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Aim: The aim of this study was to determine the incidence of thrombocytopenia in cases with liver cirrhosis and its relationship with the severity of the disease. A retrospective study of cases with liver cirrhosis was conducted out from 2017 to 2021. The information was collected from the patient’s hospital records at their first admission. The study group included 361 individuals over the age of 18 - 258 (71%) men and 103 (29%) women. A platelet count below 150 G/L was considered an indicator of thrombocytopenia. Results were analized using IBM SPSS 26 and Eхcеl statistics. Results: Thrombocytopenia was found in 171 (47.4%) subjects. In 45 (26%) cases, accounting for 12.46% of the studied population with cirrhosis, thrombocytopenia was not accompanied by hematological abnormalities. There was no statistical relationship between the Child-Pough stage and the presence of thrombocytopenia (p = .400) and no statistically significant differences in platelet counts among the three Child-Pough stages (p = .205). The thrombocytopenia cases had a higher MELD Na than those without, with a statistically significant difference between the two groups (p = .002). Of the thrombocytopenia cases, 73.7% had oesophageal varices (p = 0.000). A cut-off value of 181G/L with 73% sensitivity and 54.5% specificity for predicting the occurrence of varices was established. There was no statistical association between thrombocytopenia and portosystemic encephalopathy (PSE); (p = .591). Thrombocytopenia is an important laboratory finding in the progression of portal hypertension in liver cirrhosis. An isolated finding also requires ruling out chronic liver disease and endoscopic examination to exclude oesophageal varices.

Felty syndrome is a rare and serious complication of Rheumatoid Arthritis (RA), characterised by a triad of RA, splenomegaly (enlarged spleen), and neutropenia (low neutrophil count). RA, a systemic autoimmune inflammatory disease marked by synovitis, commonly occurs in the fifth or sixth decade of life and often affects patients with a history of RA exceeding ten years. It is more prevalent in the Caucasian population due to the underexpression of the Human Leukocyte Antigen (HLA)-DR4 gene in African Americans. Felty syndrome requires the presence of neutropenia, defined as an Absolute Neutrophil Count (ANC) below 2000 cells/mm³, alongside splenomegaly and long-standing RA. Hereby, the authors present a case report of a 44-year-old female with a three-year history of RA, who presented with ascites for nine months and was found to have portal hypertension. Her diagnosis of Felty syndrome was confirmed based on the triad of RA, neutropenia, and splenomegaly, highlighting the importance of early recognition and management to prevent severe complications such as infections and systemic issues like portal hypertension.

Felty syndrome is a rare and serious complication of Rheumatoid Arthritis (RA), characterised by a triad of RA, splenomegaly (enlarged spleen), and neutropenia (low neutrophil count). RA, a systemic autoimmune inflammatory disease marked by synovitis, commonly occurs in the fifth or sixth decade of life and often affects patients with a history of RA exceeding ten years. It is more prevalent in the Caucasian population due to the underexpression of the Human Leukocyte Antigen (HLA)-DR4 gene in African Americans. Felty syndrome requires the presence of neutropenia, defined as an Absolute Neutrophil Count (ANC) below 2000 cells/mm³, alongside splenomegaly and long-standing RA. Hereby, the authors present a case report of a 44-year-old female with a three-year history of RA, who presented with ascites for nine months and was found to have portal hypertension. Her diagnosis of Felty syndrome was confirmed based on the triad of RA, neutropenia, and splenomegaly, highlighting the importance of early recognition and management to prevent severe complications such as infections and systemic issues like portal hypertension. [ABSTRACT FROM AUTHOR]

Background and aims: Cirrhotic patients frequently undergo screening endoscopy for the presence of oesophageal varices (OV). In the future, this social and medical burden will increase due to the greater number of patients with chronic liver disease and their improved survival. Researches showed that the use of the platelet count/spleen diameter ratio and portal vein diameyter for the noninvasive assessment of EV seems to fulfill these requirements and is based on pathophysiological criteria as well. In this study, our aims were to determine the correlation of OV with portal vein diameter (PVD) and platelet count/spleen diameter (PC/SL) ratio and their comparative evaluation in patients of liver cirrhosis. Methods: The cross sectional study was conducted in the department of medicine, SNMC and MDM Hospital, Jodhpur on 60 patients of liver cirrhosis. Then the patients were classified into two groups, those having esophageal varices and those without esophageal varices. Portal vein diameter' and platelet count to spleen length ratio' were compared between these two groups to obtain conclusions Results: There were significant difference in term of portal vein diameter, platelet count, spleen length, and PC/SL ratio in patients with esophageal varices and patients without esophageal varices. Use of the PC/SL ratio along with thrombocytopenia, splenomegaly and increased portal vein diameter will help create a lower-cost and more effective method to identify esophageal varices in patients with portal hypertension. The PC/SL ratio cannot substitute for upper gastrointestinal endoscopy in the scrutiny of esophageal varices. When compared with other noninvasive predictor tools, the PC/SL ratio is elegant, simple, and inexpensive. With some minor modifications, it may become a helpful tool to limit the number of endoscopies to be performed in patients for primary prophylaxis of variceal bleeding in portal hypertension. [ABSTRACT FROM AUTHOR]

Background: Variceal bleeding is an important cause of mortality in patients with chronic liver disease (CLD). The gold standard for detection and grading of oesophageal varices (EV) is upper gastrointestinal endoscopy. However, it is expensive, time-consuming and invasive. Objectives: This study aimed to find any association between splenic shear wave velocity (SWV) measured by acoustic radiation force imaging (ARFI) and the presence of EV. Method: The quasi-experimental study included 50 patients with CLD and 50 subjects without CLD as the control group. Both underwent upper abdominal ultrasonography followed by elastographic assessment on a Siemens Acuson S2000TM ultrasound system. A comparison of the findings was made between the control and patient groups. Results: Both groups had similar hepatic size while patients with CLD had larger splenic size and area (p < 0.05). The CLD patients had higher mean hepatic and splenic SWV compared with the control group (p < 0.05). The mean splenic size and splenic SWV were higher in patients with varices than in those without varices (p < 0.05). Conclusion: Chronic liver disease causes significant increase in liver and splenic stiffness with splenic SWV values being higher for patients with varices emphasising the role of elastography as a non-invasive predictor for the presence of EVs. Splenic SWV had the highest sensitivity and specificity, which was augmented by a combination of hepatic and splenic SWV. Thus, splenic SWV alone or in combination with hepatic SWV is a useful technique for prediction of the presence of EVs. Contribution: This study aims to find an alternative non-invasive and cost-effective technique for screening of EV. [ABSTRACT FROM AUTHOR]

Background: Cirrhosis is the end-stage of different chronic liver diseases, which is a major cause of mortality and morbidity worldwide. The majority of patients with cirrhosis are likely to develop oesophageal varices, with patients at risk of variceal bleeding. Thrombocytopenia is a common complication affecting cirrhotic patients which can be used to predict the presence of oesophageal varices. The present study was conducted to determine the correlation of thrombocytopenia with oesophageal varices grading in chronic liver disease patients as well as to determine if platelet count can predict the presence of oesophageal varices in a patient of cirrhosis of liver with portal hypertension. Materials & Methods: This study was conducted on 50 cirrhotic patients in the department of Medicine, Government Medical College, Amritsar. The study protocol was approved by the institutional ethics committee. The patients were enrolled in the study after obtaining written informed consent. All the patients were interviewed and clinically examined. Upper gastrointestinal endoscopy, Child-Pugh scoring and platelet count was calculated for every patient. The results were then analyzed. Results: The mean age was 46.8±12.65 years with a slight male preponderance (56% male vs 44% female patients). The mean platelet count was 103292.00 ± 57441.38 lakhs/cumm. Platelet count was <0.50 lacs/µl in 6 (12%) patients, 0.50-0.99 lacs/µl in 22 (44%) patients, 1.0-1.4 lacs/µl in 12 (24%) patients, 1.5-2.0 lacs/µl in 8 (16%) patients, and >2.0 lacs/µl in 2 (4%) patients. On correlation of platelet count with grades of oesophageal varices it was evident that 56% patients had their platelet count less than 1 lac/µl out of which 12 patients had grade II varices followed by 7 patients with grade III varices (p value=0.0012; highly significant). Conclusion:The present study found that there is significant negative correlation between platelet count and grades of oesophageal varices. Low platelet count is associated with higher grades of oesophageal varices. This suggest that platelet count can be used as a predictor to predict the grade of oesophageal varices. The platelet count is a non-invasive parameter with high accuracy for prediction of oesophageal varices. [ABSTRACT FROM AUTHOR]

