Non-contrast-enhanced MR angiography of left gastric vein in patients with gastroesophageal varices: morphology and blood supply analysis.

OBJECTIVES: To investigate the feasibility of non-contrast-enhanced MR angiography (NCE-MRA) in evaluating the morphology and blood supply of left gastric vein (LGV) in patients with gastroesophageal varices. METHODS: Between March 2021 and October 2022, patients with gastroesophageal varices and who underwent NCE-MRA were retrospectively reviewed. In order to evaluate the blood supply of LGV, superior mesenteric vein (SMV) and splenic vein (SV) were visualized separately by using inflow-sensitive inversion recovery sequence. Two radiologists independently assessed the image quality, determined the origination and the blood supply of LGV, and measured the diameter of LGV. The origination and diameter of LGV were compared between NCE-MRA and contrast-enhanced CT. Differences in blood supply were compared between LGVs with different originations. RESULTS: A total of 53 patients were enrolled in this study and the image quality was categorized as good or excellent in 52 patients. No significant differences were observed in visualizing the origination and the diameter of LGV between NCE-MRA and contrast-enhanced CT (p > .05). The blood supply of LGV was related to its origination (p < .001). Most LGVs with SV origination were supplied by SV. If LGV was originated from the portal vein (PV), about 70% of them were supplied by both SV and SMV. Compared with LGVs with SV origination, LGVs with PV origination showed more chance to receive blood from SMV (p < .001). CONCLUSION: Non-contrast-enhanced MR angiography appears to be a reliable technique in evaluating the morphology and blood supply of LGV in patients with gastroesophageal varices. CLINICAL RELEVANCE STATEMENT: Non-contrast-enhanced MR angiography provides valuable information for the management of gastroesophageal varices. Especially, it benefits patients with renal insufficiency. KEY POINTS: • Non-contrast-enhanced MR angiography using inflow-sensitive inversion recovery technique can be used for evaluating not only morphology as CT but also blood supply of left gastric vein. • The blood supply of left gastric vein is related to its origination and left gastric vein with portal vein origination shows more chance to receive blood from superior mesenteric vein.

A new criterion including the aspartate aminotransferase-to-platelet ratio index and liver and spleen stiffness to rule out varices needing treatment in children with biliary atresia: Modification of the Baveno VII criteria.

AIMS: Biliary atresia (BA) is a congestive biliary disease that develops in the neonatal period or early infancy. It may present with portal hypertension and varices needing treatment (VNT) even after successful Kasai portoenterostomy. This study aimed to stratify the risk of VNT in children and adolescents with BA. METHODS: In this prospective cross-sectional study, we measured liver stiffness (LS) and spleen stiffness (SS) by two-dimensional shear wave elastography and checked for VNT endoscopically in 53 patients with BA who attended for follow-up between July 2018 and September 2022. Varices needing treatment were defined as large esophageal varices, esophageal varices of any size with red color signs, and/or gastric varices along the cardia. RESULTS: Twenty-five patients (aged 0-18 years) had VNT. Eighteen patients met the Baveno VI criteria (LS <20 kPa; platelet count >150 000/L) and were deemed to be at low risk of VNT (spared endoscopies) while three had missed VNT (16.7%). Applying the Baveno VII criteria, which combines the SS cut-off value of 40 kPa with the Baveno VI criteria, resulted in five missed VNTs among 22 spared endoscopies (22.7%). A modification of the Baveno VII criteria using the aspartate aminotransferase-to-platelet ratio index (APRI) instead of the platelet count with cut-off values of 25 kPa, 30 kPa, and 1.04 for LS, SS, and APRI, respectively, missed only one VNT (5.0%) among 20 spared endoscopies. CONCLUSIONS: A novel diagnostic criterion that combines LS, SS, and APRI reduced the risk of missing VNT to 5% in children and adolescents with BA.

An imaging-based machine learning model outperforms clinical risk scores for prognosis of cirrhotic variceal bleeding.

