Risk stratification in acute variceal bleeding: Far from an ideal score

OBJECTIVES: Acute variceal bleeding (AVB) results from rupture of esophageal or gastric varices. It is a life-threatening complication of portal hypertension. Nevertheless, it remains unclear how to predict adverse outcomes and identify high-risk patients. In variceal hemorrhage, high Child-Turcotte-Pugh (Child) and Model for End-stage Liver Disease (MELD) scores are associated with a worse prognosis. The Rockall system (Rockall), Glasgow-Blatchford (Blatchford), and AIMS65 scores have been validated for risk stratification for nonvariceal upper gastrointestinal bleeding; however, their use is controversial in AVB. The aim of this study was to compare the performance of Child, MELD, Rockall, Blatchford, and AIMS65 scores in risk stratification for rebleeding and/or mortality associated with AVB. METHODS: This retrospective study was conducted at a tertiary care hospital over 42 months. The outcomes were 6-week rebleeding and mortality. The AUROC was calculated for each score (1-0.9, 0.9-0.8, and 0.8-0.7, indicating excellent, good, and acceptable predictive power, respectively). RESULTS: In total, 222 patients were included. Six-week rebleeding and mortality rates were 14% and 18.5%, respectively. No score was useful for discriminating patients at a higher risk of rebleeding. The AUROCs were 0.59, 0.57, 0.61, 0.63, and 0.56 for Rockall, Blatchford, AIMS65, Child, and MELD scores, respectively. Prediction of 6-week mortality based on Rockall (AUROC 0.65), Blatchford (AUROC=0.60), and AIMS65 (AUROC=0.67) scores were also not considered acceptable. The AUROCs for predicting mortality were acceptable for Child and MELD scores (0.72 and 0.74, respectively). CONCLUSION: Rockall, Blatchford, and AIMS65 scores are not useful for predicting 6-week rebleeding or mortality in patients with AVB. Child and MELD scores can identify patients at higher risk for 6-week mortality but not for 6-week rebleeding.

Riesgo de resangrado en hemorragia digestiva alta según la escala de Glasgow-Blatchford: herramienta de triaje / Upper gastrointestinal hemorrhage re-bleeding risk according to the Glasgow-Blatchford scale: a triage tool

Resumen Introducción: Con la escala de Glasgow-Blatchford (EG-B) se califica mediante datos clínicos, el riesgo de resangrado después de hemorragia del tubo digestivo alto (HTDA); y con las escalas de Forrest y Dagradi, mediante endoscopia. Objetivo: Evaluar la capacidad de la EG-B para identificar riesgo de resangrado a 30 días después de una HTDA; el estándar de oro de comparación fue la endoscopia. Método: Se analizaron 129 expedientes de pacientes con HTDA y endoscopia. Se cuantificaron las escalas de Glasgow-Blatchford, Forrest y Dagradi; se calculó sensibilidad, especificidad y área bajo la curva ROC (ABC-ROC) del riesgo de resangrado reportado por EG-B. Resultados: La EG-B identificó a 53 pacientes con riesgo bajo de resangrado (41.09 %) y 76 con riesgo alto (58.91 %). Con la endoscopia se identificó a 107 pacientes con hemorragia no variceal (82.94 %), 98 con riesgo bajo (89.9 %) y 11 con riesgo alto (10.09 %); además, 22 pacientes con hemorragia variceal (17.05 %), 12 con riesgo bajo (54.54 %) y 10 con riesgo alto (45.45 %). La EG-B mostró sensibilidad de 0.857, especificidad de 0.462 y ABC-ROC de 0.660. Conclusiones: La EG-B es sencilla, objetiva y útil para identificar riesgo de resangrado después de HTDA; se sugiere como herramienta de triaje en urgencias.

Abstract Introduction: The Glasgow-Blatchford scale (GBS) classifies the risk of re-bleeding after upper gastrointestinal bleeding (UGIB) using clinical data, whereas the Forrest and Dagradi scales do it by endoscopy. Objective: To assess GBS’s ability to identify re-bleeding risk within 30 days of an UGIB, using endoscopy as the gold standard for comparison. Method: 129 medical records of patients with UGIB and endoscopy were analyzed. The Glasgow-Blatchford, Forrest and Dagradi scales were quantified; sensitivity, specificity and area under the ROC curve (AUC-ROC) of GBS-reported re-bleeding risk were calculated. Results: GBS identified 53 patients with low re-bleeding risk (41.09 %) and 76 with high risk (58.91 %). Endoscopy identified 107 patients with non-variceal bleeding (82.94 %): 98 with low risk (89.9 %) and 11 with high risk (10.09 %); in addition, it identified 22 patients with variceal hemorrhage (17.05 %): 12 with low risk (54.54 %) and 10 with high risk (45.45 %). GBS showed a sensitivity of 0.857, specificity of 0.462 and an AUC-ROC of 0.660. Conclusions: GBS is simple, objective and useful to identify the risk of re-bleeding after UGIB; it is suggested as a triage tool in the emergency department.