The oesophagus is the part of the digestive tract between the pharynx and stomach. The oesophagus is susceptible to several pathological conditions, both congenital and acquired, which may require surgical management. These include congenital oesophageal atresia, functional disorders such as achalasia cardia and hiatus hernia, corrosive strictures, traumatic oesophageal perforation, and oesophageal cancer. This article describes, in detail, those aspects of the topographical anatomy of the oesophagus which are of relevance to clinical diagnosis and surgical management. [ABSTRACT FROM AUTHOR]

Background: Variceal bleeding is an important cause of mortality in patients with chronic liver disease (CLD). The gold standard for detection and grading of oesophageal varices (EV) is upper gastrointestinal endoscopy. However, it is expensive, time-consuming and invasive. Objectives: This study aimed to find any association between splenic shear wave velocity (SWV) measured by acoustic radiation force imaging (ARFI) and the presence of EV. Method: The quasi-experimental study included 50 patients with CLD and 50 subjects without CLD as the control group. Both underwent upper abdominal ultrasonography followed by elastographic assessment on a Siemens Acuson S2000TM ultrasound system. A comparison of the findings was made between the control and patient groups. Results: Both groups had similar hepatic size while patients with CLD had larger splenic size and area (p 0.05). The CLD patients had higher mean hepatic and splenic SWV compared with the control group (p 0.05). The mean splenic size and splenic SWV were higher in patients with varices than in those without varices (p 0.05). Conclusion: Chronic liver disease causes significant increase in liver and splenic stiffness with splenic SWV values being higher for patients with varices emphasising the role of elastography as a non-invasive predictor for the presence of EVs. Splenic SWV had the highest sensitivity and specificity, which was augmented by a combination of hepatic and splenic SWV. Thus, splenic SWV alone or in combination with hepatic SWV is a useful technique for prediction of the presence of EVs. Contribution: This study aims to find an alternative non-invasive and cost-effective technique for screening of EV.

Background and Aims: Post‐banding ulcer bleeding (PBUB) is an understudied complication of oesophageal varices endoscopic band ligation (EBL). This systematic review with meta‐analysis aimed at: (a) evaluating the incidence of PBUB in patients with cirrhosis treated with EBL in primary or secondary prophylaxis or urgent treatment for acute variceal bleeding and (b) identifying predictors of PBUB. Methods: We conducted a systematic review of articles in English published in 2006–2022 using the Preferred Reporting Items for Systematic Reviews and Meta‐analyses guidelines. Searches were made in eight databases including Embase, PubMed and Cochrane Library. Random‐effects meta‐analysis was used to determine the incidence, mean interval and predictors of PBUB. Results: Eighteen studies (9034 patients) were included. The incidence of PBUB was 5.5% (95% CI 4.3–7.1). The mean time for it to occur was 11 days (95% CI 9.94–11.97). Model for End‐stage Liver Disease (MELD) score (OR 1.162, 95% CI 1.047–1.291) and EBL done in emergency setting (OR 4.902, 95% CI 2.99–8.05) independently predicted post‐ligation ulcer bleeding. Treatment included drugs, endoscopic procedures and transjugular intrahepatic portosystemic shunt. Refractory bleeding was treated with self‐expandable metallic stents or balloon tamponade. Mortality was on average 22.3% (95% CI 14.1–33.6). Conclusions: Patients with high MELD score and receiving EBL in an emergency setting are more prone to develop PBUB. Prognosis is still poor and the best therapeutic strategy to address remains to be ascertained. [ABSTRACT FROM AUTHOR]

Background Portal hypertensive gastropathy (PHG) is an overlooked complication of liver cirrhosis, as it is a source of acute upper gastrointestinal bleeding and cause of chronic blood loss.Objective To assess the role of narrow band endoscopy in the diagnosis of PHG in cirrhotic patients.Methods Fifty patients with liver cirrhosis were examined by both conventional White Light Endoscopy (WLE) and Narrow Band Technology Variable Intelligent Staining Technology (VIST) using Sonoscape endoscope HD500. Biopsies were taken from the body of gastric mucosa during endoscopy.Results The prevalence of PHG among patients with liver cirrhosis is around 94% by WLE, 92% by VIST, and 55.3% by pathology. There is no statistical significance between VIST and WLE in case of PHG p = 0,750. The risk of developing oesophageal varices grade 3 in severe PHG is higher than in no or mild PHG (OR = 6.8571, 95% CI 1.6270 to 28.9001, p = 0.0087).Conclusion VIST is comparable and complementary to WLE in diagnosis of PHG. There is poor correlation between pathology and WLE in diagnosis of PHG.

Abstract: Many causes of cirrhosis are modifiable. Therefore, etiologic clarification is mandatory. After diagnosis, the underlying disease must be treated and patients advised as to alcohol abstinence, smoking cessation, healthy diet, vaccinations and physical exercise. Gastroscopic screening for oesophageal varices is recommended. Patients with cirrhosis should undergo surveillance for hepatocellular carcinoma (biannual sonography and alpha-fetoprotein assessment). Following a first complication (e.g., variceal haemorrhage, ascites, encephalopathy) or deterioration of liver function, listing for liver transplantation should be evaluated. Control intervals should be individualized according to disease severity and previous decompensations. Many complications (e.g., bleeding, spontaneous bacterial peritonitis, acute renal failure due to NSAIDs or diuretics) have insidious onsets but may rapidly lead to multiple organ failure. Rapid diagnostics are recommended if patients show clinical, mental or lab deterioration. [ABSTRACT FROM AUTHOR]

Background & Aims: Alcohol abuse and metabolic disorders are leading causes of hepatocellular carcinoma (HCC) worldwide. Alcohol-related aetiology is associated with a worse prognosis compared with viral agents, because of the lower percentage of patients diagnosed with HCC under routine surveillance and a higher burden of comorbidity in alcohol abusers. This study aimed to describe the evolving clinical scenario of alcohol-related HCC over 15 years (2006–2020) in Italy. Methods: Data from the Italian Liver Cancer (ITA.LI.CA) registry were used: 1,391 patients were allocated to three groups based on the year of HCC diagnosis (2006–2010; 2011–2015; 2016–2020). Patient characteristics, HCC treatment, and overall survival were compared among groups. Survival predictors were also investigated. Results: Approximately 80% of alcohol-related HCCs were classified as cases of metabolic dysfunction-associated fatty liver disease. Throughout the quinquennia,

