable, la devascularización tipo Sugiura modificado puede ser la única alternativa. Se ha documentado su uso en pacientes con cirrosis, pero hay poca información en personas no cirróticas. En este artículo se describe una serie de 4 casos de pacientes no cirróticos, en los cuales se realizó dicho procedimiento. Los pacientes fueron seguidos durante 12 meses y ninguno presentó episodios de resangrado de las várices esofágicas, ni tampoco se requirió la ligadura de las várices residuales. Esta cirugía se perfila como una alternativa terapéutica para este tipo de pacientes.

Abstract One of the most serious consequences of extrahepatic portal vein thrombosis is portal hypertension with recurrent variceal bleeding. Once endoscopic variceal ligation fails and the spleno-portal axis is not permeable, modified Sugiura devascularization may be the only alternative. Its use in patients with cirrhosis has been reported, but there is little information on non-cirrhotic patients. This article presents a series of four cases of non-cirrhotic patients that underwent this procedure. Patients were followed for twelve months; none presented episodes of esophageal varices re-bleeding nor required ligation of residual varices. This surgery is outlined as a therapeutic alternative for this type of patients.

Esophageal varices presenting as lower GI bleed in an infant: a rare presentation

GI Bleeding is a common problem encountered in the emergency department and in the primary care settings. Lower GI Bleeding is relatively rare as compared to upper GI bleeding. Common causes of lower GI Bleeding are Polyp (32.5%), chronic nonspecific colitis (20.7%), lymphoid nodular hyperplasia (20%), Proctitis (18.2%), Solitary rectal ulcer (10%), Inflammatory bowel disease (6.5%).Among the various causes of lower GI Bleeding, esophageal varices is a rare cause. One such case presented to us with lower GI bleeding, on further evaluation was found to having esophageal varices due to portal hypertension. Child improved after conservative and definitive management.

Manifestaciones clínico-endoscópicas del paciente cirrótico / Clinical-endoscopic manifestations of the cirrhotic patient

RESUMEN Introducción: la cirrosis es un proceso dinámico y actualmente se conoce que cuando se elimina el agente primario de agresión que ha producido la cirrosis, se puede llegar a remitir la fibrosis. En Cuba la enfermedad representa la décima causa de muerte, con una tendencia ascendente en los últimos 20 años y una tasa de 13,4 por 100 000 habitantes. Objetivo: caracterizar clínica y endoscópicamente a pacientes con diagnóstico de cirrosis hepática. Material y método: se realizó un estudio descriptivo transversal, en el período comprendido entre los años 2017 - 19, donde el universo y la muestra quedaron constituidos por todos los pacientes mayores de 18 años ingresados con diagnóstico de cirrosis hepática. Resultados: predominó el sexo masculino en la sexta década de la vida, siento la principal causa el alcoholismo, caracterizado por manifestaciones generales, que en muchos casos debutan por complicaciones, apareciendo várices esofágicas en el 75 % de los casos, aunque gados I y II de Paquet, dependiente a un diagnóstico precoz de la enfermedad. Conclusiones: el alcoholismo crónico es la causa más frecuente de cirrosis hepática, debuta de forma frecuente por sus complicaciones, aunque el diagnóstico se hace en etapas precoces, con varices esofágicas incipientes (AU).

Summary Introduction: liver cirrhosis is a dynamic process and currently it is known that, when the primary agent of aggression that has produced the cirrhosis is eliminated, the fibrosis could remit. In Cuba, this diseases is the tenth cause of death, with an increasing tendency in the last twenty years and a rate of 13.4 per 100 000 inhabitants. Objective: to characterize, clinically and endoscopically, patients with hepatic cirrhosis diagnosis. Material and methods: a cross-sectional descriptive study was carried out, in the period 2017 - 2019, where the universe and the sample were formed by all the patients aged more than 18 years who entered the hospital with diagnosis of liver cirrhosis. Results: in this paper, male patients in their sixties predominated, being alcoholism the main cause of disease, characterized by general manifestations; patients debuted due to complications, appearing esophageal varices in 75 % of the cases, although Paquet I and II grades, in dependence to a disease precocious diagnosis. Conclusions: the authors concluded that chronic alcoholism is the most frequent cause in hepatic cirrhosis, almost always debuting by its complications, though the diagnosis is made in precocious stages, with emerging esophageal varices (AU).

Várices esofágicas superiores ( Downhill varices ). Presentación de casos y revisión de la literatura / Upper esophageal varices (Downhill varices): Case presentation and literature review

Resumen Se describen 21 casos con hallazgo incidental de várices esofágicas superiores (Downhill varices) en endoscopia de las vías digestivas altas. Además, se detallan algunos datos relevantes de la historia clínica y de los hallazgos endoscópicos. La relación hombres/mujeres fue 1:1 y la edad promedio fue de 67,9 años. La comorbilidad más frecuente fue la enfermedad pulmonar obstructiva crónica (EPOC), seguida de las neumoconiosis, la obesidad y el síndrome de apnea-hipopnea, todas con hipertensión pulmonar (HTP) asociada. Las tres últimas causas no han sido descritas previamente en la literatura sobre várices esofágicas superiores. Ningún paciente tenía antecedente de hemorragia variceal.