Esofagitis por píldoras / Pill-induced esophageal injury

Si bien no se encuentra entre las principales causas de disfagia u odinofagia, la lesión de la mucosa del esófago a causa de la medicación administrada como píldoras debe ser tenida en cuenta, en particular en algún grupo etario con patologías crónicas. Presentamos el caso de una mujer con dolor retroesternal de confuso diagnóstico y buena evolución con tratamiento conservador. El mecanismo preciso por el cual se producen las lesiones no está bien claro. La videoendoscopia digestiva alta es la herramienta clave para observar las lesiones producidas y realizar diagnóstico diferencial; además puede resolver algunas complicaciones. En la mayoría de los casos, el tratamiento es médico. Esta situación debe tenerse presente para realizar un correcto interrogatorio y examen endoscópico.

Dysphagia and odynophagia should be considered as symptoms of pill-induced esophageal injury, particularly in age groups with chronic diseases. We report a case of a female patient with retrosternal chest pain of unclear diagnosis and favorable outcome with conservative treatment. The precise mechanism of esophageal injury remains uncertain. Upper gastrointestinal videoendoscopy is the essential tool to examine the lesions, make differential diagnosis and treat some complications. Medical treatment is useful in most cases. This condition should be kept in mind for proper interrogation and endoscopic examination.

Desempeño del índice FIB-4 en el despistaje de várices esofágicas en pacientes con el diagnóstico de cirrosis hepática / Performance of the FIB-4 index in esophageal varices screening in patients with the diagnosis of liver cirrhosis

RESUMEN Introducción: El diagnóstico de várices esofágicas en pacientes cirróticos se realiza mediante la endoscopía digestiva alta. Se han estudiado predictores no invasivos para el diagnóstico de estas. Objetivo: El objetivo de este estudio es evaluar el desempeño del índice FIB-4 en el despistaje de várices esofágicas en pacientes con diagnóstico de cirrosis hepática. Materiales y métodos: Se realizó un estudio transversal analítico en cuatro hospitales nacionales utilizando historias clínicas de pacientes cirróticos. Se realizó el análisis univariado y bivariado, cálculo de sensibilidad, especificidad, valor predictivo positivo y negativo, razón de verosimilitud positiva y negativa del índice FIB-4 para el despistaje de várices esofágicas, tamaño de estas y profilaxis. Se construyeron curvas ROC para cada grupo de análisis. Resultados: Se incluyó 289 pacientes con diagnóstico de cirrosis hepática, la mayor parte fueron de sexo masculino (54,33%). 77,85% presentaron várices esofágicas. La distribución del tamaño de várices fue de 19,03%, 35,99% y 22,84% para várices grandes, medianas y pequeñas, respectivamente. En el análisis del índice FIB-4 con la presencia de várices se encontró una sensibilidad de 81,3% y una especificidad de 37,5% (AUC: 0,57). Para el tamaño de várices se encontró una sensibilidad 81,8% y una especificidad de 23,9% (AUC: 0,50). En el análisis de FIB-4 para grupos de profilaxis se encontró una sensibilidad de 81,8% y una especificidad de 28,5% (AUC: 0,54). Conclusiones: El índice FIB-4 no tiene un buen desempeño en el despistaje de la presencia várices esofágicas y su tamaño en pacientes con diagnóstico de cirrosis hepática.

ABSTRACT Introduction: The diagnosis of esophageal varices in cirrhotic patients is made by the upper gastrointestinal endoscopy. Multiple non-invasive predictors have been studied for the diag-nosis of esophageal varices. The objective of this study is to testthe FIB4 index as screening of esophageal varices in patients with liver cirrhosis. Materials and methods: A cross-sectional analytic study was developed in four national hospital using hepatic cirrhosis patient's medi-cal files. We assessed the information using univariate and bivariate analysis, sensitivity, speci-ficity, predictive positive and negative value, the positive and negative likelihood ratio calcu-lation of the esophageal varices screening and its size. We built ROC curve for every analysis group. Results: The study included 289 liver cirrhosis patients. Most of the patients were male (54.33%). 77.85% patients had esophageal varices. The distribution of varices was 19.03%, 35.99% and 22.84% for large, medium and small varices, respectively. In the FIB-4 index analysis for the presence of varices, it was found a sensitivity of 81.3%, specificity of 37.5% (AUC: 0.57). The calculation for variceal size showed a sensitivity of 81.8%, specificity of 23.9% (AUC: 0.50). In the analysis of FIB-4 index for prophylaxis groups was found a sensitivity of 81.8% and a specificity of 28.5% (AUC: 0.54). Conclusions: The FIB-4 index has no good performance in the screening for the presence of esophageal varices and its size in liver cirrhosis patients.