For decades, non-selective beta-blockers (NSBBs) have been the standard of care for the primary and secondary prevention of bleeding from oesophageal varices. However, several questions regarding the best clinical use of NSBBs remain unanswered and new data continue to emerge. Herein, we aim to delineate the therapeutic window of NSBBs in cirrhosis from a more individualised perspective. We address the current controversy of widening the therapeutic window and prescribing NSBBs to all patients with clinically significant portal hypertension. Although transient elastography is useful to rule-in clinically significant portal hypertension, we lack robust data supporting the use of NSBBs in patients without varices. While most data are based on propranolol, accumulating evidence suggests that carvedilol is superior and should be the first-line treatment until the decompensated stage. The clinical risk-to-benefit ratio appears to deteriorate in advanced decompensated stages and the risk of harm is high in patients with refractory ascites, low blood pressure and renal impairment, which clinically define closure of the therapeutic window. We also critically review non-invasive surrogates and biomarkers for predicting the haemodynamic response to NSBBs and confirm that the absence of reliable non-invasive methods is one of the main challenges facing the field. [ABSTRACT FROM AUTHOR]

Background: Severe thrombocytopenia and platelet dysfunctions are common amongst patients with cirrhosis and can contribute to increase risk of bleeding in patient with cirrhosis and portal hypertension (PH). Many studies confirmed the close association between thrombocytopenia and accordance of variceal bleeding. But the relationship of platelet function disorder and risk of variceal bleeding is still a matter of debate. Objectives: This study aimed to evaluate effect of platelet count, platelets indices and platelet functions in cirrhotic patients with different grade of oesophageal varices (OV) and identifying potential risk factors associated with variceal bleeding. Patients and methods: 60 cirrhotic patients with different grades of OV were included in the study, 30 of them had a history of variceal bleeding and 30 patients never bled as well as 30 apparently healthy control subjects. They were subjected to laboratory investigations including: liver function tests, coagulation tests, platelet count, platelet indices and platelet function assessment using light transmission aggregometry. Results: The collagen corrected area at cut off point = 0.76 (AUC=0.832), with a sensitivity of 70% and a specificity of 96.7%. Ristocetin corrected area at cut off point = 0.76 (AUC=0.832) with a sensitivity of 66.7% and a specificity of 93.3% but ADP had a poor diagnostic performance as ADP corrected area at cut off point = 0.51 (AUC=0.646) sensitivity is 53.3% and specificity 90%. Conclusion: The corrected areas of ADP, collagen, and ristocetin were significantly associated with risk of OV bleeding, in which the corrected area of collagen and ristocetin were good diagnostic markers and superior to ADP for prediction of bleeders OV group. [ABSTRACT FROM AUTHOR]

Aim. Current clinical recommendations are intended to supply gastroenterologists, physicians and general practitioners with modern methods for the diagnosis and treatment of liver cirrhosis and fibrosis.Key points. Liver fibrosis develops with connective tissue accumulation in liver in the outcome of various chronic diseases, including alcohol misuse, viral hepatitises, autoimmune and more rare hereditary liver diseases. Liver cirrhosis is the final stage of most chronic diffuse liver diseases. The recommendations present current opinions on pathogenesis of liver fibrosis and cirrhosis, principles of diagnosis, treatment and prevention of their main complications: hepatic encephalopathy, oesophageal and gastric variceal bleeding, acute kidney injury/hepatorenal syndrome, infectious complications (i.a. spontaneous bacterial peritonitis), hyponatraemia, pulmonary complications, etc.Conclusion. Timely diagnosis and adequate therapy in cirrhosis can prevent life-threatening complications and improve the patients’ prognosis and quality of life.

Background: Acute upper gastrointestinal bleeding is a serious complication in cirrhotic patients. Without recommended management, recurrent bleeding happens in 30-40% within the next 2-3 days, and up to 60% within 1 week. Aim was to determine predictors of re-bleeding after oesophageal variceal banding in cirrhotic patients for 4 weeks. It was a descriptive study, conducted at the Department of Medicine, Sheikh Zayed Hospital, Rahim Yar Khan. Six months from June 21 to December 21, 2021. Methods: A total of 93 patients with active oesophageal variceal bleeding were included in this study. Upper gastrointestinal (UGI) endoscopy was performed to look for bendable varices (grades 1-4) and band ligation was applied. Patients were followed for 4 weeks for the history of hematemesis or Malena, fall in haemoglobin of 2 grams per decilitre or more and endoscopic rebleeding findings. Results: Out of 93 patients, 67(72.0%) were males, while 26(28.0%) were females. The Mean age of the patients was 45.66±16.61 years. According to Child-Pugh Classification, the majority of the patients 45(48.4%) had Child-Pugh Class-A, while 33 (35.5%) were Child B and 15 (16.1%) patients belonged to Child-Pugh Class C. Red wale sign was noted in 22 patients (23.7%). Among 93 cirrhotic patients who presented with variceal bleeding, 9 (9.7%) had re-bleeding within 4 weeks. Amongst 9 patients, 8 patients (88.9%) had red wale sign, grade II or above oesophageal varices and belonged to severe liver disease with child class B or C. Conclusion: Endoscopic variceal band Ligation is an effective treatment modality for the control of oesophageal variceal bleeding. Re-bleeding after band ligation was 9.7%. The major contributing factors to re-bleeding were the severity of cirrhosis, grades and columns of oesophageal varices, number of bands ligation and findings of red wale sign. Increasing age and duration of cirrhosis were contributing predictors of increased re-bleeding risk. [ABSTRACT FROM AUTHOR]

Background: Rupture oesophageal varices (REV) is a lifethreatening complication of liver cirrhosis. Bacterial infection is linked with the risk of variceal bleeding through complex pathophysiologic pathways. Spontaneous bacterial peritonitis (SBP) is the commonest well-known bacterial infection in patients with cirrhosis. the aim of this study is to estimate the incidence and predictors of REV in cirrhotic patients with SBP. Patients and methods: 389 patients with cirrhotic ascites out of 2880 patients with ascites and/or acute gastrointestinal bleeding were divided into two groups, group 1 included 189 patients with SBP and group 2 included 200 patients without SBP. Routine clinical and laboratory data were collected. Results: Compared to patients without SBP, patients with SBP had significant higher incidence of oesophageal variceal hemorrhage (25.4% in patients with SBP versus 14% in patients without SBP (P =0.004). multivariate analysis for factors associated with oesophageal variceal haemorrhage in patients with SBP demonstrated that, the independent predictors for rupture oesophageal varices in patients with SBP were, increased age (p value= 0.001) with EXP(B) 1.068; 95.0% C.I. was (1.026-1.113), presence of fever (p value= 0.005) with EXP(B) 3.433; 95.0% C.I. was (1.458-8.083) and hepatic encephalopathy (p value= 0.039) with EXP(B) 3.159; 95.0% C.I. was (1.060-9.421). Conclusion: Spontaneous bacterial peritonitis increases the risk of oesophageal variceal haemorrhage. Increased age, presence of fever and hepatic encephalopathy were independent predictors of acute oesophageal variceal haemorrhage in patients with SBP. [ABSTRACT FROM AUTHOR]

Portal hypertensive gastropathy (PHG) is an overlooked complication of liver cirrhosis, as it is a source of acute upper gastrointestinal bleeding and cause of chronic blood loss. To assess the role of narrow band endoscopy in the diagnosis of PHG in cirrhotic patients. Fifty patients with liver cirrhosis were examined by both conventional White Light Endoscopy (WLE) and Narrow Band Technology Variable Intelligent Staining Technology (VIST) using Sonoscape endoscope HD500. Biopsies were taken from the body of gastric mucosa during endoscopy. The prevalence of PHG among patients with liver cirrhosis is around 94% by WLE, 92% by VIST, and 55.3% by pathology. There is no statistical significance between VIST and WLE in case of PHG p = 0,750. The risk of developing oesophageal varices grade 3 in severe PHG is higher than in no or mild PHG (OR = 6.8571, 95% CI 1.6270 to 28.9001, p = 0.0087). VIST is comparable and complementary to WLE in diagnosis of PHG. There is poor correlation between pathology and WLE in diagnosis of PHG. [ABSTRACT FROM AUTHOR]

