Cirrhotic patients; incidence, of UGI bleeding factors and esophageal varices

To determine the frequency of upper GI bleeding and its predicting factors and esophageal varices in the patients with liver cirrhosis disease admitted at medicine ward of Isra university hospital. Prospective and observational study. Isra university hospital. March 2012 to August 2012 [six months]. Containing 100 patients, mean age was 45.8, and all the patients with cirrhosis disease were included in this study with liver cirrhosis disease. All patients were under went endoscopy and Frequency of upper GI bleeding and varices presentation and classification according to grade were noted. All the 100 patients were selected on the basis of presenting liver cirrhosis disease. Male were more found than the female with the mean age 45.8. Mostly cirrhotic patients were found with HCV positive and upper GI bleeding were noted in [40%] of the cases. With the endoscopic finding mostly patients were noted in II - III grad of esophageal varices and according to child pug classification majority of patients was noted in class "C" In addition, thrombocytopenia and red wale markings along with the presence of large sized varices were associated with the presence of esophageal varices. In the conclusion of this study we found majority of the cirrhotic patients with HCV, Esophageal varices and thrombocytopenia are the important factors of upper GI bleeding. Knowledge and etiology of this manuscript may helpful in the prevention of oesophageal varices and upper GI bleeding

Revising the criteria for the predictors of variceal haemorrhage outcome

Background and study aims: There are many criteria and definitions used to evaluate the failure to control and prevent variceal bleeding. Baveno criteria were developed in Baveno consensus workshops I-III. Some of these criteria are fairly difficult to apply and do not adequately reflect common situations that are observed in clinical practice. Therefore, new criteria were developed at the Baveno-IV workshop. In the present study, we aimed to evaluate the validity of Baveno II-IV criteria in the prediction of bleeding recurrence among patients with liver cirrhosis who presented with bleeding oesophageal varices

Patients and methods: Fifty patients with liver cirrhosis and acute variceal bleeding were divided into two groups according to treatment response. Group I consisted of 44 patients for whom treatment to control bleeding was successful, and Group II included 6 patients for whom treatment failed. Baveno criteria were used in the evaluation of treatment outcome in these patients

Results: The overall accuracy of Baveno II and III criteria was 87.3% within the first 6 h and 76.5% after 6 h, with a mean accuracy 81.9%. The overall accuracy of Baveno IV criteria in this study was 83%. The criterion of death was also very specific [100%], with 100% PPV, but its sensitivity was very low [16.7%]

Conclusion: Baveno IV criteria are less complicated, much easier to apply and have nearly the same accuracy as Baveno II/III criteria. However, there are some criteria that need to be modified, such as the adjusted blood requirement index [ABR1], among others

Natural History and Overlap of Functional Gastrointestinal Disorders / 대한소화기학회지

Functional gastrointestinal (GI) disorders are common in the general population. Based on the Rome III classification, these disorders are mutually exclusive disorders keeping the homogeneity of each functional GI disorder in research area. In contrast, many population and clinical studies have reported a considerably high rate of overlap between functional GI disorders. The overlap of functional GI disorders over other intestinal diseases might simply occur by chance due to a highly prevalent disorder. Moreover, functional GI disorders is considered a chronic stable disorder that may wax and wane for several years. However, a recent study about the natural history of functional GI disorders showed substantial transition among functional GI disorders over time. The natural history of functional GI disorders with overlapping other functional GI disorders are still in infancy and better understanding of these will be important in determining the efficacy of future therapeutic interventions.

Fatores preditivos de varizes esofágicas em pacientes com hipertensão porta / Predictors of esophageal varices in patients with portalhypertensio