Doença ulcerosa péptica: realmente é possível identificá-la por meio das características da dor epigástrica? / Peptic ulcer disease: is it really possible to identify it through the characteristics of epigastric pain?

OBJETIVO: Determinar se características da dor epigástrica são capazes de identificar pacientes com doença ulcerosa péptica. MÉTODOS: Estudo caso-controle, com coleta de dados de setembro de 2014 a junho de 2016. Foram incluídos pacientes com mais de 18 anos com dispepsia que realizaram endoscopia digestiva alta ambulatorialmente. Os pacientes foram abordados antes de realizar a endoscopia digestiva alta, verificando, em suas guias, a presença de dispepsia, tendo sido convidados a responder um questionário, e, posteriormente, o prontuário de cada entrevistado foi avaliado para verificação do diagnóstico, sendo, então, divididos entre o Grupo Doença Ulcerosa Péptica (casos), com 32 pacientes, e o Grupo Controle, com 44 pacientes com dispepsia atribuída a outras causas. RESULTADOS: Dos pacientes com dispepsia não ulcerosa, 52,27% caracterizaram a dor como em queimação, sendo 47,72% moderada e que piorava com alimentação. Dentre os demais sintomas, 45,45% relataram náuseas e 25% desconforto pós-prandial, com 52,27% relatando histórico familiar negativo de doença ulcerosa péptica. Em contrapartida, dos pacientes com doença ulcerosa péptica, 53,12% referiram dor em queimação e de moderada intensidade, e 50% relataram piora com alimentação. Dentre os demais sintomas, prevaleceram também náuseas (53,12%) e desconforto pós-prandial (40,62%). A maioria (81,25%) relatou histórico familiar de doença ulcerosa péptica. Observou-se diferença estatística em dor noturna, predominando na doença ulcerosa péptica (p=0,0225) e dor em cólica na dispepsia não ulcerosa (p=0,0308), assim como na ausência de histórico familiar entre os pacientes com dispepsia não ulcerosa (p=0,0195). CONCLUSÃO: A dispepsia relacionada à doença ulcerosa péptica relaciona-se, principalmente, à piora noturna, sendo que a intensidade da dor, a relação com alimentação e os sintomas associados não auxiliaram na diferenciação da dispepsia não ulcerosa, diferentemente do que a literatura tradicionalmente informa. (AU)

To determine whether it is possible to identify Peptic Ulcer Disease through the characteristics of epigastric pain. METHODS: This is a case-control study with data collected between September 2014 and June 2016 including patients over 18 years of age with dyspepsia who underwent upper gastrointestinal endoscopy as outpatients. The patients were approached before the upper gastrointestinal endoscopy when their test requisition form indicated the presence of dyspepsia. The subjects were invited to answer a questionnaire and, afterwards, the records of all interviewees were evaluated to check for the diagnosis. Then, they were divided into a peptic ulcer disease group (cases), with 32 patients, and a control group, with 44 patients with dyspepsia from other causes. RESULTS: Among non-ulcer dyspepsia patients, 52.27% described the pain as a "burning pain", with 47.72% reporting it as moderate and aggravated by food intake. As for other symptoms, 45.45% of subjects reported nausea, and 25% reported postprandial discomfort; 52.27% had no family history of peptic ulcer disease. In contrast, 53.12% of peptic ulcer disease patients reported "burning" and moderate pain, and 50% said the pain was aggravated by eating. As for the other symptoms, nausea (53.12%) and postprandial discomfort (40.62%) prevailed; most of the patients (81.25%) had family history of peptic ulcer disease. There was a statistical difference in night pain, which was more prevalent in peptic ulcer disease (p=0.0225), and colicky pain, which was more frequent in nonulcer dyspepsia (p=0.0308), as well as absence of family history in non-ulcer dyspepsia patients (p=0.0195). CONCLUSION: Dyspepsia caused by peptic ulcer disease is mainly related to night worsening, and pain intensity, the relationship with food intake, and associated symptoms did not help differentiate nonulcer dyspepsia, differently from what the medical literature traditionally suggests. (AU)

Razão da contagem de plaquetas ao quadrado/diâmetro do baço-aspartato aminotransferase: avaliação de um novo método não-invasivo para a predição de varizes esofágicas / Platelet count squared/spleen diameter-aspartate aminotransferase ratio: non-invasive method to predict esophageal varices