Abstract Background Esophageal varices (EV) is the most common apprehensive complication of portal hypertension in patients with cirrhotic liver. Guidelines recommend Upper gastro-intestinal endoscopic screening for EV in patients with newly diagnosed chronic cirrhosis (Imperiale et al. in Hepatology 45(4):870–878, 2007). Yet, it is invasive, time consuming and costly. To avoid unnecessary endoscopy, some studies have suggested Doppler ultrasound examination as simple, and noninvasive tool in prediction and assessment of severity of EV (Agha et al. in Dig Dis Sci 54(3):654–660, 2009). Our study was to assess the role of different Doppler indices of portal vein, hepatic and splenic arteries as a noninvasive tool for prediction of esophageal varices in cirrhotic patients. Results This prospective case control study was conducted on 100 cirrhotic liver patients and 100 of healthy volunteers as control group. Patients were subjected to clinical examination, upper gastrointestinal tract endoscopy, abdominal ultrasonography with duplex Doppler evaluation of different portal Doppler hemodynamic indices were done for each patient. The results revealed that portal vein diameter, hepatic artery pulsatility index, portal hypertensive index, portal vein flow velocity, portal congestion index have high sensitivity for prediction of EV. However, Splenic artery resistance index, hepatic artery resistance index HARI, liver vascular index and platelet count/spleen diameter have less sensitivity for prediction of EV. Conclusion Measuring the portal hemodynamic indices can help physicians as noninvasive predictors of EV in cirrhotic patients to restrict the need for unnecessary endoscopic screening especially when endoscopic facilities are limited.

Background: Infection with hepatitis C virus is reported to have infected almost 71 million people worldwide. This study was done to assess the frequency and associated factors leading to oesophageal varices in patients presenting with hepatitis C related liver cirrhosis. Methods: A cross-sectional study was conducted at Patel Hospital, Karachi, Pakistan from 9th May to 5th October 2019. Patients of either gender having age >20 years presenting with HCV related liver cirrhosis, and Child Pugh class A, B and C were consecutively enrolled in the study. Data on variables like: age, gender, Childs Pugh Score (A/B/C), smoking status, laboratory characteristics like hemoglobulin (Hb), TLC, platelets, serum albumin level, cholesterol, alkaline phosphate (ALK), alkaline transaminase (ALT), ascites and presence of oesophageal varices was recorded and analysed using SPSS-21.0. Results: Out of 167 patients, mean age was 44.86±14.74 years. Eight-nine (53.3%) of the patients were males. The mean duration of cirrhosis was 5.78±1.10 months. Thrombocytopenia was observed in majority (n=130, 77.8%) of the patients. There were 33 (19.8%) patients with Child Pugh score A while Child-Pugh score B and C was found in 67 (40.1%) each. The frequency of oesophageal varices was 141 (84.4%). A significantly higher proportion of oesophageal varices were found among thrombocytopenic patients (p<0.001), ascites (p-0.024), and having “C” Child-Pugh score (p-0.012). Conclusion: Oesophageal varices were found in a considerable proportion. Thrombocytopenia, ascites and Child-Pugh class C were found as leading contributing factors to oesophageal varices [ABSTRACT FROM AUTHOR]

Background and aim: Anticipating the existence of esophageal varices (EVs) by non-intrusive methods in cirrhotic may build consistency and limit the presentation of upper gastrointestinal endoscopy (UGIE) to those individuals with a high likelihood of having EVs. Prophecy of EVs utilizing simple blood indices and also for estimation of clinically important large esophageal varices (LEVs).Materials and methods: A cross-sectional experimental examination was done on 107 cirrhotic enlisted sequentially. Platelet count (PC), the ratio of aspartate aminotransferase to alanine aminotransferase (the AST/ALT ratio or AAR), AST-platelet-ratio index (APRI), Fib-4, and King's Score were determined and linked with UGIE discoveries taken as the best quality level. The execution manifested affectability, particularity, positive and negative prescient values (PPV, NPV), and area under the curve (AUC).Results: Middle age 44 years, male (90%), and etiology-ethanol (87%). 60/107 had LEVs. For anticipating LEVs, PC at cutoff esteem < 1.5 lakhs c/mm3 exhibited affectability 66.7%; particularity 44.7%, PPV 60.6%, NPV 51.2%, and AUC 0.621. AAR for estimation of LEVs at cutoff esteem 1, showed affectability 93.3%, particularity 42.1%, PPV 54.9%, NPV 20% and AUC 0.638. Lie 4 for expectation of LEVs at cutoff esteem 3.5, showed affectability 80%, and particularity 31.9%, PPV 60%, NPV 55.6% and AUC 0.614.Conclusion: PC, AAR, and FIB-4 had simple demonstrative precision for LEVs in cirrhosis. They recognized the subcategory that requires UGIE for the preventive administration of EVs. Generally, basic blood lists probably will not have the option to substitute the efficacy of UGIE for the finding of EVs in cirrhosis.

Of the gastrointestinal causes of sudden death, upper gastrointestinal bleeding is the most common and is usually due to the rupture of oesophageal varice, which is a complication of portal hypertension associated with cirrhosis of the liver. Here, we present two cases of sudden death due to acute upper gastrointestinal bleeding diagnosed at autopsy. One was a known alcoholic suffering from liver cirrhosis. In the other case, the individual was undergoing treatment for liver cirrhosis but was non-alcoholic with a history of consuming herb medication for a long time. Here, we highlight the importance of obtaining a detailed medical history to better correlate the autopsy findings with the disease condition. [ABSTRACT FROM AUTHOR]

Background: Liver cirrhosis is defined pathologically as fibrosis and inflammation of the liver which is caused by chronic HBV, chronic HCV, NASH, NAFLD, chronic alcohol use and auto immune diseases which lead to portal hypertension. Aim and Objectives: The aim of this study is to evaluate whether non-inflammatory gall bladder wall thickness serve as predictor of oesophageal varices in combination and comparison with other non-invasive clinical and laboratory parameters. Subjects and Methods: This case-control study was conducted at the Hepatology and Gastroenterology Department, Ain Shams University, Egypt. The study was conducted over a period of one year, from January 2022 until January 2023. Result: There was no statistically significant difference between both groups as regard age, sex and associated comorbidities. There was statistically significant higher rate of clinical findings either gastrointestinal or systematic in subjects with esophageal varices that those without varices. 37.78% of subjects with cirrhosis without esophageal varices have normal clinical examination. Conclusion: According our study, measuring gallbladder wall thickness is very useful for detection of esophageal varices in cirrhotic patients aswe find significant association between gallbladder wall thickness and liver cirrhosis patients with esophageal varices. GBWT improve the non-invasive monitoring of liver disease patients to assess the risk for the presence of EV. [ABSTRACT FROM AUTHOR]