OBJECTIVES: To develop and validate a machine learning model based on contrast-enhanced CT to predict the risk of occurrence of the composite clinical endpoint (hospital-based intervention or death) in cirrhotic patients with acute variceal bleeding (AVB). METHODS: This retrospective study enrolled 330 cirrhotic patients with AVB between January 2017 and December 2020 from three clinical centers. Contrast-enhanced CT and clinical data were collected. Centers A and B were divided 7:3 into a training set and an internal test set, and center C served as a separate external test set. A well-trained deep learning model was applied to segment the liver and spleen. Then, we extracted 106 original features of the liver and spleen separately based on the Image Biomarker Standardization Initiative (IBSI). We constructed the Liver-Spleen (LS) model based on the selected radiomics features. The performance of LS model was evaluated by receiver operating characteristics and calibration curves. The clinical utility of models was analyzed using decision curve analyses (DCA). RESULTS: The LS model demonstrated the best diagnostic performance in predicting the composite clinical endpoint of AVB in patients with cirrhosis, with an AUC of 0.782 (95% CI 0.650-0.882) and 0.789 (95% CI 0.674-0.878) in the internal test and external test groups, respectively. Calibration curves and DCA indicated the LS model had better performance than traditional clinical scores. CONCLUSION: A novel machine learning model outperforms previously known clinical risk scores in assessing the prognosis of cirrhotic patients with AVB CLINICAL RELEVANCE STATEMENT: The Liver-Spleen model based on contrast-enhanced CT has proven to be a promising tool to predict the prognosis of cirrhotic patients with acute variceal bleeding, which can facilitate decision-making and personalized therapy in clinical practice. KEY POINTS: • The Liver-Spleen machine learning model (LS model) showed good performance in assessing the clinical composite endpoint of cirrhotic patients with AVB (AUC ≥ 0.782, sensitivity ≥ 80%). • The LS model outperformed the clinical scores (AUC ≤ 0.730, sensitivity ≤ 70%) in both internal and external test cohorts.

Association between air temperature and emergency admission for esophagogastric variceal bleeding: a case-crossover study in Beijing, China.

BACKGROUND AND AIMS: Studies concerning the impact of air temperature on esophagogastric variceal bleeding (EGVB) have yielded conflicting results. Our study aimed to evaluate the correlation between air temperature and EGVB. METHODS: A time-stratified case-crossover study design was performed. Patients received emergency gastroscopic hemostasis for upper gastrointestinal bleeding between Jan 1, 2014, and Dec 31, 2018 in the Fifth Medical Center of PLA General Hospital were enrolled. Conditional logistic regression analysis was applied to determine the association between air temperature and EGVB for different lag structures. RESULTS: A total of 4204 cirrhotic patients diagnosed with EGVB and received emergency gastroscopic hemostasis were enrolled. The mean number of daily EGVB cases peaked in October (2.65 ± 1.69) and fell to the lowest level in July (1.86 ± 1.38), and was 2.38 ± 1.58 in spring, 2.00 ± 1.46 in summer, 2.37 ± 1.58 in autumn, and 2.45 ± 1.58 in winter, respectively (P < 0.0001). In conditional logistic regression analysis, no significant correlations between air temperature and EGVB were observed and no significant difference were found when stratified by age, sex, etiology, liver cancer status, and grade of varices. CONCLUSION: Emergency admission for EGVB showed significant monthly and seasonal fluctuations, while in conditional logistic regression analysis, no association between minimum temperature and emergency admission for EGVB were observed.

Gastroesophageal Balloon Tamponade Simulation Training with 3D Printed Model Improves Knowledge, Skill, and Confidence.

BACKGROUND: Gastroesophageal balloon tamponade (BT) tube placement is a life-saving procedure for refractory bleeding from gastroesophageal varices performed by gastroenterologists, intensivists, internists, and emergency medicine physicians. Despite a recognized need for procedural training, no standard curriculum or assessment tools exist. Given the infrequent performance of this procedure, the development of a representative and accessible simulation model would permit hands-on training to practice and maintain proficiency with BT tube placement. AIMS: To assess BT tube placement performance before and after a novel simulation-based learning module in gastroenterology fellows and faculty. METHODS: A 16-item knowledge questionnaire and 22-item procedural skill checklist utilizing a novel 3D printed esophagus model were developed to assess participant knowledge, procedural skills, and confidence prior to our simulation-based intervention and again 8-12 weeks after. Performance metrics were compared pre- and post-intervention within groups and between participant groups. RESULTS: Fifteen gastroenterology fellows (of 15 eligible; 100%) and 14 gastroenterology faculty (of 29 eligible; 48%) completed training. Fellows demonstrated improvement in knowledge (55% to 79%, p < 0.001) and procedural skill (35% to 57%, p < 0.001) following training. Baseline faculty performance did not differ from fellows' performance and post-intervention showed similar improvement in knowledge (61% to 77%, p = 0.001) and procedural skill (40% to 49%, p = 0.147). Overall satisfaction with training was high in both groups post-intervention and faculty felt more confident teaching fellows. CONCLUSION: The presented learning module offers a unique, low stakes opportunity for learners to improve skills, gain knowledge, and build confidence in placing BT tubes using a realistic simulation model.