ABSTRACT BACKGROUND - Variceal bleeding has a high mortality among cirrhotics, and screening with endoscopy is indicated at the diagnosis of cirrhosis. Screening with endoscopy implies discomfort, risks and considerable costs. OBJECTIVE - To evaluate platelet count squared/spleen diameter-aspartate aminotransferase ratio (PS/SA), as a non-invasive predictor of esophageal varices in cirrhotics. METHODS - This cross-sectional study evaluated cirrhotics for PS/SA and presence of esophageal varices. Outpatient records of cirrhotic patients were reviewed for the abovementioned data. Sensitivity, specificity, negative and positive predictive values of PS/SA were calculated. After the univariate analysis, variables with P<0.10 were submitted to a logistic regression. RESULTS - The study included 164 cirrhotics, 59.70% male, with a mean age of 56.7 years. Hepatitis C was the most frequent cause of cirrhosis, being present in 90 patients. Patients were classified as Child-Pugh A in 52.44% and as Child-Pugh B or C in 47.56%. Esophageal varices were present in 72.56% of the patients at endoscopy. PS/SA, with a cutoff of 3x108, had a sensitivity of 95.80% (confidence interval of 95% - 95%CI=0.92-0.99), a specificity of 22.70% (95%CI=0.10-0.35), a positive predictive value of 77.20% (95%CI=0.70-0.84) and a negative predictive value of 66.70% (95%CI=0.42-0.91). In the logistic regression, only platelet count and Child-Pugh score were associated to esophageal varices (P<0.05). CONCLUSION - PS/SA has an excellent sensitivity to predict esophageal varices, allowing almost one fourth of patients without esophageal varices to spare endoscopy. Nevertheless, PS/SA is not independently associated to esophageal varices.

RESUMO CONTEXTO - A hemorragia varicosa tem elevada mortalidade entre cirróticos, e o rastreamento endoscópico de varizes está indicado no momento do diagnóstico da cirrose. O rastreamento endoscópico implica desconforto, riscos e custos consideráveis. OBJETIVO - Avaliar a razão da contagem de plaquetas ao quadrado/diâmetro do baço-aspartato aminotransferase (PQ/BA) como preditor não-invasivo de varizes esofágicas em cirróticos. MÉTODOS - Este estudo transversal avaliou cirróticos quanto ao PQ/BA e à presença de varizes esofágicas. Prontuários ambulatoriais de cirróticos foram revisados quanto a tais dados. Sensibilidade, especificidade e valores preditivos negativo e positivo do PQ/BA foram calculados. Após a análise univariada, variáveis com P<0,10 foram submetidas à regressão logística. RESULTADOS - O estudo incluiu 164 cirróticos, 59,70% masculinos, com média de idade de 56,7 anos. Hepatite C foi a mais frequente causa de cirrose, estando presente em 90 pacientes. Os pacientes foram classificados como Child-Pugh A em 52,44% e em Child-Pugh B ou C em 47,56%. As varizes esofágicas estiveram presentes à endoscopia em 72,56% dos pacientes. PQ/BA, com um ponto de corte de 3x108, teve sensibilidade de 95,80% (intervalo de confiança de 95% - IC95%=0,92-0,99), especificidade de 22,70% (IC95%=0,10-0,35), valor preditivo positivo de 77,20% (IC95%=0,70-0,84) e valor preditivo negativo de 66,70% (IC95%=0,42-0,91). Na regressão logística, apenas a contagem de plaquetas e o escore de Child-Pugh associaram-se às varizes esofágicas (P<0,05). CONCLUSÃO - PQ/BA apresentou excelente sensibilidade para predizer varizes esofágicas, permitido que cerca de um quarto dos pacientes sem varizes esofágicas evitasse a endoscopia. Entretanto, PQ/BA não se associou de maneira independente às varizes esofágicas.

Caput Medusae due to portal hypertension in schistosomiasis mansoni / Cabeza de Medusa debida a la hipertensión portal en esquistosomiasis mansoni

A 62-year-old Brazilian man who lived in endemic areas of tropical diseases had an episode of hematemesis associated with portal hypertension. He used to swim in natural ponds during childhood and developed the hepatosplenic form of schistossomiasis with moderate ascites, in addition to the characteristic features of abdominal Caput Medusae. The aim of the report is highlight the role of chronic liver disease and schistossomiasis

Un hombre natural de Brasil de 62 años de edad que vivía en zonas endémicas de enfermedades tropicales presentó un episodio de hematemesis asociada con hipertensión portal. Frecuentemente se bañaba en los estanques naturales durante la infancia y desarrolló la forma hepatosplénica de la esquistosomiasis con ascitis moderada, además de los rasgos abdominales característicos de la Cabeza de Medusa. El objetivo del informe es poner de relieve el papel de la enfermedad hepática crónica y de la esquistosomiasis

Approche non endoscopique du diagnostic des varices oesophagiennes d'origine cirrhotique dans une population d'Afrique noire subsaharienne

