Can Endothelin-1 Levels in Patients with Esophageal Variceal Bleeding at Admission Predict Rebleeding Within 5 Days?

BACKGROUND/AIMS: Portal hypertension complicating liver cirrhosis is associated with vascular resistance, possibly due to overexpression of humoral vasoconstrictors, including endothelin. The study aimed to evaluate the efficacy of serum endothelin-1 levels as a noninvasive predictor of early esophageal rebleeding (within 5 days) following endoscopic treatment. MATERIALS AND METHODS: Of the patients presented to the endoscopy unit at Mansoura University Hospital, 50 patients were chosen for this study on the basis of endoscopically proven acute esophageal variceal bleeding consequent to hepatitis C viral infection complicated by liver cirrhosis and portal hypertension. Routine laboratory parameters and serum endothelin-1 levels were assessed prior to endoscopic treatment. Patients were divided into 2 groups depending on the development of early postendoscopic rebleeding. Group A consisted of 16 patients who developed rebleeding, while group B included 34 patients who did not. Statistical analysis was performed to determine the predictors of rebleeding. RESULTS: Multivariate logistic regression demonstrated that endothelin-1 level (P < .001) and serum albumin level (P = .04) were independent risk factors for early rebleeding. The most efficient cutoff value for endothelin-1 levels in predicting variceal rebleeding within the 5 days after endoscopic intervention was 65.29, which had an 88.2% specificity, 87.5% sensitivity, 88% accuracy, and area under the curve value of 0.89. In addition, hemoglobin, albumin, and creatinine levels were significantly different between bleeding and nonrebleeding groups (P = .03, P = .014, and P <.001, respectively), as was the duration of hospital stay (P < .001). CONCLUSION: Serum endothelin-1 levels appear to be a reliable, practical, noninvasive predictor of early variceal rebleeding and related comorbidities such as the severity of kidney affection and duration of hospital stay.

Mansoura simple scoring system for prediction of spontaneous bacterial peritonitis: lesson learnt.

BACKGROUND AND OBJECTIVE: Spontaneous bacterial peritonitis (SBP) is a common bacterial infection with life-threatening sequelae in cirrhotic ascites. The purpose of this retrospective cohort study was to recognize the predictors of SBP to build up a noninvasive system to exclude or establish an episode of SBP. PATIENTS AND METHODS: Of 1194 consecutive patients with cirrhotic ascites, only 966 patients were enrolled in this study. SBP was diagnosed once polymorphonuclear count was at least 250 cells/mm and/or there was a positive ascitic fluid culture result. Biochemical and clinical parameters were evaluated as predictors of SBP. A scoring system was established in the training group of 682 and validated in a second group of 284 participants. RESULTS: The incidence of SBP was 12.3 and 12% in the training and validation groups, respectively. Age of at least 55 years, mean platelet volume (MPV) of at least 8.5 fl, neutrophil-to-lymphocyte ratio (NLR) of at least 2.5, and C-reactive protein (CRP) of at least 40 mg/l were identified as independent predictors of SBP. A scoring system including these four variables (age, MPV, and NLR with 1 point each, whereas CRP with 2 points) achieves a specificity of 98.2% with a positive predictive value for the diagnosis of SBP of 88.1% (score≥4). At a threshold of 1 point, the negative predictive value is 97.5% with a sensitivity of 92.9%. SBP is not associated with a high Model for End-stage Liver Disease score (P=0.135). CONCLUSION: The combination of age, MPV, NLR, and CRP in a simple scoring system, Mansoura simple scoring system, supports quick and accurate exclusion or diagnosis of SBP.

Diagnostic non-invasive model of large risky esophageal varices in cirrhotic hepatitis C virus patients.

AIM: To build a diagnostic non-invasive model for screening of large varices in cirrhotic hepatitis C virus (HCV) patients. METHODS: This study was conducted on 124 post-HCV cirrhotic patients presenting to the clinics of the Endemic Medicine Department at Mansoura University Hospital for evaluation before HCV antiviral therapy: 78 were Child A and 46 were Child B (score ≤ 8). Inclusion criteria for patients enrolled in this study was presence of cirrhotic HCV (diagnosed by either biopsy or fulfillment of clinical basis). Exclusion criteria consisted of patients with other etiologies of liver cirrhosis, e.g., hepatitis B virus and patients with high MELD score on transplant list. All patients were subjected to full medical record, full basic investigations, endoscopy, and computed tomography (CT), and then divided into groups with no varices, small varices, or large risky varices. In addition, values of Fibrosis-4 score (FIB-4), aminotransferase-to-platelet ratio index (APRI), and platelet count/splenic diameter ratio (PC/SD) were also calculated. RESULTS: Detection of large varies is a multi-factorial process, affected by many variables. Choosing binary logistic regression, dependent factors were either large or small varices while independent factors included CT variables such coronary vein diameter, portal vein (PV) diameter, lieno-renal shunt and other laboratory non-invasive variables namely FIB-4, APRI, and platelet count/splenic diameter. Receiver operating characteristic (ROC) curve was plotted to determine the accuracy of non-invasive parameters for predicting the presence of large esophageal varices and the area under the ROC curve for each one of these parameters was obtained. A model was established and the best model for prediction of large risky esophageal varices used both PC/SD and PV diameter (75% accuracy), while the logistic model equation was shown to be (PV diameter × -0.256) plus (PC/SD × -0.006) plus (8.155). Values nearing 2 or more denote large varices. CONCLUSION: This model equation has 86.9% sensitivity and 57.1% specificity, and would be of clinical applicability with 75% accuracy.