Endoscopic N-butyl-2-cyanoacrylate and ethanolamine oleate injection is equivalent to balloon-occluded retrograde transvenous obliteration for preventing gastric variceal bleeding.

OBJECTIVES: Endoscopic injection sclerotherapy (EIS) is effective for temporary hemostasis, but EIS and balloon-occluded retrograde transvenous obliteration (BRTO) have been reported as effective for secondary prophylaxis of gastric varices (GV) bleeding. This study retrospectively compared EIS and BRTO in patients with GV in terms of the efficacy for secondary prevention of GV bleeding and effects on liver function. METHODS: From our database of patients with GV who underwent EIS or BRTO between February 2011 and April 2020, a total of 42 patients with GV were retrospectively enrolled. The primary endpoint was the bleeding rate from GV, which was compared between EIS and BRTO groups. Secondary endpoints were liver function after treatment and rebleeding rate from EV, compared between EIS and BRTO groups. Rebleeding rates from GV and EV and liver function after treatment were also compared between EIS-ethanolamine oleate (EO)/histoacryl (HA) and EIS-HA groups. RESULTS: Technical success was achieved for all EIS cases, but two cases were unsuccessful in the BRTO group and underwent additional EIS. No significant differences in bleeding rates or endoscopic findings for GV improvement were seen between EIS and BRTO groups. Liver function also showed no significant difference in the amount of change after treatment between groups. CONCLUSION: EIS therapy appears effective for GV in terms of preventing GV rebleeding and effects on liver function after treatment. EIS appears to represent an effective treatment for GV.

Countering hemorrhagic shock due to duodenal variceal rupture with resuscitative endovascular balloon occlusion of the aorta.

Resuscitative endovascular balloon occlusion of the aorta (REBOA) has become an important option for managing life-threatening, traumatic or non-traumatic, arterial bleeding. The use of REBOA in variceal hemorrhagic shock, however, has rarely been reported. A 54-year-old man with untreated alcoholic liver cirrhosis presented with hematochezia and altered mental status. Contrast-enhanced computed tomography suggested ruptured duodenal varices. Since the patient had profound hypotension, we performed REBOA to temporize the hemorrhage. Immediately after balloon inflation, his blood pressure increased, allowing us to safely perform endoscopic variceal ligation. Our case indicates that REBOA is effective in controlling portal venous flow in acute gastrointestinal variceal hemorrhage.

Prediction of high-risk esophageal varices in patients with chronic liver disease with point and 2D shear wave elastography: a systematic review and meta-analysis.

OBJECTIVE: To assess the diagnostic performance of liver stiffness (LS) and spleen stiffness (SS) measured by point shear wave elastography (pSWE) and 2D shear wave elastography (2D-SWE) in the detection of high-risk esophageal varices (HREV) and to compare their diagnostic accuracy. METHODS: Through systematic search of PubMed, Embase, and Web of Science databases, we included 17 articles reporting the diagnostic performance of LS or SS measured by pSWE or 2D-SWE for HREV. We used a bivariate random-effects model to estimate pooled sensitivity, specificity, positive likelihood ratio (PLR), negative likelihood ratio (NLR), area under summary receiver operator characteristic curve (AUSROC), and diagnostic odds ratio (DOR). RESULTS: For LS, there was no significant difference between the pooled sensitivity, 0.89 (95% confidence interval CI, 0.81-0.94) vs. 0.8 (95% CI, 0.72-0.86) (p = 0.13), and specificity, 0.81 (95% CI, 0.73-0.87) vs. 0.73 (95% CI, 0.65-0.79) (p = 0.07) of pSWE and 2D-SWE. The AUSROC and DOR of pSWE were higher than those of 2D-SWE: 0.92 (95% CI, 0.89-0.94) vs. 0.84 (95% CI, 0.80-0.87), p = 0.03, 33 (95% CI, 25-61) vs. 11 (95% CI, 5-22), (p < 0.01). For SS, there was no significant difference between the pooled sensitivity 0.91 (95% CI, 0.78-0.96) vs. 0.89 (95% CI, 0.80-0.94) (p = 0.43); specificity, 0.79 (95% CI, 0.72-0.84) vs. 0.72 (95% CI, 0.63-0.79) (p = 0.06); and DOR, 35 (95% CI, 13-100) vs. 20 (95% CI, 8-50) (p = 0.16) of pSWE and 2D-SWE. CONCLUSION: LS and SS measured by pSWE and 2D-SWE have good accuracy in predicting HREV. KEY POINTS: • There is modest difference between the diagnostic performance of LS and SS measured by pSWE and 2D-SWE. • LS and SS measured by pSWE and 2D-SWE both have high sensitivity, specificity, and AUSROC for the evaluation of HREV in patients with CLD. • pSWE and 2D-SWE are promising tools for noninvasive monitoring risk of esophageal varices bleeding of CLD patients.