Abstract We describe 21 cases with incidental endoscopic findings of upper esophageal varices (downhill varices) and relevant data from patients' clinical histories and endoscopic findings. The male/female ratio was 1:1 and patients' average age was 67.9 years. The most frequent comorbidity was chronic obstructive pulmonary disease, followed by pneumoconiosis, obesity and apnea-hypopnea syndrome. All comorbidities had associated pulmonary hypertension. The last three causes have not been previously described in the literature on upper esophageal varices. None of the patients had histories of variceal hemorrhaging.

Application of artificial intelligence in various liver and pancreas diseases / 临床肝胆病杂志

A large amount of information, such as clinical hematological data and imaging images, can be extracted by artificial intelligence to form various quantifiable features, analyze the association between different features and problems concerned (such as diagnosis), and thus solve complex medical problems. This article elaborates on the efficiency of various artificial intelligence algorithms in the diagnosis of pancreatic cancer, hepatic fibrosis, and esophageal varices, so as to help clinicians with clearer understanding and better decision-making.

Effects of diabetes on rebleeding after endoscopic treatment in liver cirrhosis patients with esophageal varices / 中华消化内镜杂志

Objective@#To investigate whether combined diabetes affects rebleeding after endoscopic treatment in cirrhosis patients with esophageal varices.@*Methods@#A total of 207 liver cirrhosis cases with esophageal varices bleeding who underwent initial treatment of endoscopic variced ligation or endoscopic injection sclerotherapy in the First Affiliated Hospital of Anhui Medical University from June 2015 to March 2018 were included in the retrospective study. The cases were divided into bleeding group (n=54) and non-bleeding group (n=153) according to the presence or absence of rebleeding within 6 months after treatment. The influencing factors on postoperative bleeding were analyzed by univariate analysis and logistic regession analysis.@*Results@#Univariate analysis showed that gender composition, age, presence or absence of portal vein thrombosis, smoking history, drinking history (P=0.05), hypertension, platelet count, total bilirubin level, albumin level, alanine aminotransferase level, prothrombin time, degree of esophageal varices, and surgical methods were not significantly different (all P≥0.05) between the bleeding group and the non-bleeding group. There were significant differences in diabetes, hemoglobin level, blood glucose level, ascites composition, and liver function grade composition between the two groups (all P<0.05). Combined diabetes (yes/no), hemoglobin levels, blood glucose levels, ascites (none-mild/medium-severe), liver function Child-Pugh classification (Grade A/B-C), and history of drinking (yes/no) were included in multivariate analysis, and results showed that diabetes was an independent risk factor for rebleeding after endoscopic treatment of esophageal varices (P=0.008, OR=2.973, 95%CI: 1.322-6.689).@*Conclusion@#After endoscopic treatment of liver cirrhosis patients with esophageal varices, rebleeding is more likely to occur in patients complicated with diabetes.

Platelet count splenic diameter ratio as predictor for esophageal varices in patients with cirrhosis: a diagnostic evaluation study

Background: Esophageal variceal bleeding is one among the common complication of cirrhosis which is fatal. Latest studies are focusing more on using non-invasive techniques to classify cirrhotic patients according to their risk of having varices. The platelet count-splenic diameter ratio is considered as one such parameter and is used in predicting esophageal varices in patients with cirrhosis. Objectives of the study was to assess the utility of platelet count-splenic diameter ratio as a useful non- invasive parameter in predicting the presence/ absence /size of esophageal varices in patients with cirrhosis.Methods: Diagnostic evaluation study was done in a tertiary hospital of Kerala state India. 93 adults above the age of 18 yrs with diagnosis of cirrhosis was selected and detailed history, physical, systemic examination and imaging was done. The degree of correlation between platelet count-splenic size ratio and the presence/absence/size of esophageal varices was studied along with its utility as an independent non- invasive marker. Frequency was expressed in percentages.Results: Best cut-off for prediction of esophageal varices Grade 1 was platelet count/spleen diameter ratio of 954, which had Specificity of 85.7% and Positive predictive value of 94.1% Cut-off for prediction of Grade 2 esophageal varices was platelet count/spleen diameter ratio of 916 which had a Sensitivity of 78.9%, Specificity of 88.9%. Whereas cut-off for prediction of Grade 3 esophageal varices was a ratio of 899 which had a high Sensitivity of 88% and Negative predictive value of 93.6 % but Specificity was only 64.7% and Positive predictive value of 47.8% only.Conclusions: The platelet count splenic diameter ratio is accurate to be used as screening tool to predict the presence of Grade 2 Esophageal varices in Patients with Cirrhosis. More studies need to be done around the globe for more evidence.