Hemodynamic predictors for acute variceal hemorrhage in cirrhotic patients

In cirrhotic patients once varices occur they tend to progressively increase in size and the risk of bleeding has been shown to be related to varix size and appearance as well as the severity of the underling liver disease. About 30% of patients with varices will experience bleeding. This work was a trial to study if the portal hemodynamic parameters can be considered as predictors for the onset of acute variceal bleeding in cirrhotic patients? And to study the possible correlation of these predictors to the clinical and laboratory prognostic indicators. The study was conducted on 50 patients with liver cirrhosis, 40 of them had acute variceal bleeding [group 1], and 10 with non-bleeding esophageal varices [group l]. All patients were subjected to thorough history taking, clinical examination, and a series of investigations including upper gastrointestinal endoscopy, laboratory investigations [complete blood picture, some liver function tests, viral markers, serum creatinine], and radiological assessment [abdominal ultrsound, Dopuler study of the portal venous system, and portal angiography]. Group I patients had more worsening of Child-Pugh score with B/C classes [75%] than group Il [30%]. Lower platelet count [p=0.001], higher serum bilirubin [P=0.007], and pro-longed prothrombin time [p=0.007] were found in-group I patients. Both North Italian Endoscopic Club index and the Endoscopic Prognostic Index exhibited significant importance in group I patients [p=0.001]. Significant increase in portal vein diameter [p=0.006], in its cross sectional area [p=0.05], and in portal vein flow [p-0.006], in free pressure [p=0.001], wedged hepatic vein pressure [p=0.001], and hepatic vein pressure gradient [p=0.003] were found in group I. Also, in group I patients, hepatic vein pressure gradient was found to be positively correlated with ascites, splenic size, and prolonged prothrombin time, but, negatively correlated with platelet count

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In Conclusion: in the presence of cirrhosis with non-bleeding esophageal varices, the clinician has to evaluate the risk for bleeding. In those patients, non-invasive hemodynamic study of the portal circulation by endoscopic prognostic index and/ or Doppler study of the portal venous system can be considered as non-invasive tools for prediction of variceal bleeding and would help to enable better understanding of this condition overall. Furthermore, these parameters could replace the invasive measurements of portal vein pressure and hepatic vein pressure gradient as predictors for variceal bleeding in cirrhotic patients