A hemorragia digestiva alta decorrente da ruptura de varizes esofágicas é causa importante de morbimortalidade entre os pacientes com hipertensão porta. A profilaxia primária da hemorragia digestiva requer triagem precoce para a presença de varizes. No entanto, a triagem rotineira de todos os pacientes tem implicações econômicas. Seria desejável identificar, por meio do exame clínico ou por exames complementares menos invasivos, a população com alto risco de apresentar varizes. Selecionado o paciente com risco, a confirmação seria realizada pela endoscopia digestiva alta, uma vez que esse exame apresenta custo significativo e desconforto para o paciente, especialmente para as crianças. Os dados disponíveis na literatura são insuficientes para determinar fatores preditivos não-invasivos que possam identificar e discriminar adequadamente os adultos cirróticos com e sem varizes. Os resultados são discrepantes, com valores preditivos baixos. Enquanto novos estudos são aguardados, a triagem endoscópica é a melhor conduta, estabelecida por consenso, para a detecção de varizes esofágicas em adultos. Em crianças, não existe recomendação formal de triagem endoscópica, sendo necessária a realização de mais estudos nessa faixa etária. O objetivo deste trabalho é apresentar revisão sobre os preditores de varizes esofágicas entre adultos cirróticos e sobre a prevalência de varizes esofágicas e hemorragia digestiva em crianças e adolescentes com hipertensão porta.

High digestive hemorrhage due to esophageal varices rupture is relevant cause of morbimortality for patients with portal hypertension. The primary prophylaxis for gastrointestinal bleeding requires early screening for the presence of varicose veins. However routine screening of all patients has economic Implications. It would be desirable to identify, through less invasive clinical examination, or by imaging studies, the population at high risk for varicose veins. Once the patient at risk was selected, the confirmation would be carried out by the high digestive endoscopy, as this examination has significant price and discomfort for the patient, especially children. The data available in the literature are not sufficient to determine non-invasive predictive methods that can identify and properly discriminate adults with cirrhosis with and without varices. The results are discrepant with low predictive values. While further studies are awaited, endoscopic screening is the best approach, established by consensus for the detection of esophageal varices in adults. In children, there is no formal recommendation for endoscopic screening, which requires further studies in this age group. The aim of this paper is to present review of the predictors of esophageal varices in adults with cirrhosis and the prevalence of esophageal varices and gastrointestinal bleeding in children and adolescents with portal hypertension.

Management of oesophagogastric varices in patients treated in Algamhouria Teaching Hospital

This is a retrospective and descriptive study performed in Alghamhorea Teaching Hospital in Aden-Yemen, using the registry of the Surgical Department, during the period June 2003-June 2009. The main objectives were to analyse sex, age group, clinical manifestations and types of management of oesophagogastric varices bleeding. The total number of patients admitted to the Surgical Department of Al-ghamhorea Teaching Hospital, under diagnosis of upper gastrointestinal bleeding, were 126. Of these [126], the number of patients with oesophagogastric varices was 58 [46%] with a mean age of 39.9 years, ranging between 3-70years of whom males were 46 [79.31%] with mean age of 39.28 years, ranging between 3 -65 years and the females were 12 [20.69%] with mean age of 38.33 years [ranging between 5-70 years]. The male to female ratio was 3.83:1. The age group most affected was 41-60 years old. Re-organization and establihment of the Gastroenterology Department in Algamhouria Teaching is highly recommended

Frequency and characteristic features of portal hypertensive gastropathy in patients with viral cirrhosis

To determine the frequency and specific characteristic features of portal hypertensive gastropathy [PHG] in cirrhosis due to viral etiology. Cross-sectional descriptive study. The Aga Khan University Hospital, Karachi, from June 2006 till June 2008. Patients with hepatitis B and C cirrhosis were included who underwent screening esophago-gastro-duodenoscopy [EGD] for varices. Baveno III consensus statement was used for diagnosing PHG on endoscopy and divided them into two subgroups i.e. mild and severe. Data related to platelet/spleen ratio, MELD score and Child Turcotte Pugh [CTP] score indicating severity of cirrhosis were recorded in all patients. Findings were compared by using independent sample t-test. Out of 360 patients who underwent screening EGD, 226 [62.8%] were males. Two hundred and eighty one [78%] had hepatitis C while 79 [22%] suffered from hepatitis B related cirrhosis. Three hundred patients [83.3%] had PHG while 71 [24%] had severe PHG. Higher proportion of esophageal varices [89.7%] was present among those who had PHG [p < 0.001]. On univariate analysis lower platelet counts [117 +/- 55 vs. 167 +/- 90; p < 0.001], increased spleen size [14.1 +/- 2.9 cm vs. 12 +/- 2.4cm; p < 0.001] were found in PHG patients as compared to those without it. Similarly, lower platelet/spleen ratio was noted in patients with severe PHG [916 +/- 400 vs. 1477 +/- 899; p < 0.001]. Furthermore, on multivariate analysis CTP score > 8 MELD score > 12 and platelets/spleen ratio < 900 were significantly associated factors with severe PHG. Frequency of PHG was 83% while severe PHG was seen in 24% cases of viral hepatic cirrhosis. MELD score > 12, CTP score >/= 8 and platelets/spleen ratio