OBJECTIFS. Identifier des parametres cliniques et para cliniques pour l'approche non endoscopique du diagnostic des varices osophagiennes chez les patients atteints de cirrhose; en contexte sub-saharien. MATeRIELS ET MeTHODES. Les dossiers de patients cirrhotiques camerounais examines au Centre Hospitalier et Universitaire de Yaounde entre mars 2013 et novembre 2014 ont ete revus. Les donnees cliniques; biologiques; echographiques et ont ete analysees et comparees a la severite des varices osophagiennes retrouvees par endoscopie. La methode de classification et regression par carte a permis de construire un arbre de prediction des varices osophagiennes. ReSULTATS. Nous avons inclus 98 patients cirrhotiques d'age compris entre 14 et 80 ans. Les hepatites virales B et C ont ete retrouvees chez 78 patients (79;59%). 53 patients (54;08%) etaient classes Child-Pugh C. La prevalence des varices osophagiennes etait de 92% (90/98) avec 63;27% de grade III. Les variables independamment associes a la severite des varices osophagiennes etaient les taux de prothrombine; d'hemoglobine; d'albumine; de leucocytes; de creatinine serique et la taille de la rate. Ces facteurs ont ete utilises pour construire un arbre de prediction de survenue des VO. CONCLUSION. A l'aide d'un arbre decisionnel integrant la taille de la rate et cinq facteurs biologiques; il est possible de predire la severite des varices osophagiennes post-cirrhotiques en contexte sub-saharien

Diagnóstico no invasivo de la presencia de várices esofágicas en pacientes cirróticos / [Noninvasive diagnosis of esophageal varices in cirrhotic patients].

INTRODUCTION: Variceal bleeding is a frequent and serious complication of cirrhosis. Early detection of varices by videogastroscope (VGC) is recommended in all patients with cirrhosis to determine the need for prophylactic treatment. Have been described noninvasive markers of the presence of esophageal varices, which could prevent the realization of VGC for that purpose. OBJECTIVE: To determine and compare noninvasive (longitudinal diameter of spleen, platelet count, platelet reason / spleen) as predictors of the presence of esophageal varices. MATERIAL AND METHODS: We retrospectively studied 125 patients with cirrhosis from any cause. They had VGC, blood count and abdominal ultrasonography. The diagnostic accuracy for determining the presence of esophageal varices or large varices according to the different variables was studied using the area under the ROC curve (AUROC). RESULTS: The prevalence of esophageal varices was 63.2

were diagnosed with large varices. The reason platelets/spleen and platelet count showed an AUROC of 0.74 for the detection of esophageal varices. The cut-off for the ratio platelets / spleen was 1.010 (sensitivity 72.15

) for the presence of varices and 870 for the presence of clinically significant varices (sensitivity 62.26

). The analysis according to these breakpoints showed that 23.6

of patients with scores higher than 1,010 had large varices and 45

of patients with values lower than 870 had not large varices. CONCLUSIONS: Although the reason platelets/spleen showed an AUROC acceptable, its implementation would entail a risk of not diagnosing large varices in almost a quarter of the population studied.

Clinical features and outcomes of gastric variceal bleeding: retrospective Korean multicenter data

BACKGROUND/AIMS: While gastric variceal bleeding (GVB) is not as prevalent as esophageal variceal bleeding, it is reportedly more serious, with high failure rates of the initial hemostasis (>30%), and has a worse prognosis than esophageal variceal bleeding. However, there is limited information regarding hemostasis and the prognosis for GVB. The aim of this study was to determine retrospectively the clinical outcomes of GVB in a multicenter study in Korea. METHODS: The data of 1,308 episodes of GVB (males:females=1062:246, age=55.0+/-11.0 years, mean+/-SD) were collected from 24 referral hospital centers in South Korea between March 2003 and December 2008. The rates of initial hemostasis failure, rebleeding, and mortality within 5 days and 6 weeks of the index bleed were evaluated. RESULTS: The initial hemostasis failed in 6.1% of the patients, and this was associated with the Child-Pugh score [odds ratio (OR)=1.619; P<0.001] and the treatment modality: endoscopic variceal ligation, endoscopic variceal obturation, and balloon-occluded retrograde transvenous obliteration vs. endoscopic sclerotherapy, transjugular intrahepatic portosystemic shunt, and balloon tamponade (OR=0.221, P<0.001). Rebleeding developed in 11.5% of the patients, and was significantly associated with Child-Pugh score (OR=1.159, P<0.001) and treatment modality (OR=0.619, P=0.026). The GVB-associated mortality was 10.3%; mortality in these cases was associated with Child-Pugh score (OR=1.795, P<0.001) and the treatment modality for the initial hemostasis (OR=0.467, P=0.001). CONCLUSIONS: The clinical outcome for GVB was better for the present cohort than in previous reports. Initial hemostasis failure, rebleeding, and mortality due to GVB were universally associated with the severity of liver cirrhosis.