CHESS-ALARM score to stratify decompensation risk in compensated advanced chronic liver disease patients: An international multicenter study.

BACKGROUND AND AIM: A combination of platelet and elastography (PE criteria) was proposed to identify compensated advanced chronic liver disease (cACLD) patients at risk of liver decompensation. We aim to validate and refine PE criteria by developing a new predictive score to predict decompensation in Asian cACLD patients. METHODS: An international cohort of 633 cACLD patients with liver stiffness measurement (LSM) and esophagogastroduodenoscopy performed were included. We validated PE criteria to predict first liver decompensation using competing risk analysis, with death and hepatocellular carcinoma as competing events. We developed a predictive model using proportional subdistribution hazard regression. Prognostic accuracy was compared with the model of end-stage liver disease (MELD), albumin-bilirubin (ALBI), and ALBI-FIB-4 score using time-dependent area under operative characteristic curve (tAUC). RESULTS: Sixty patients developed decompensation over the median follow-up of 39 months. Favorable Baveno VI status ruled out cACLD patients at risk of liver decompensation. LSM > 25 kPa was suboptimal to predict cACLD patients who will develop liver decompensation. We developed CHESS-ALARM score by incorporating age, platelet, and gender into LSM. CHESS-ALARM score (tAUC = 0.86, 95% confidence interval [CI]: 0.79-0.94) has significantly higher accuracy than MELD (tAUC: 0.61), ALBI (tAUC: 0.62), ALBI-FIB-4 (tAUC: 0.70), and LSM > 25 kPa (tAUC: 0.54) to predict liver decompensation at 5 years (P < 0.05 for all). Patients with CHESS-ALARM score ≥ -0.37 had an 11-fold higher risk of decompensation (subdistribution hazard ratio = 11.2, 95% CI: 5.1-24.5). CONCLUSION: CHESS-ALARM score can be readily incorporated into clinical practice of cACLD patients to estimate individual risk of liver decompensation; however, more data are required in morbidly obese cACLD patients of nonviral etiology.

Usefulness of the d-dimer to albumin ratio for risk assessment in patients with acute variceal bleeding at the emergency department: retrospective observational study.

BACKGROUND: Acute variceal bleeding (AVB) is a severe complication of portal hypertension that is caused by rupture of the esophageal or gastric varix. Scoring system for risk stratification of AVB is difficult to use because various variables must be entered, and it is difficult to apply early in the emergency department (ED). We compared and analyzed the usefulness of the D-dimer to albumin ratio (DAR) for risk stratification of AVB. METHODS: In this retrospective observational study, medical records of patients with AVB Between January 2019 and December 2020 were assessed. The primary endpoint was to evaluate whether DAR was a predictor of clinical outcomes for AVB. Receiver operating characteristic (ROC) curves were constructed using cut-off values determined by the Youden Index. Univariate and multivariate logistic regression analyses were performed to assess the factors contributing to the development of outcomes. RESULTS: Overall, 67 patients required intensive care. The cut-off value of DAR for patients requiring intensive care was 400. A DAR > 400 (adjusted HR: 5.636 [95% CI: 2.216-14.332]) independently predicted the need for ICU admission in these patients. Overall, 13 patients required long-term hospitalization. The cut-off value of DAR for patients requiring long-term hospitalization was 403. A DAR > 403 (adjusted HR: 9.899 [95% CI: 2.012-48.694]) independently predicted the need for long-term hospitalization. Overall, 95 patients required transfusion. The cut-off value of DAR for patients requiring transfusion was 121. A DAR > 121 (adjusted HR: 4.680 [95% CI: 1.703-12.862]) independently predicted the need for transfusion. Overall, 11 patients died during study period. The cut-off value of DAR for mortality was 450. A DAR > 450 (adjusted HR: 26.261 [95% CI: 3.054-225.827]) independently predicted mortality. CONCLUSIONS: The DAR can be used for outcome assessment in patients with AVB with various scoring systems, but its explanatory power is not high.