Frequency of oesophageal varices among patients undergoing GI endoscopy

At least two thirds of cirrhotic patients develop Oesophageal Varices [OV] during their lifetime. Severe Upper Gastro Intestinal [UGI] bleeding as a complication of portal hypertension develops in about 30%-40% of cirrhotics. Despite significant improvements in the early diagnosis and treatment of oesophagogastric variceal haemorrhage, the mortality rate of first variceal haemorrhage remains high [20%-35%].Aim: To find out frequency of OV in two different areas of Karachi.Method: We prepared a register of 255 patients who underwent upper GI endoscopy at Murshid Hospital and Health Care Centre between 1999 and 2003 and compared it with 254 patients scoped at Hamdard University Hospital Karachi during the same period. At Murshid Hospital oesophageal varices were present in 58 cases 22.75%, age specific occurrence was 10.3% [20-30 years], 25.8% [>30-40 years], 63.7% [>40 years] while at Hamdard University Hospital the frequency of oesophageal varices was 18 cases 7.1%, age specific occurrence at this centre showed that all cases of oesophageal varices were above the age of 45 years. A record linkage population based study of oesophageal varices allows outcomes to be identified and workout the cost. Those at risk in the population should be informed about the future implication to their health and costs. The health service should investigate the increasing incidence and prevalence of oesophageal varices at local as well as national level

Hemorragia por várices esofágicas. Alternativas actuales de tratamiento / Esophageal variceal bleeding. Current treatment options

El manejo de la hemorragia secundaria a várices esofágicas continúa evolucionando. Contando con un mayor número de opciones de tratamiento, el reto es proporcionar las más óptimas. El único tratamiento profiláctico aceptado hasta la fecha es el farmacológico. El manejo del episodio agudo requiere instalar de inmediato adecuadas medidas de reanimación y manejo específico que incluye tratamiento farmacológico y endoscópico. Hay un papel muy limitado para procedimientos de descompresión en el episodio agudo de hemorragia. La prevención de hemorragia recurrente incluye varias fases de tratamiento: tratamiento farmacológico, endoscópico o ambos, procedimientos de descompresión y trasplante hepático. El manejo de la hemorragia secundaria a várices esofágicas requiere una estrecha colaboración y coordinación de un equipo multidisciplinario.

Bleeding isolated gastric varices: a retrospective analysis.

OBJECTIVE: Isolated gastric varices (IGV) are rare and are believed to be associated with left-sided portal hypertension. We studied patients presenting with bleeding from IGV and compared them with those bleeding from both esophageal and gastric varices. METHODS: A retrospective analysis of 14 patients with bleeding from IGV was carried out. Portovenography findings (pattern of collateralization and natural shunts) in these patients were compared with a matched group of 69 patients with both esophageal and gastric varices. RESULTS: Of 14 patients with IGV, 2 had isolated splenic vein thrombosis and 12 had generalized portal hypertension. Portovenograms in 11 of the latter 12 revealed predominantly 'left-sided' collateralization in 8 patients as compared to 17 of 69 (25%) patients with esophageal and gastric varices (p = 0.004); natural shunts were seen in 6 of 11 cases and 15 of 69 (22%) patients in the two groups, respectively (p = 0.05). Abdominal devascularization operation gave good short- and long-term control of bleeding. CONCLUSIONS: Contrary to belief most patients with isolated gastric varices may have generalized portal hypertension rather than splenic vein obstruction as the cause and hence should be treated by a more extensive procedure than just splenectomy. The IGV could be a result of predominant collateralization to the retroperitoneal area (left-sided collateralization and natural shunts) rather than the usual pattern to the azygos system which results in esophageal varices.

End point for sclerosis of esophageal varices.