Practical Approach to Endoscopic Management for Bleeding Gastric Varices

Bleeding from gastric varices is generally more severe than bleeding from esophageal varices, although it occurs less frequently. Recently, new endoscopic treatment options and interventional radiological procedures have broadened the therapeutic armamentarium for gastric varices. This review provides an overview of the classification and pathophysiology of gastric varices, an introduction to current endoscopic and interventional radiological management options for gastric varices, and details of a practical approach to endoscopic variceal obturation using N-butyl-2-cyanoacrylate.

Profilaxis primaria de várices esofágicas en pediatría / Primary prophylactic treatment of esophageal varices in pediatrics

Children with chronic liver disease or portal vein thrombosis frequently develop portal hypertension. The main complication of the portal hypertension are the development of esophageal varices who are at risk of variceal bleeding, which is associated with significant morbidity and mortality. Guidelines for adults with portal hypertension recommend performing esophagogastroduodenoscopy to identify those with varices that may benefit from prophylactic therapy, however there are no consensus in the pediatric age. This revision includes the incidence, diagnostic and the evidence for primary prophylactic treatment of the esophageal varices in children.

Pacientes pediátricos con daño hepático crónico o con trombosis de la vena porta frecuentemente desarrollan hipertensión portal. La principal complicación de la hipertensión portal es el desarrollo de várices esofágicas que conlleva riesgo de hemorragia variceal, la cual se asocia a significativa morbimortalidad. Las guías clínicas para adultos recomiendan realizar, en pacientes cirróticos, una endoscopia como screening para el diagnóstico de várices esofágicas y su tratamiento profiláctico, sin embargo, en pacientes pediátricos no existe consenso. En esta revisión se actualiza la incidencia, diagnóstico y evidencia del tratamiento profiláctico primario de várices esofágicas en pediatría.

Prediction of large esophageal varices in cirrhotic patients using classification and regression tree analysis

OBJECTIVES: Recent guidelines recommend that all cirrhotic patients should undergo endoscopic screening for esophageal varices. That identifying cirrhotic patients with esophageal varices by noninvasive predictors would allow for the restriction of the performance of endoscopy to patients with a high risk of having varices. This study aimed to develop a decision model based on classification and regression tree analysis for the prediction of large esophageal varices in cirrhotic patients. METHODS: 309 cirrhotic patients (training sample, 187 patients; test sample 122 patients) were included. Within the training sample, the classification and regression tree analysis was used to identify predictors and prediction model of large esophageal varices. The prediction model was then further evaluated in the test sample and different Child-Pugh classes. RESULTS: The prevalence of large esophageal varices in cirrhotic patients was 50.8 percent. A tree model that was consisted of spleen width, portal vein diameter and prothrombin time was developed by classification and regression tree analysis achieved a diagnostic accuracy of 84 percent for prediction of large esophageal varices. When reconstructed into two groups, the rate of varices was 83.2 percent for high-risk group and 15.2 percent for low-risk group. Accuracy of the tree model was maintained in the test sample and different Child-Pugh classes. CONCLUSIONS: A decision tree model that consists of spleen width, portal vein diameter and prothrombin time may be useful for prediction of large esophageal varices in cirrhotic patients.

Comparative study of endoscopic variceal ligation and endoscopic variceal sclerotherapy in children with portal hypertension

Gastroesophageal variceal bleebing is a serious complication of portal hypertension. Endoscopic variceal Sclerotherapy [EVS] has been considered the mainstay of therapy for bleeding esophageal varices but it is associated with substantial local and systemic complications. However, recent data have shown that ehdoscopic variceal ligation [EVL] is just as efficacious and has fewer complications than EVS. Although there are many reports concerning EVL in adults, only a few studies have been done in children. The aim of this work was to compare the effectiveness and safety of endoscopic variceal ligation [EVL] and endoscopic variceal Sclerotherapy [EVS] in children with portal hypertension who had proved recent bleeding from esophageal varices. This study was conducted on 30 children [17 males and 13 females] with portal hypertension who had proved recent bleeding from esophageal varices. Their ages ranged from 5 to 18 years. They were selected from those admitted to the Hepatology Unit of Pediatric Department, Tanta University Hospitals. In this study all patients were subjected to the following: full clinical history, thorough physical examination, routine abdominal ultrasonography as well as laboratory investigations. The latter included complete blood count, liver function tests, blood urea, serum creatinine and hepatitis markers. Upper gastrointestinal endoscopy was performed after resuscitation of bleeding patients for diagnosis and treatment of bleeding esophageal varices. Fifteen patients were treated with Sclerotherapy [Group I], and the other 15 patients were treated with band ligation [Group II]. Initial treatment for acute bleeding was followed by elective retreatment to eradicate varices. The patients were followed for a mean of 10 months, during which we determined the incidence of complications, the number of sessions needed to eradicate varices, rebleeding and recurrences of varices. Endoscopic Sclerotherapy and ligation were equally effective for the control of active variceal bleeding and no significant differences were found between the Sclerotherapy and ligation groups in arresting active index bleeding and achieving variceal eradication. The rate of variceal eradication in the EVS group was not significantly different from the EVL group [86.7% vs. 93.3%, respectively, P = 0.55], but band ligation eradicated varices more quickly than did Sclerotherapy [59.2 +/- 17 vs. 91.3 +/- 32.6 days, respectively, P = 0.0001] and in fewer endoscopic sessions [4.7 +/- 1.1 vs. 7.3 +/- 2.6, respectively, P= 0.0001]. The overall rate of rebleeding before variceal eradication wassignificantly higher in patients undergoing EVS than those undergoing EVL [39.9% vs. 6.6%, P = 0.034] as was the rate of major complications [46.2% vs. 6.6%, P =0.035] After eradication, esophageal variceal recurrence was not significantly different in patients treated by ligation than by sclerotherapy [21.4%% vs. 15.4%, P =0.927]. EVL is superior to EVS for acute and long-term management of bleeding esophageal varices because of its relative ease, faster obliteration, and lower complication and rebleeding rates. It appears that band ligation may replace sclerotherapy as the first choice for control of acute variceal bleeding and for eventual esophageal variceal eradication. Further long-term studies are needed to understand the evolution of variceal recurrence and portal hypertensive gastropathy in patients undergoing EVL