Effect of Direct-Acting Antiviral Agents on Gastroesophageal Varices in Patients with Hepatitis C Virus-Related Cirrhosis.

Aim: In patients with hepatitis C virus-related liver cirrhosis (LC) who achieve sustained virological responses (SVRs) through treatment with direct-acting antiviral agents (DAAs), it remains unclear whether there are improvements in gastroesophageal varices (GEVs) and portal hypertension. We investigated changes in liver function and GEVs that occurred after DAA therapy. Materials and Methods: We evaluated the medical records of 195 patients with hepatitis C virus-related LC who received DAAs. A total of 171 patients achieved SVRs, among whom 36 had GEVs before or after receiving DAA therapy. The liver function, fibrosis, and GEVs were re-evaluated every 6 months after receiving DAA therapy. The risk factors for progressive GEVs were investigated. Results: DAA therapy resulted in improvements in liver function (indicated by aspartate transaminase, alanine transaminase, and serum albumin levels) and fibrosis (indicated by type IV collagen levels and the Fibrosis-4 index). After receiving DAA therapy, 27 patients had stable GEVs and 9 had progressive GEVs. With respect to GEV grades before DAA therapy, there was a significant difference between patients with stable and progressive GEVs (p = 0.027). Presence of grade-2 GEVs before starting DAA therapy was a risk factor for GEV progression (odds ratio: 5.83; p = 0.04). Patients with grade-2 GEVs had significantly shorter progression-free periods than those with grade < 2 GEVs (p = 0.025). Conclusions: DAA therapy does not ameliorate GEVs. Furthermore, grade-2 GEVs can worsen after DAA therapy. Therefore, patients with GEVs of grades ≥ 2 should undergo endoscopic surveillance after receiving DAAs.

Retrograde transvenous obliteration for the prevention of variceal rebleeding in patients with portal vein thrombosis: a multicenter study.

OBJECTIVES: To evaluate the effectiveness of retrograde transvenous obliteration (RTO) for the prevention of variceal rebleeding in cirrhotic patients with portal vein thrombosis (PVT). METHODS: Consecutive cirrhotic patients with PVT who underwent RTO for the prevention of variceal rebleeding between January 2002 and June 2019 were included in this multicenter retrospective study. The primary outcome measure was rebleeding. The secondary outcome measures were survival, other complications of portal hypertension, liver function, and PVT. RESULTS: Forty-five patients (mean age, 66.0 ± 10.6 years; mean Model for End-Stage Liver Disease (MELD) score, 13.9 ± 5.5) were included. The 1-year actuarial probability of remaining free of rebleeding was 92.8 ± 4.0%. The 6-week, 1-year, and 3-year actuarial probabilities of survival were 79.8 ± 6.0%, 48.8 ± 7.7%, and 46.1 ± 7.9%, respectively. MELD score (hazard ratio (HR), 1.09 (95% confidence interval (CI), 1.01-1.17); p = .013) and ascites (HR, 2.84 (95% CI, 1.24-6.55); p = .014) were identified as significant predictors of survival. The 1-year actuarial probabilities of remaining free of new or worsening ascites and esophageal varices were 81.2 ± 8.7% and 89.2 ± 6.0%, respectively. No patients had overt hepatic encephalopathy during follow-up. MELD score significantly increased by a mean of 3.8 (95% CI, 1.7-6.0) at 3 months (p = .001). PVT had improved in 32.0%, worsened in 12.0%, and remained unchanged in 56.0% of patients at 3 months. CONCLUSION: RTO may be effective for the prevention of variceal rebleeding in cirrhotic patients with PVT. KEY POINTS: • Retrograde transvenous obliteration may prevent variceal rebleeding in cirrhotic patients with portal vein thrombosis. • The risks of other complications of portal hypertension may not be high after retrograde transvenous obliteration in cirrhotic patients with portal vein thrombosis. • Portal vein thrombosis may improve in approximately one-third of cirrhotic patients within 3 months after retrograde transvenous obliteration.