Background and aims: To evaluate two‐dimensional shear wave elastography (2DSWE) in parallel with transient elastography (TE) for diagnosing clinically significant portal hypertension (CSPH) and high‐risk varices (HRV) in patients with chronic liver disease. Patients and methods: Consecutive patients with suspicion of compensated advanced chronic liver disease (cACLD) [liver stiffness measurement (LSM) ≥ 10 kPa by TE, or morphological signs suggestive of cACLD on imaging], with no history of liver decompensation, underwent hepatic venous pressure gradient (HVPG) measurement, transjugular liver biopsy and esophagogastroduodenoscopy, which served as the reference methods for diagnosing CSPH, cACLD and HRV. All patients underwent LSM and spleen stiffness measurements (SSM) by 2DSWE and TE. Results: Seventy‐six (76) patients were included (78% men, mean age 62 years, body mass index 28.3 kg/m2, 36.8% alcoholic, 30.3% non‐alcoholic fatty liver disease, 14.5% viral hepatitis). Of them, 80.3%, 69.7%, 52.6% and 22.4% had cACLD, cirrhosis, CSPH and HRV respectively. LSM performed better than SSM in diagnosing CSPH and HRV. For CSPH, AUROCs (0.926 vs. 0.866), optimal cut‐offs (20.1 vs. 20.2 kPa) and sensitivity/specificity (80.5%/94.3% vs. 77.5% /86.1%) were comparable for 2DSWE and TE. Ruling‐out of CSPH by 2DSWE (LSM at cut‐off with ≥90% sensitivity (13.5 kPa) and platelets ≥ 150 x 109/L) performed comparably to TE, with 1/24 cases falsely classified as negative. For HRV, AUROCs were similar (0.875 2DSWE, 0.851 TE) with similar optimal LSM cut‐offs enabling 100% sensitivity and ruling‐out HRV. Conclusion: Liver stiffness measurement by 2DSWE appears to perform equally well as TE for diagnosing CSPH and ruling‐out HRV in compensated chronic liver disease. [ABSTRACT FROM AUTHOR]

Introduction: Liver plays an essential role in the metabolism, synthesis, transport and clearance of lipids and lipoproteins, therefore, changes in the lipid profile in liver pathology reflects the degree of its dysfunction. Leading role in the development of atherosclerosis belongs to lipid spectrum disorders in the form of hyperlipidaemia and dyslipidaemia, associated with an increased cardiovascular risk in liver cirrhosis. Aim: To study the relationship between violations of lipid profile of blood with the features and the clinical picture of Liver Cirrhosis (LC). Material and methods: The study was an open prospective and comparative analysis of patients with LC, conducted at Stavropol State Medical University (Stavropol State, Russia). Research was conducted from June 2020 till August 2020. In 108 patients with LC, blood concentration of total cholesterol, triglycerides, High Density Lipoproteins (HDL) and Low Density Lipoproteins (LDL) were studied in association with manifestations of the disease. Control group constituted of 45 healthy individuals, comparable in sex, age and ethnicity. Two sample Student's t-test, Newman Keuls test, chi-square test with Yates's correction and Pearson's linear correlation coefficient (r) were calculated. Receiver Operating Characteristic (ROC) analysis was used, the Odds Ratio (OR) and its 95% Confidence Interval (CI), sensitivity, specificity, positive and negative predictive value, and accuracy were determined. Differences were considered statistically significant at p≤0.05. Results: Regardless of gender and age of patients, decrease of serum levels of total cholesterol (p<0.05), triglycerides (p<0.05), HDL (p<0.05) and LDL (p<0.05) were marked, associated with expression of portal hypertension and severity of liver cirrhosis. Parameters of LDL more than 2.16 mmol/L {OR 6.78-95% CI (2.74-16.78)} were connected with absence of oesophageal varices. Levels of triglycerides less than 0.83 mmol/L {OR 10.85-95% CI (2.86-41.19)} were associated with presence of oesophageal varices of grade III. Generally, hyperlipidaemia was observed in 17.6% of patients, and it was associated with alcoholic etiology of liver cirrhosis (Χ2=3.7; p=0.053). Hypocholesterolaemia (81.5% of cases) or hypotriglyceridemia (48.1% of cases) was more commonly observed in patients with ascites (Χ2=8.8; p=0.003), and classes B, C according Child- Pugh score (Χ2=4.0; p=0.045). Conclusion: In this study it was found that, in liver cirrhosis, there is a decrease in the serum content of total cholesterol, triglycerides, HDL and LDL, regardless of gender and age of patients. The LDL values of more than 2.16 mmol/L are associated with an increased chance of absence of oesophageal varices in patients with liver cirrhosis. [ABSTRACT FROM AUTHOR]

Introduction: Liver plays an essential role in the metabolism, synthesis, transport and clearance of lipids and lipoproteins, therefore, changes in the lipid profile in liver pathology reflects the degree of its dysfunction. Leading role in the development of atherosclerosis belongs to lipid spectrum disorders in the form of hyperlipidaemia and dyslipidaemia, associated with an increased cardiovascular risk in liver cirrhosis. Aim: To study the relationship between violations of lipid profile of blood with the features and the clinical picture of Liver Cirrhosis (LC). Materials and Methods: The study was an open prospective and comparative analysis of patients with LC, conducted at Stavropol State Medical University (Stavropol State, Russia). Research was conducted from June till August 2020. In 108 patients with LC, blood concentration of total cholesterol, triglycerides, High Density Lipoproteins (HDL) and Low Density Lipoproteins (LDL) were studied in association with manifestations of the disease. Control group constituted of 45 healthy individuals, comparable in sex, age and ethnicity. Two sample student’s t-test, Newman Keuls test, chi-square test with Yates’s correction and Pearson’s linear correlation coefficient (r) were calculated. Receiver Operating Characteristic (ROC) analysis was used, the Odds Ratio (OR) and its 95% Confidence Interval (CI), sensitivity, specificity, positive and negative predictive value and accuracy were determined. Differences were considered statistically significant at p≤0.05. Results: Regardless of gender and age of patients, decrease of serum levels of total cholesterol (p

Aim of the study: Oesophageal and gastric varices are well-known causes of morbidity and mortality in patients with liver cirrhosis. The aim of this retrospective observational study was to analyse clinical characteristics and outcomes for patients with oesophageal and gastric varices at Norrland's University Hospital, Umeå,, Sweden. Material and methods: Data from medical records were collected retrospectively from 246 patients with oesophageal and gastric varices between 2006 and 2019. Results: At the end of the study 60.1% of the patients had died at a median age of 69 years (range 26-95). Mortality of patients with gastro-oesophageal varices was significantly greater than that of the general population. Median survival from the time of variceal diagnosis was 59 months (confidence interval [CI] 95%: 45-73 months). Five-year and 10-year cumulative survival rates in the entire cohort were 49.7% and 27.7%, respectively, with no sex-related differences. The highest mortality rate was seen in alcoholic cirrhosis with concomitant hepatitis. Mortality was higher in Child-Turcotte-Pugh (CTP) B and C compared to CTP A. Liver failure and liver cancer were the most common causes of death (43.8%). Thirty-one percent of the patients had a variceal haemorrhage. Eleven percent were subjected to liver transplantation, whereas 3.9% of the patients had been submitted to a transjugular intrahepatic portosystemic shunt (TIPS) procedure. Conclusions: Despite the latest therapeutic advances, the survival of patients with gastro-oesophageal varices remains significantly reduced. All-cause mortality was significantly related to CTP class, aetiology, occurrence of variceal bleeding, whether variceal bleeding was the primary symptom and whether patients had undergone liver transplantation or not. [ABSTRACT FROM AUTHOR]