Can serum fibrosis markers predict medium/large oesophageal varices in patients with liver cirrhosis?

Non-invasive predictors of medium/large oesophageal varices [LOVs] could reduce the number of screening endoscopies. As portal hypertension is a consequence of liver fibrosis, serum fibrosis markers were evaluated together with other variables as possible non-invasive predictors of medium OV/LOV. A total of 154 cirrhotic patients with splenomegaly and 30 healthy control subjects were recruited in a prospective study in two gastroenterology centres in Upper Egypt. Clinical parameters assessed included Child-Pugh class, liver size and ascites. Laboratory parameters included complete blood count, liver function tests, and aspartate aminotransferase [AST]/platelet ratio. Transforming growth factor-p! [TGF-beta [1]], alpha2 macro globulin [A[2]M] and hyaluronic acid [HA] were assayed. Ultraso-nographic examination was done for assessment of liver span, portal vein diameter and detection of minimal ascites. Oesophageal varices were diagnosed and graded by oesophagogastroduodenoscopy. Fifty-four patients [35%] had no or small varices and 100 [65%] patients had medium OV/LOV by endoscopy. On multivariate analysis, the independent predictors of medium OV/LOV were the presence of ascites [beta = 0.258, p = 0.047] and serum HA [beta = 0.449, p = 0.009]. The receiver operating characteristic curve for HA showed the area under the curve to be 0.916. The sensitivity, specificity, positive and negative predictive values and diagnostic accuracy of HA at a cut-off value of 207 micro g T[1] were 94%, 77.8%, 88.7%, 87.5% and 88.3%, respectively. The presence of ascites and serum HA level higher than 207 micro g T[1] can predict the presence of medium OV/LOV in cirrhotic patients. This would help physicians to identify patients who would most likely benefit from screening endoscopy and thus, reduce costs and discomfort from unnecessary endoscopic procedures

Platelet count/spleen diameter ratio: analysis of its capacity as a predictor of the existence of esophageal varices / Índice contagem de plaquetas/diâmetro do baço: análise de sua capacidade como preditor da existência de varizes esofágicas

CONTEXT: Upper gastrointestinal bleeding associated to esophageal varices is the most dramatic complication of cirrhosis. It is recommended screening every cirrhotic for esophageal varices with endoscopy. OBJECTIVES: To evaluate the capacity of the platelet count/spleen diameter ratio in non-invasively predicting esophageal varices in a population of cirrhotics originated in an independent center from the one in which it was developed. METHODS: The study included patients from the ambulatory care clinic of cirrhosis of a Brazilian hospital and studied platelet count, spleen diameter and presence of esophageal varices, as well as Child and MELD scores. It used a cutoff value of 909 for the platelet count/spleen diameter ratio, as previously published. A sample of 139 patients was needed to grant results a 95 percent confidence level. RESULTS: The study included 164 cirrhotics, 56.7 percent male, with a mean age of 56.6 ± 11.6 years. In the univariate analysis, platelet count, spleen diameter, presence of ascites, Child and MELD scores and the platelet count/spleen diameter ratio were related to esophageal varices (P<0.05). The platelet count/spleen diameter ratio had sensitivity of 77.5 percent (95 percent CI = 0.700-0.850), specificity of 45.5 percent (95 percent CI = 0.307-0.602), positive predictive value of 79.5 percent (95 percent CI = 0.722-0.868), negative predictive value of 42.6 percent (95 percent CI = 0.284-0.567) and accuracy of 68.9 percent (95 percent CI = 0.618-0.760). In the multivariate analysis, platelet count was the only variable which related to esophageal varices (P<0.05). CONCLUSION: Platelet count/ spleen diameter ratio is not adequate to predict esophageal varices in cirrhotics.