An index based on deep learning-measured spleen volume on CT for the assessment of high-risk varix in B-viral compensated cirrhosis.

OBJECTIVES: Deep learning enables an automated liver and spleen volume measurements on CT. The purpose of this study was to develop an index combining liver and spleen volumes and clinical factors for detecting high-risk varices in B-viral compensated cirrhosis. METHODS: This retrospective study included 419 patients with B-viral compensated cirrhosis who underwent endoscopy and CT from 2007 to 2008 (derivation cohort, n = 239) and from 2009 to 2010 (validation cohort, n = 180). The liver and spleen volumes were measured on CT images using a deep learning algorithm. Multivariable logistic regression analysis of the derivation cohort developed an index to detect endoscopically confirmed high-risk varix. The cumulative 5-year risk of varix bleeding was evaluated with patients stratified by their index values. RESULTS: The index of spleen volume-to-platelet ratio was devised from the derivation cohort. In the validation cohort, the cutoff index value for balanced sensitivity and specificity (> 3.78) resulted in the sensitivity of 69.4% and the specificity of 78.5% for detecting high-risk varix, and the cutoff index value for high sensitivity (> 1.63) detected all high-risk varices. The index stratified all patients into the low (index value ≤ 1.63; n = 118), intermediate (n = 162), and high (index value > 3.78; n = 139) risk groups with cumulative 5-year incidences of varix bleeding of 0%, 1.0%, and 12.0%, respectively (p < .001). CONCLUSION: The spleen volume-to-platelet ratio obtained using deep learning-based CT analysis is useful to detect high-risk varices and to assess the risk of varix bleeding. KEY POINTS: • The criterion of spleen volume to platelet > 1.63 detected all high-risk varices in the validation cohort, while the absence of visible varix did not exclude all high-risk varices. • Visual varix grade ≥ 2 detected high-risk varix with a high specificity (96.5-100%). • Combining spleen volume-to-platelet ratio ≤ 1.63 and visual varix grade of 0 identified low-risk patients who had no high-risk varix and varix bleeding on 5-year follow-up.

Early transjugular intrahepatic portosystemic shunt for acute variceal bleeding: a systematic review and meta-analysis.

OBJECTIVES: The alleged benefit of early placement of transjugular intrahepatic portosystemic shunt (TIPS) in patients with cirrhosis and acute variceal bleeding (AVB) remains controversial. This meta-analysis was conducted to evaluate the therapeutic effect of early TIPS on cirrhotic patients with AVB. METHODS: MEDLINE, Embase, and Cochrane Central Register of Controlled Trials databases were searched for relevant literatures. Data from included studies were extracted, and random-effects meta-analyses were performed. RESULTS: Three randomized control trials and six observational studies involving 2878 participants were included. Compared with those undergoing standard treatment, patients undergoing early TIPS had a significantly lower all-cause mortality (RR, 0.64; 95% CI, 0.52-0.79). Furthermore, early TIPS was associated with a significantly reduced incidence of failure to control bleeding (RR, 0.15; 95% CI, 0.07-0.29) and rebleeding (RR, 0.40; 95% CI, 0.23-0.71), without increasing the risk of hepatic encephalopathy (RR, 1.13; 95% CI, 0.92-1.38). In a stratification analysis based on Child-Pugh classification, the survival benefit was observed in Child-Pugh B patients with active bleeding (RR, 0.53; 95% CI, 0.31-0.93) and Child-Pugh C patients (RR 0.55, 95% CI, 0.37-0.82), but not in low-risk patients (Child-Pugh A and Child-Pugh B without active bleeding) (RR, 0.93; 95% CI, 0.55-1.57). CONCLUSION: Early TIPS is a feasible therapeutic option for cirrhotic patients with AVB, especially benefiting high-risk patients in terms of improved survival. Given the current low utilization rate in clinical practice, this study favors the placement of early TIPS in a wider range of patients with cirrhosis and AVB, especially high-risk patients. KEY POINTS: • Early TIPS is associated with improved survival in high-risk patients (Child-Pugh B plus active bleeding at endoscopy or Child-Pugh C 10-13) with cirrhosis and acute variceal bleeding. • Current utilization rate of early TIPS is low in clinical practice.

Validation of the Expanded Baveno-VI Criteria for Screening Gastroscopy in Asian Patients with Compensated Advanced Chronic Liver Disease.