Objectives: Beta-blockers and endoscopic variceal band ligation (VBL) have been preferred therapies for primary prophylaxis of variceal bleeding. However, the choice of therapy in patients with advanced liver disease with high-risk varices is not clear. A comparison of these therapies alone or in combination to prevent the first variceal bleed in advanced cirrhosis patients was carried out., Design: 330 Child-Turcotte-Pugh (CTP) B and C cirrhosis patients, with 'high-risk' varices were prospectively enrolled (n=110 per group) to receive carvedilol (group A), VBL (group B) or combination (group C). Primary endpoint was reduction in the incidence of first variceal bleed at 12 months. The secondary endpoints included overall mortality, bleed-related mortality, new-onset decompensation, change in hepatic vein pressure gradient (HVPG) and treatment-related adverse events., Results: The patients were predominantly males (85.2%), aged 51.4±10.5 years with CTP score of 8.87±1.24, MELD score 15.17±3.35 and HVPG-16.96±3.57 mm Hg. The overall incidence of variceal bleed was 23.8% (n=78) at 1 year. Intention-to-treat analysis showed that the combination arm (group C) significantly reduced the incidence of first variceal bleed by 62.9% as compared with group B (HR 0.37, 95% CI 0.192 to 0.716, p<0.003) and by 69.3% as compared with group A (HR 0.31, 95% CI 0.163 to 0.578, <0.001). The overall mortality was 13.6% (45/330). The 1-year mortality in group C was lowest among the three groups (A, B, C=20%, 14.5%, 6.3%, p=0.012). Reduction in HVPG (20.8% vs 25.1%, p=0.54) and the rate of non-response to carvedilol (53.4% vs 41.25%, p=0.154) were not different between group A and C patients. The incidence of new-onset ascites, spontaneous bacterial peritonitis, shock, and acute kidney injury and postbleed organ failure was also comparable between the groups., Conclusion: In CTP B and C cirrhosis patients with high-risk varices, combination of carvedilol and VBL is more effective than either therapy alone, for primary prevention of variceal bleeding., Trial Registration Number: NCT03069339., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Oesophageal varices (EV) rupture remains one of the most severe complications of cirrhosis. As the gold standard to predict this accident, esophagogastroduodenoscopy (EGD) itself also has a weakness. Not all patients are convenient with this modality in clinical practice apart from the risk and cost burden. Hence, the search for other non-invasive modalities with high accuracy is still noteworthy. Among them, spleen stiffness measurement (SSM) with 100 Hz probe, liver stiffness measurement (LSM), and the aspartate amino transferase to platelet ratio index (APRI) score became popular and intensively studied with good accuracy, but the results remain conflicting. This study aims to investigate the performance of SSM, LSM, APRI score, and their combination especially as a screening tool for predicting EV in liver cirrhosis patients., Methods: In this cross-sectional study, we included 141 patients with liver cirrhosis who had undergone endoscopy, SSM, LSM, and APRI score calculation between January and March 2023 were enrolled. Diagnostic accuracy was assessed by the area under the receiver-operator curve (AUC). Transient elastography (TE) measurement was performed using a spleen-dedicated FibroScan with a 100-Hz probe., Results: Of the 141 patients, the most common aetiology was hepatitis B in 71 patients (50.4 %). EV were found in 116 patients. Using the AUC, SSM at a cutoff of 40 kPa had the best performance with an AUC of 0.892 (CI 95 %: 0.814-0.969, p <0.0001), with sensitivity 88.79 % and specificity 80 %). Meanwhile, LSM and APRI score had an AUC of 0.832 (CI 95 %: 0.742-0.922, p <0.0001) and 0.780 (CI 95 %: 0.660-0.900, p <0.0001), respectively. The combination of all measurement tools did not show better performance than SSM alone with an AUC of 0.892 (CI 95 %: 0.802-0.982, P <0.0001) CONCLUSION: SSM provides better performance than LSM and APRI scores for predicting EV. Performance of SSM alone is non-inferior compare to multiple diagnostic tools combined., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Masson SAS. All rights reserved.)

Competing Interests: Competing interests: None declared.

Introduction: Liver stiffness measurement (LSM) using vibration-controlled transient elastography (VCTE) is being increasingly used as a screening tool to predict varices. Our aim was to test the utility of Baveno VII criteria and other combinations of LSM, platelet count (PC), and splenic stiffness measurement (SSM) to predict the presence of varices in a cohort of Sri Lankan patients with compensated advanced liver cell disease (cALCD)., Methods: Consecutive patients with newly diagnosed Child-Pugh class A cALCD (non-viral, BMI<30) were recruited prospectively. They underwent gastroscopy. LSM and SSM were taken using vibration-controlled transient elastography (VCTE) (Echosens FibroScan 502 Touch; Echosens SA, Paris, France) by a single operator who was unaware of endoscopy findings. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy of different Baveno VII criteria to predict the varices and different combinations of LSM, SSM, and PC were also explored., Results: One hundred and seventy-four individuals were recruited. The mean age was 61.4 ((95% CI: 59.7-62.8) years. A total of 110 individuals were males, and 106 had varices. Our results indicated that the three Baveno VII criteria had sensitivities of 61%, 63%, and 42%, and specificities of 79%, 77%, and 87% to predict varices. SSM>30kPa alone and in combination with LSM>15kPa had sensitivities of 81 and 75%, specificities of 72 and 83%, PPVs of 82 and 87%, NPVs of 71% and 67%, and accuracies of 78 and 78%, respectively, to predict varices., Conclusion: Baveno VII criteria had a low sensitivity but high specificity in predicting the presence of varices. However, SSM>30kPa alone or in combination with LSM>15kPa had better sensitivity, specificity, PPV, NPV, and accuracy in predicting varices., Competing Interests: Human subjects: Consent was obtained or waived by all participants in this study. Ethics review Committee, Faculty of Medicine, University of Kelaniya, Sri Lanka issued approval P188/11/2021. Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, de Silva et al.)

Background: Esophageal varices (EV) is the most common apprehensive complication of portal hypertension in patients with cirrhotic liver. Guidelines recommend Upper gastro-intestinal endoscopic screening for EV in patients with newly diagnosed chronic cirrhosis (Imperiale et al. in Hepatology 45(4):870–878, 2007). Yet, it is invasive, time consuming and costly. To avoid unnecessary endoscopy, some studies have suggested Doppler ultrasound examination as simple, and noninvasive tool in prediction and assessment of severity of EV (Agha et al. in Dig Dis Sci 54(3):654–660, 2009). Our study was to assess the role of different Doppler indices of portal vein, hepatic and splenic arteries as a noninvasive tool for prediction of esophageal varices in cirrhotic patients. Results: This prospective case control study was conducted on 100 cirrhotic liver patients and 100 of healthy volunteers as control group. Patients were subjected to clinical examination, upper gastrointestinal tract endoscopy, abdominal ultrasonography with duplex Doppler evaluation of different portal Doppler hemodynamic indices were done for each patient. The results revealed that portal vein diameter, hepatic artery pulsatility index, portal hypertensive index, portal vein flow velocity, portal congestion index have high sensitivity for prediction of EV. However, Splenic artery resistance index, hepatic artery resistance index HARI, liver vascular index and platelet count/spleen diameter have less sensitivity for prediction of EV. Conclusion: Measuring the portal hemodynamic indices can help physicians as noninvasive predictors of EV in cirrhotic patients to restrict the need for unnecessary endoscopic screening especially when endoscopic facilities are limited. [ABSTRACT FROM AUTHOR]

Background Portal vein thrombosis (PVT) has been described in nearly 50% of patients who underwent oesophagogastric devascularization combined with splenectomy (EGDS), but no previous study has compared its occurrence in surgical and non-surgical groups. This study aimed to investigate PVT in hepatosplenic schistosomiasis (HSS) and its association with EGDS and upper variceal bleeding (UVB). Methods Retrospectively, 104 HSS individuals were enrolled. Following EGDS, the occurrence of PVT, mesenteric vein thrombosis (MVT), hospital admissions and UVB were recorded. Results EGDS was performed in 27 (26%) patients. PVT and MVT were detected in 30 (33%) and 8 (9.8%) patients, respectively. Patients who underwent EGDS were at greater risk of PVT (63% vs 19.7%; odds ratio [OR] 6.12 [95% confidence interval {CI} 2.3 to 16.1], p<0.001) when compared with a non-surgical approach. There was no significant difference in UVB occurrence and β-blocker usage. PVT was associated with more hospital admissions (p=0.030) and higher alkaline phosphatase levels (p=0.008). UVB occurrence in patients with and without thrombosis was similar. In multivariate analysis, after adjustment, PVT was associated with the surgical approach (OR 4.56 [95% CI 1.55 to 13.38], p=0.006) and age at HSS diagnosis (OR 0.94 [95% CI 0.90 to 0.99], p=0.021). Conclusions EGDS was not associated with a decreased frequency of UVB when compared with the non-surgical approach but was an independent risk factor for PVT. [ABSTRACT FROM AUTHOR]