CONTEXTO: Hemorragia digestiva por varizes esofágicas é a complicação mais dramática da cirrose. É recomendada triagem de varizes esofágicas em todo o cirrótico. OBJETIVO: Avaliar o índice de contagem de plaquetas/diâmetro do baço como predição de varizes esofágicas em uma população distinta daquela em que ele foi desenvolvido. MÉTODOS: O estudo incluiu pacientes do ambulatório de cirrose de um hospital brasileiro quanto ao número de plaquetas, diâmetro ecográfico do baço, presença de varizes esofágicas, Child e MELD. O ponto de corte do índice foi de 909. Amostra de 139 pacientes foi estimada para conferir nível de confiança de 95 por cento. RESULTADOS: Incluíram-se 164 cirróticos, 56,7 por cento homens e com média de idade de 56,6 anos. Na análise univariada, número de plaquetas, diâmetro do baço, ascite, Child, MELD e o índice de contagem de plaquetas/diâmetro do baço relacionaram-se às varizes esofágicas (P<0,05). Na multivariada, só a contagem de plaquetas associou-se a elas (P<0,05). O índice de contagem de plaquetas/diâmetro do baço apresentou sensibilidade de 77,5 por cento (IC 95 por cento = 0,700-0,850), especificidade de 45,5 por cento (IC 95 por cento = 0,307-0,602), valor preditivo positivo de 79,5 por cento (IC 95 por cento = 0,722-0,868), valor preditivo negativo de 42,6 por cento (IC95 por cento = 0,284-0,567) e precisão de 68,9 por cento (IC 95 por cento = 0,618-0,760). CONCLUSÃO: O índice de contagem de plaquetas/diâmetro do baço não é adequado para a triagem de varizes esofágicas em cirróticos.

Aspectos novedosos de la hipertensión portal: [revisión] / Novel aspects of portal hypertension: [review]

Fundamento: la hipertensión portal es la complicación más común de la cirrosis que explica una importante morbilidad y mortalidad, principalmente debido a hemorragia por várices esofágicas, la ascitis y sus infecciones bacterianas sobreañadidas, la encefalopatía hepato-amoniacal, y el síndrome hepatorrenal. Los avances en el diagnóstico y su manejo son examinados a continuación en vistas a las perspectivas actuales. Desarrollo: la medición del gradiente de presión de la vena hepática, aporta una importante información pronóstico en estos pacientes. La prueba no invasiva con elastografía, cápsula endoscópica, y tomografía computarizada para el diagnóstico de várices esofágicas son prometedoras pero se necesita más información. Los datos clínicos en pacientes con sangramiento por várices esofágicas proveen una información importante para la terapia inicial y el pronóstico. Las nuevas terapias para pacientes con hiponatremia dilucional con antagonistas de la vasopresina son prometedoras y pueden mejorar el manejo de esta afección. Conclusiones: el terlipressin es la mejor terapia médica actualmente disponible para el manejo del síndrome hepatorrenal como se confirmó recientemente. Los pacientes con la enfermedad hepática avanzada se benefician de la administración por largos períodos del norfloxacin para prevenir el desarrollo del síndrome hepatorrenal y mejorar la supervivencia. Los avances en el diagnóstico y manejo de pacientes con cirrosis e hipertensión portal mejoraran la morbilidad y mortalidad de sus complicaciones.

Background: portal hypertension is the most common complication of cirrhosis that explains an important morbidity and mortality, mainly due to hemorrhage for esophageal varices, ascites and its superadded bacterial infections, the hepato-ammoniacal encephalopathy, and the hepatorenal syndrome. Advances in diagnosis and their management are examined next in view of current perspectives. Development: the pressure gradient mensuration of the hepatic vein, contributes an important prognostic information in these patients. The non invasive test with elastography, endoscopic capsule, and computed tomography for esophageal varices diagnosis are promising but more information is needed. Clinical data in patients with bleeding for esophageal varices provide important information for initial therapy and prognosis. New therapies for patients with dilutional hyponatremia with vasopressin antagonists are promising and may improve this affection management. Conclusions: the terlipressin is currently the best available medical therapy for the hepatorenal syndrome management as has been confirmed recently. Patients with advanced liver disease are benefiting with norfloxacin administration for long periods to prevent hepatorenal syndrome development and to improve survival. Advances in diagnosis and patients’ management with cirrhosis and portal hypertension improved morbidity and mortality of their complications.