BACKGROUND: Small esophageal varices are difficult to inject intravariceally and complete eradication of varices may not be therapeutically necessary. METHODS: A prospective study designed to compare the use of different end points of sclerotherapy ie (i) total eradication (grade 0) (ii) grade I varices or (iii) grade II white (IIw) varices, by stopping variceal injection when one of these was reached. The patients were followed endoscopically and clinically at 3-4 mo intervals. OUTCOME MEASURES: Variceal recurrence and rebleeding rates. RESULTS: Of 266 patients with portal hypertension (147 cirrhosis, 51 non-cirrhotic portal fibrosis, 68 extra-hepatic portal venous obstruction), 232 (87.2%) reached one of the three end points--six to grade 0, 96 to grade I and 130 to grade IIw. Among 212 patients followed up for a mean post-sclerotherapy period of 12.2 mo (range 3-48 mo), variceal recurrence rates, time intervals to recurrence and rebleed rates were comparable in patients with endpoints of grade I and grade II (white) varices (28.5% vs 38.9%, 10.8 mo vs 9.2 mo, and 7.7% vs 7.8%, respectively; all p = ns). Overall, 51 patients had interval bleed before reaching the end point--50 (98%) of them bled from grade III and IV varices while only one patient (2%) bled with grade IIw varices. CONCLUSION: Grade I or grade IIw varices should be acceptable as the end points for endoscopic sclerotherapy of esophageal varices.

Endoscopic variceal ligation: an effective method of variceal obliteration.

Endoscopic variceal ligation was performed in 20 patients with portal hypertension of varied etiology. Variceal obliteration was achieved in 18 patients (90%) while recurrence of bleeding occurred in two patients (10%). The average number of bands required was four per patient and average number of sessions required for variceal obliteration was two. We found the procedure to be cheap, safe and effective in achieving early variceal obliteration.

Pancreatitis crónica; metodología diagnóstica en la hipertensión portal segmentaria, tratamiento / Chronic pancreatitis; segmentary portal hypertensión methodology diagnóstic, treatment

En una serie de 38 pancreatitis crónicas se observaron 13 pacientes con hipertensión portal segmentaria manifestada por esplenomegalia y várices esofágicas efectuándosele esplenomanometrías y esplenoportografías por punción esplénica. En 11 casos se comprobó una trombosis del tronco de la vena esplénica, en 1 paciente una cavernomatosis esplenoportal total y en uno se halló patología. Sólo un paciente sufrió hemorragias digestivas por ruptura varicosa. Esta repercusión venosa esplénica se relacionó con lesiones histopatológicas graves que obligaron a una intervención quirúrgica en 10 de los 12 pacientes.

Trasplante hepatico: experiencia en Medellin / Hepatic transplantation: experience in Medellin

Presentamos los primeros trasplantes hepaticos, variedad ortotopica, hechos en Medellin. La indicacion mas comun entre nosotros fue la cirrosis biliar primaria. Sin embargo, no hemos practicado trasplantes en menores de 1 ano, en los cuales la indicacion mas frecuente es la atresia de las vias biliares. Los factores que motivaron la decision del trasplante fueron en su orden: varices esofagicas con episodios de sangrado recurrente, en 8 casos: encefalopatias, en 5; y prurito intratable, en 3. Hubo dos casos en los cuales se usaron higados con grupo sanguineo diferente, uno de ellos sobrevivio 2 meses y el otro, mas de 4 anos. Las complicaciones biliares posoperatorias se presentaron en el 30% de los pacientes y fueron: necrosis del coledoco, necrosis vesicular y moldes biliares. Las vasculares se presentaron en el 40% e incluyeron: dos trombosis de la arteria hepatica, una ruptura de falso aneurisma con hemobilia y un embolismo aereo cerebral. Esto nos obliga a depurar mas la tecnica quirurgica. En el 70% de los casos empleamos tratamiento inmunosupresor triconjugado con ciclosporina, azatioprina y corticoides. Todos los episodios de rechazo se controlaron bien con bolos de metilprednisolona; no hubo casos de rechazo hiperagudo o acelerado en los pacientes que sobrevivieron un lapso prolongado. El empleo de la derivacion venosa solo se necesito en un 20% de los casos. La sobrevida a 1 y 2 anos es del 29%, aunque tenemos un caso que sobrevivio 4 anos y 3 meses