BACKGROUND: The expanded Baveno-VI criteria may further reduce the need for screening gastroscopy compared to Baveno-VI criteria. AIM: We sought to validate the performance of these criteria in a cohort of compensated advanced chronic liver disease (cACLD) patients with predominantly hepatitis B infection. METHODS: Consecutive cACLD patients from 2006 to 2012 with paired liver stiffness measurements and screening gastroscopy within 1 year were included. The expanded Baveno-VI criteria were applied to evaluate the sensitivity (SS), specificity (SP), positive predictive value (PPV) and negative predictive value (NPV) for the presence of high-risk varices (HRV). RESULTS: Among 165 cACLD patients included, 17 (10.3%) had HRV. The commonest etiology of cACLD was chronic hepatitis B (36.4%) followed by NAFLD (20.0%). Application of expanded Baveno-VI criteria avoided more screening gastroscopy (43.6%) as compared to the original Baveno-VI criteria (18.8%) without missing more HRV (1 with both criteria). The overall SS, SP, PPV and NPV of the expanded Baveno-VI criteria in predicting HRV were 94.1%, 48.0%, 17.2% and 98.6%, respectively. CONCLUSION: Application of the expanded Baveno-VI criteria can safely avoid screening gastroscopy in 43.6% of cACLD patients with an excellent ability to exclude HRV.

[Transjugular intrahepatic portosystemic shunt for the treatment cavernous transformation of the portal vein with vareceal bleeding].

Objective: To evaluate the efficacy and safety of transjugular intrahepatic portosystemic shunt(TIPS) for the treatment of patients with cavernous transformation of portal vein (CTPV) with vareceal bleeding. Methods: From September 2016 to June 2018, a total of 21 patients suffered CTPV complicated with vareceal bleeding were admitted to First Affiliated Hospital of Zhengzhou University. TIPS were performed combined with percutaneous transhepatic portal vein assist. There were 13 males and 8 females, with an average age of 27-67 (48±11) years. Blood routine examination, liver function test, blood ammonia and ultrasound Doppler were conducted 1,3,6 months after operation, and every 6 months during follow-up. Abdominal enhanced CT and digital substraction angiography were followed every year. Results: TIPS were successfully performed in 19 cases (90.5%), esophageal and gastric varices were embolized in 17 cases; 2 cases failed to selective catheterized, then endoscopic therapy was performed.All bleeding stopped after operation. The pressure of portal vein decreased from 25.0-44.0 (33.7±5.4) mmHg (1 mmHg=0.133 kPa) to 17.0-30.0 (24.5±3.1) mmHg, portosystemic pressure gradient decreased from 16.0-32.0 (23.5±4.6) mmHg to 9.0-15.0 (11.4±1.9) mmHg after TIPS (all P<0.05). During 3-24 months follow-up, 2 patients suffered from hepatic encephalopathy, 3 patients had recurrent upper gastrointestinal bleeding, including 1 duodenal ulcer and 2 esophageal varices. In-stent restenosis were found in 6 patients,in which 3 patients underwent shunt revision operation. At the end of the follow-up, the cumulative patency was 16/19. Conclusion: For patients with CTPV and vareceal bleeding, TIPS could reduce portal hypertension while embolizing varicose veins.It is a safe and effective treatment.

[The progress in management of esophagogastric variceal bleeding in cirrhotic portal hypertension].

Esophagogastric variceal bleeding (EVB) is the most dangerous complication of cirrhotic portal hypertension.With the continuous emergence of research findings on EVB, multiple disciplinary team, including internal medicine department, surgery department, intervention therapy department, radiology department, has become a new mode for the prevention and treatment of EVB. This article first reviewed the classification of esophageal varices and gastric varices, and then reviewed the recent research findings of EVB from three aspects: primary prophylaxis, active variceal bleeding treatment, and secondary prophylaxis.The aim was to provide new ideas for the individualized prevention and treatment of EVB.

Comparison of TIPS alone and combined with partial splenic embolization (PSE) for the management of variceal bleeding.