Abstract Background In cirrhosis upper-gastrointestinal-endoscopy (UGIE) identifies oesophageal varices (OV). UGIE is unavailable in most resource-limited settings. Therefore, we assessed prediction of presence of OV using hematological parameters (HP) and Child-Turcott-Pugh (CTP) class. Methods A prospective study was carried out on consecutive, consenting, newly-diagnosed patients with cirrhosis, in the University Medical Unit, Colombo North Teaching Hospital, Ragama, Sri Lanka from April 2014–April 2016. All patients had UGIE to evaluate presence and degree of OV, prior to appropriate therapy. HP (full blood count with indices using automated analyzer and peripheral blood smear using Leishmann stain) and CTP class were assessed on admission. Linear logistic regression model was developed to predict OV using HP and CTP class. Results 54-patients with cirrhosis were included [14(26%), 24(44%) and 16(30%) belonged to CTP class A, B and C respectively]. 37 had varices [CTP-A 4/14(26.6%), CTP-B 19/24(79.2%), CTP-C 14/16(87.5%)] on UGIE. Generalized linear model fitting showed decreasing percentage of small platelets (%SP) (P = 0.002), CTP-B (P = 0.003) and CTP-C (P = 0.003) compared to CTP-A had higher probability of having OV. The model predicts the log odds for having OV = − 0.189 – (0.046*%SP) + 2.9 [if CTP-B] + 3.7 [if CTP-C]. Based on receiver operating characteristic (ROC) analysis, a model value > − 0.19 was selected as the cutoff point to predict OV with 89%-sensitivity, 76%-specificity, 89%-positive predictive value and 76%-negative predictive value. Conclusions We constructed a model using %SP on peripheral blood smear and CTP class. This model may be used to predict the presence of OV, in newly diagnosed patients with cirrhosis, with acceptable sensitivity and specificity, to prioritize the patients who deserve early UGIE in limited resource settings.

Aim: Hepatic venous pressure gradient (HVPG) measurement is a gold standard for the diagnosis of portal hypertension but can be invasive and difficult to conduct. Per‐rectal portal scintigraphy (PRPS) can estimate portal haemodynamics noninvasively. However, no report to date has examined the association between HVPG and PRPS in patients with chronic liver disease, including cirrhosis. Methods: This single‐centre study included a total of 21 patients with chronic liver disease who underwent HVPG measurement and PRPS. For PRPS, the transit times from injection of the radiotracer to its inflow into the liver (TTL) and heart (TTH) were set and the time difference between TTL and TTH (TDLH) was calculated, while the shunt index (SI) was measured. Results: Cirrhosis was observed in 18 cases (86%), and the median HVPG was 13 mmHg. HVPG (p = 0.028), TTL (p = 0.018), TDLH (p = 0.003) and SI (p = 0.033) were higher in patients with oesophageal varices (EV). Considering the diagnostic ability for EV, the area under the curve was 0.88 for TDLH and 0.80 for HVPG. TDLH was significantly correlated with the risk of EV rupture (p = 0.004). Conclusion: Patients with chronic liver disease should undergo upper gastrointestinal endoscopy when the TDLH is high. [ABSTRACT FROM AUTHOR]

Background: Direct oral anticoagulants (DOACs) are recommended for stroke prevention in patients with atrial fibrillation (AF) or for treatment of deep vein thrombosis, although some concerns about safety and efficacy were raised on the use of these drugs in patients with advanced liver disease (ALD). We want to investigate the association of DOACs use with the bleeding and ischaemic risk. Material and Methods: We performed a systematic review and metanalysis of clinical studies retrieved from PubMed (via MEDLINE) and Cochrane (CENTRAL) databases addressing the impact of DOACs therapy on bleeding events including intracranial haemorrhage (ICH), gastrointestinal and major bleeding. Secondary end points were all‐cause death, ischaemic stroke/systemic embolism (IS/SE) and recurrence/progression of vein thrombosis (rDVT). Results: 12 studies were included in the meta‐analysis: a total of 43 532 patients with ALD or cirrhosis, of whom 27 574 (63.3%) were on treatment with DOACs and 15 958 were in warfarin/low molecular weight heparin. DOACs reduced the incidence of major bleeding by 61% (pooled Hazard Ratio [HR] 0.39, 95% Confidence Interval [CI] 0.21‐0.70), ICH by 52% (HR 0.48, 95% CI 0.40‐0.59), while no difference in the reduction of any and gastrointestinal bleeding were observed. DOACs reduced also rDVT by 82% (HR 0.18, 95%CI 0.06‐0.57), but did not reduce death and IS/SE. No difference was shown according to oesophageal varices and Child Pugh score in the meta‐regression analysis between warfarin/heparin and DOACs performed on each outcome. Conclusions: DOACs are associated with a lower incidence of bleeding and may be an attractive therapeutic option in patients with cirrhosis. [ABSTRACT FROM AUTHOR]

Oral Direct‐acting antivirals (DAAs) are safe, highly effective altering disease burden and prognosis in hepatitis C patients. Sustained virologic response (SVR) is achieved nowadays in more than 90% of the treated patients and related to the improvements in functions of the liver, fibrosis plus survival. Furthermore, portal hypertension is thought to be improved with achievement of virological response, parallel to the improvements in hepatic inflammation and fibrosis. We aimed to assess the recurrence rate of oesophageal varices by long‐term follow‐up in patients treated with different DAAs regimens who had achieved SVR. We studied 176 Child A cirrhotic HCV patients who achieved SVR after DAAs treatment and had a history of endoscopic oesophageal varices obliteration and were on maximum tolerated propranolol dose. They were subjected to follow‐up upper gastrointestinal endoscopy repeated every 6 months for 4 years. Fifty‐two patients (29.5%) had recurrence of oesophageal varices observed during the 4‐years follow‐up upper GIT endoscopy. On multivariate analysis, platelet count was the only significant variable, P‐value =.007*. HbA1C, HOMA IR, BMI 1 and BMI 2 showed non‐significant differences between the studied groups. By ROC analysis, we identified baseline platelet count of 96 000/µL with 100% sensitivity (95% confidence interval [CI] [91%‐100%]) and 74% specificity (95% CI [65%‐81%]). Spearman correlation showed a positive correlation between AFP, age, AST, Bilirubin, creatinine, INR. Patients who achieved SVR post DAAs showed a significant decrease in oesophageal varices recurrence post endoscopic obliteration. Baseline platelet count was found to be a strong independent predictor for oesophageal varices recurrence. [ABSTRACT FROM AUTHOR]

This report describes a case of extrahepatic portal venous obstruction (EHPVO) with esophageal varices that would have led to significant bleeding if left untreated or inadequately managed. A 56-year-old diabetic and hypothyroid female visited our medical outpatient clinic to be assessed for pancytopenia and easy fatiguability. She experienced acute calculus cholecystitis 24 years ago, which was treated with a partial cholecystectomy. The laboratory tests showed indications of hypersplenism, characterized by anemia, leucopenia, and thrombocytopenia. The MRI results showed signs of long-term blockage of the portal vein outside the liver, with the liver tissue seeming normal. The upper gastrointestinal endoscopy showed grade IV esophageal varices, gastroesophageal varices 1, fundal varices, isolated gastric varices 2, and antral varices. The patient was diagnosed with EHPVO, and banding was performed as a preventive measure against upper gastrointestinal bleeding. Additionally, she was treated using conservative management techniques such as beta blockers. Endoscopic treatment is the standard of care for treating acute varices, while beta blockers are given as a secondary preventive measure. Despite cholelithiasis being a cause and/or sequelae to portal venous thrombosis, a clear explanation has not been offered to this patient while taking consent for cholecystectomy or thereafter. EHPVO is not frequently detected, and there is still a dearth of appropriate guidelines for managing this illness, even though it is a frequent cause of acute calculus cholecystitis and upper gastrointestinal bleeding., Competing Interests: Human subjects: Consent was obtained or waived by all participants in this study. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Johnson et al.)

Esophageal varices are life-threatening complications in which the enlargement of the esophageal veins causes bleeding and reduces blood flow to the esophagus. They are complications caused by portal hypertension, renal failure, hepatic dysfunction, and infection. The leading cause of esophageal varices is cirrhosis, as patients with this disease are more susceptible to forming esophageal varices. Bleeding episodes occur due to the rupture of the blood vessels. We present the case of a 45-year-old male patient in the hospital with a history of chronic alcohol use and clinical symptoms of hematemesis, a distended abdomen, and melena. The patient experienced mild symptoms of giddiness and dizziness after undergoing various radiological investigations, laboratory tests, ultrasonography (USG), and CT scans. USG diagnosed portal hypertension, gross ascites, pleural effusion, and hepatosplenomegaly. A CT scan diagnosed the patient with esophageal varices and testicular carcinoma. Laboratory tests diagnosed anemia. The treatment plan included oral and intravenous iron supplements, blood transfusions, vitamin B12, folate supplements, and nonselective beta-blockers to manage portal hypertension and reduce variceal bleeding risk. During acute bleeding episodes, vasoconstrictors and endoscopic band ligation were employed. Regular endoscopies and hepatic venous catheterization were conducted to monitor and manage the condition. Follow-up included regular assessments of hemoglobin levels, iron status, liver function tests, and periodic endoscopies. The patient's adherence to beta-blockers was closely monitored. Esophageal varices, often resulting from portal hypertension because of cirrhosis, require early diagnosis and a combination of pharmacological and endoscopic treatments to prevent complications. Advances in treatment have reduced mortality rates, but effective management of portal hypertension and liver dysfunction remains crucial., Competing Interests: Human subjects: Consent was obtained or waived by all participants in this study. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Tivaskar et al.)

Introduction: Portal vein thrombosis (PVT) is the most frequent cause of portal hypertension in paediatric population. Baveno VI Consensus considers endoscopic variceal ligation as the second therapeutic option after meso-Rex bypass (surgical shunt)., Aim: Analyse the diagnostic profitability of non-invasive scales in order to predict the risk of oesophageal varices (OV) in children with PVT., Material and Methods: Descriptive retrospective study where every upper gastrointestinal endoscopy (UGE) carried on patients <15 years old with non-cirrhotic PVT were included. There were divided according to the presence of OV and sex, cause, age, previous gastrointestinal bleeding or treatments, results of UGE and scales (Clinical Prediction Rule - CPR), Varices Prediction Rule - VPR), King's Variceal Prediction Score - K-VaPS) and Platelet count/Spleen diameter Ratio - PSR). Qualitative variables were expressed as absolute frequency and percentage, and quantitative variables as median and interquartile range. U Mann-Whitney and Hanley-McNeil tests were used for comparisons., Results: Forty-five UGE were analysed. 80% (n=36) presented OV: median of 3 (2-3) and 33.3% (n=12) required endoscopic variceal ligation. Statistical differences were demonstrated between both groups: CPR (142.39 [132.22-166.53] vs. 122.75 [115.24-133.15]; p=0.003), VPR (9.91 [9.36-11.75] vs. 5.6 [3.34-8.39]; p=0.001), K-VaPS (117.86 [99.66-126.58] vs. 99.64 [94.88-10.18]; p=0.019), PSR (2384.62 [1902.22-3201.63] vs. 1252.5 [579.6-2144.42]; p=0.05), with and area under the curve AUROC>75%, without statistical differences between scales., Conclusions: In paediatric patients with non-cirrotic PVT non-invasive scales can be used as a tool to predict the presence of OV and raise the indication of UGE., (Copyright © 2023 Elsevier España, S.L.U. All rights reserved.)

Oesophageal varices are a dilated submucosal venous plexus in the lower third of the oesophagus which result from increased pressure in the portal venous system. The portal system is connected to the systemic circulation in specific locations referred to as sites of portosystemic anastomosis. An increase in portal venous pressure is therefore reflected at these anastomotic sites, causing manifestations such as oesophageal varices, rectal varices, caput medusae and splenorenal shunts. Varices do not cause symptoms until they leak or rupture and this is the main complication which requires prompt treatment. Here, we present a post-liver transplant patient with metastatic hepatocellular carcinoma who had oesophageal varices that fistularized with a left pulmonary vein, thus creating a right-to-left shunt. Right-to-left shunts are usually intracardiac or intrapulmonary in location. The complications of a right-to-left shunt include predominantly hypoxia, cyanosis and, sometimes, paradoxical emboli in the case of intracardiac shunts. This patient had a very uncommon cause of such a shunt caused by a direct fistulous connection.

Introduction and Aim. EVBL is a procedure frequently performed in cirrhotic patients for primary prophylaxis of bleeding. Patients with cirrhosis display various degrees of alteration of common coagulation parameters, and it is not known whether these alterations may predict post-EVBL bleeding. To evaluate factors predictive of post-endoscopic variceal band ligation (EVBL) bleeding in cirrhotic patients with thrombocytopenia.Material and methods. We included 109 patients with cirrhosis undergoing EVBL for primary prophylaxis of variceal bleeding. Common coagulation parameters (INR, fibrinogen levels) and complete haemogram were obtained in all patients and evaluated subdividing patients in bleeders and non bleeders following EVBL.Results. The incidence of post-EVBL bleeding was 5.5% (6 patients). INR and platelet counts, considered as continuous or dichotomous variables according to common cut-offs (i.e., INR > 1.5, platelet count < 50 × 109/L) were not predictors of post-EVBL bleeding. Patients who bled had significantly lower fibrinogen levels [146 mg/dL (98 - 262) vs. 230 mg/dL (104 - 638), P = 0.009], and no other biochemical or clinical predictors of bleeding were identified. A fibrinogen cut-off of 179 mg/dL had 98.6% negative predictive value for bleeding.Conclusion. Low fibrinogen levels are associated with an increased risk of bleeding following prophylactic EVBL in cirrhotic patients, and might be used to stratify patients’ risk. However, due to their preliminary nature, these findings need to be confirmed in larger populations.

Jan Kubovy, Tom D Boswell, Guy Vautier, Malcolm M Arnold Department of Gastroenterology, Hawkes Bay Hospital, Hastings, New ZealandAbstract: Endoscopic variceal ligation (EVL) is an important treatment modality in managing complications of portal hypertension. Since its advent 30 years ago, the procedural complications have decreased significantly, especially when compared with variceal sclerotherapy. With the current widespread use of EVL, rare complications are now becoming increasingly recognized. We present a case of complete esophageal obstruction, its management, and clinical course. Our literature review identified only eight reported cases. We compare the varied treatment approaches and outcomes in the cited articles. Keywords: portal hypertension, esophageal varices, endoscopic variceal ligation, esophageal obstruction