OBJECTIVES: Transjugular intrahepatic portosystemic shunt (TIPS) and partial splenic embolization (PSE) were two interventional radiological treatments for the complications of cirrhosis. This study aimed to investigate the effects of concomitant PSE on the long-term shunt patency and overall survival of TIPS-treated patients. METHODS: Forty-eight patients with TIPS insertion were enrolled and studied retrospectively. They were divided into TIPS+PSE (n = 16) and TIPS groups (n = 32), undergoing combined therapy using TIPS and PSE, and monotherapy using TIPS alone, respectively. RESULTS: The 5-year cumulative primary patency rate in the TIPS+PSE group was markedly higher than in the TIPS group (56.8% vs. 32.8%, p = 0.028), whereas the 5-year cumulative secondary patency rate (93.8% vs. 87.7%, p = 0.749) and overall survival rate (62.5% vs. 30.7%, p = 0.414) were not significantly different between the two groups. Cox-regression models revealed that group (hazard ratio [HR], 0.235; 95% CI, 0.084-0.665; p = 0.006), portal venous pressure decline (HR, 0.687; 95% CI, 0.563-0.838; p = 0.000), and baseline portal vein thrombosis (HR, 3.955; 95% CI, 1.634-9.573; p = 0.002) were significant predictors for shunt dysfunction, while only ascites (HR, 2.941; 95% CI, 1.250-6.920; p = 0.013) was a significant predictor for mortality. No severe adverse event was noted in the two groups except for the potential risk of splenic abscess development in the TIPS+PSE group. CONCLUSIONS: Concomitant PSE may help increase the long-term primary shunt patency rate, but not the overall survival of TIPS-treated patients. Further prospective studies are needed to validate these retrospective findings and to investigate the potential mechanisms. KEY POINTS: • Combined therapy using TIPS and PSE is associated with higher primary patency rates than TIPS alone. • Combined therapy using TIPS and PSE is associated with similar rates of secondary patency and overall survival of patients than TIPS alone. • Group (TIPS alone or TIPS+PSE), PVD, and baseline PVT are three independent predictors for shunt dysfunction, while ascites is the only independent predictor for mortality.

Spleen stiffness by 2-D shear wave elastography is the most accurate predictor of high-risk esophagogastric varices in children with biliary atresia.

AIM: Esophagogastric variceal hemorrhage is a cause of poor prognosis in patients with biliary atresia (BA). To prevent variceal hemorrhage, simple and reliable screening methods for high-risk esophagogastric varices (HR-EGV) are needed. We evaluated the efficacy of liver stiffness (LS) and spleen stiffness (SS) as measured by 2-D shear wave elastography (2D-SWE), which was reported to be more accurate than transient elastography, for detecting HR-EGV in children with BA. METHODS: Thirty-four children with BA were enrolled. Both LS and SS were measured by 2D-SWE. The presence of large esophageal varices or esophageal varices of any size with red wale marking and/or the presence of gastric varices along the cardia were defined as HR-EGV. Clinical data were collected and previously reported prediction indices for varices were calculated. RESULTS: Liver stiffness and SS were obtained from all patients. Fourteen patients showed HR-EGV. Significantly different variables between patients with and without HR-EGV were as follows: spleen diameter (116 mm vs. 95 mm), clinical prediction rule (104.7 vs. 124.7), King's variceal prediction score (78.8 vs. 99.4), aspartic aminotransferase-to-platelet ratio index (2.03 vs. 0.98), LS (2.63 m/s vs. 1.87 m/s), and SS (4.44 m/s vs. 3.69 m/s). The highest area under the receiver operating characteristic curve for detecting HR-EGV was that for SS (0.900), and the cut-off SS of 4.12 m/s yielded 92.9% sensitivity and 90% specificity. The intraclass correlation coefficient for intra-observer reproducibility was 0.828. CONCLUSIONS: Spleen stiffness from 2D-SWE offered the most accurate predictor of HR-EGV in BA children.

[Expert consensus on diagnosis and treatment of esophagogastric variceal bleeding in cirrhotic portal hypertension (2019 edition)].

Portal hypertension is a clinical syndrome which is a consequence of a pathological increase in portal vein pressure due to various causes, among which, cirrhosis being the most common cause. The most basic pathophysiological features of portal hypertension in cirrhosis are increased portal vein pressure due to blocked portal vein blood flow and open collateral circulation. Among the clinical manifestations of portal hypertension in cirrhosis, esophageal and gastric fundus varicose bleeding is the most urgent and the mortality rate is the highest. In order to standardize the diagnosis and treatment plan of esophagogastric variceal bleeding in cirrhotic portal hypertension, the Chinese Society of Spleen and Portal Hypertension Surgery, Chinese Society of Surgery, have renewed and revised this consensus on diagnosis and treatment of esophagogastric variceal bleeding in cirrhotic portal hypertension (2015 edition) hope to provide references for the clinical practices.