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Diagnosis of Esophageal Varices

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Variceal Hemorrhage

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Abstract

Diagnosing and grading esophageal varices are mainstays in the management of patients with chronic liver disease. Esophagogastroduodenoscopy (EGD) is, at present, the gold standard for diagnosis, and must be performed in all patients when the diagnosis of cirrhosis is established and repeated every 2–3 years if no varices are found, or even earlier if decompensation occurs. However, in compensated cirrhotic patients, esophageal varices are present in only about 30 % of cases at baseline endoscopy, and they are large, thus requiring treatment to prevent bleeding in a small minority. Moreover, EGD is an invasive, costly, and unpleasant procedure. The possibility of a noninvasive screening to identify patients with esophageal varices or with large esophageal varices is therefore attractive, particularly in patients with compensated cirrhosis, and has led to the proposal of many noninvasive or minimally invasive tests or techniques. The most promising of these are discussed in this chapter. However, none of them has entered clinical practice, due to lack of accuracy or of adequate validation. Therefore EGD, although non-cost-effective in compensated cirrhotic patients, cannot at present be replaced by other tests in the diagnosis and grading of esophageal varices.

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References

  1. D’Amico G, Garcia-Tsao G, Pagliaro L. Natural history and prognostic indicators of survival in cirrhosis: a systematic review of 118 studies. J Hepatol. 2006;44(1):217–315.

    Article  PubMed  Google Scholar 

  2. Garcia-Tsao G, Sanyal AJ, Grace ND, Carey W. Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis. Hepatology. 2007;46(3):922–38.

    Article  CAS  PubMed  Google Scholar 

  3. Liebowitz HR. Pathogenesis of esophageal varix rupture. JAMA. 1961;175:874–9.

    Article  CAS  PubMed  Google Scholar 

  4. North Italian Endoscopic Club for the Study and Treatment of Esophageal Varices. Prediction of the first variceal hemorrhage in patients with cirrhosis of the liver and esophageal varices. A prospective multicentre study. N Engl J Med. 1988;319(15):983–9.

    Article  Google Scholar 

  5. Kleber G, Sauerbruch T, Ansari H, Paumgartner G. Prediction of variceal hemorrhage in cirrhosis: a prospective follow-up study. Gastroenterology. 1991;100(5 Pt 1):1332–7.

    CAS  PubMed  Google Scholar 

  6. Pagliaro L, D’Amico G, Pasta L, Politi F, Vizzini G, Traina M, et al. Portal hypertension in cirrhosis: natural history. In: Bosch J, Groszmann RJ, editors. Portal hypertension. Pathophysiology and treatment. Oxford: Blackwell Science; 1994. p. 72–92.

    Google Scholar 

  7. Idezuki Y. General rules for recording endoscopic findings of esophagogastric varices (1991). Japanese Society for Portal Hypertension. World J Surg. 1995;19(3):420–2.

    Article  CAS  PubMed  Google Scholar 

  8. Rigo GP, Merighi A, Chahin NJ, Mastronardi M, Codeluppi PL, Ferrari A, et al. A prospective study of the ability of three endoscopic classifications to predict hemorrhage from esophageal varices. Gastrointest Endosc. 1992;38(4):425–9.

    Article  CAS  PubMed  Google Scholar 

  9. Bendtsen F, Skovgaard LT, Sørensen TI, Matzen P. Agreement among multiple observers on endoscopic diagnosis of esophageal varices before bleeding. Hepatology. 1990;11(3):341–7.

    Article  CAS  PubMed  Google Scholar 

  10. Calès P, Oberti F, Bernard-Chabert B, Payen JL. Evaluation of Baveno recommendations for grading esophageal varices. J Hepatol. 2003;39(4):657–9.

    Article  PubMed  Google Scholar 

  11. Calès P, Pascal JP. Gastroesophageal endoscopic features in cirrhosis: comparison of intracenter and intercenter observer variability. Gastroenterology. 1990;99(4):1189.

    PubMed  Google Scholar 

  12. de Franchis R, Pascal JP, Ancona E, Burroughs AK, Henderson M, Fleig W, et al. Definitions, methodology and therapeutic strategies in portal hypertension. A Consensus Development Workshop, Baveno, Lake Maggiore, Italy, April 5 and 6, 1990. J Hepatol. 1992;15(1–2):256–61.

    Article  PubMed  Google Scholar 

  13. Merkel C, Zoli M, Siringo S, van Buuren H, Magalotti D, Angeli P, et al. Prognostic indicators of risk for first variceal bleeding in cirrhosis: a multicenter study in 711 patients to validate and improve the North Italian Endoscopic Club (NIEC) index. Am J Gastroenterol. 2000;95(10):2915–20.

    Article  CAS  PubMed  Google Scholar 

  14. de Franchis R. Evolving consensus in portal hypertension. Report of the Baveno IV consensus workshop on methodology of diagnosis and therapy in portal hypertension. J Hepatol. 2005;43(1):167–76.

    Article  PubMed  Google Scholar 

  15. D’Amico G, de Franchis R. Upper digestive bleeding in cirrhosis. Post-therapeutic outcome and prognostic indicators. Hepatology. 2003;38(3):599–612.

    Article  PubMed  Google Scholar 

  16. Sanyal AJ, Fontana RJ, Di Bisceglie AM, Everhart JE, Doherty MC, Everson GT, et al. The prevalence and risk factors associated with esophageal varices in subjects with hepatitis C and advanced fibrosis. Gastrointest Endosc. 2006;64(6):855–64.

    Article  PubMed  Google Scholar 

  17. Ng FH, Wong SY, Loo CK, Lam KM, Lai CW, Cheng CS. Prediction of oesophagogastric varices in patients with liver cirrhosis. J Gastroenterol Hepatol. 1999;14(8):785–90.

    Article  CAS  PubMed  Google Scholar 

  18. Pilette C, Oberti F, Aubé C, Rousselet MC, Bedossa P, Gallois Y, et al. Noninvasive diagnosis of esophageal varices. J Hepatol. 1999;31(5):867–73.

    Article  CAS  PubMed  Google Scholar 

  19. Schepis F, Cammà C, Niceforo D, Magnano A, Pallio S, Cinquegrani M, et al. Which patients should undergo endoscopic screening for esophageal varices detection? Hepatology. 2001;33(2):333–8.

    Article  CAS  PubMed  Google Scholar 

  20. Zaman A, Becker T, Lapidus J, Benner K. Risk factors for the presence of varices in cirrhotic patients without history of variceal hemorrhage. Arch Intern Med. 2001;161(21):2564–70.

    Article  CAS  PubMed  Google Scholar 

  21. Madhotra R, Mulcahy HE, Willner I, Reuben A. Prediction of esophageal varices in patients with cirrhosis. J Clin Gastroenterol. 2002;34(1):81–5.

    Article  CAS  PubMed  Google Scholar 

  22. Thomopoulos KC, Labropoulou-Karatza C, Mimidis KP, Katsakoulis EC, Iconomou G, Nikolopoulou VN. Non-invasive predictors of the presence of large oesophageal varices in patients with cirrhosis. Dig Liver Dis. 2003;35(7):473–8.

    Article  CAS  PubMed  Google Scholar 

  23. Zein CO, Lindor KD, Angulo P. Prevalence and predictors of esophageal varices in patients with primary sclerosing cholangitis. Hepatology. 2004;39(1):204–10.

    Article  PubMed  Google Scholar 

  24. Burton JR, Liangpunsakul S, Lapidus J, Giannini E, Chalasani N, Zaman A. Validation of a multivariate model predicting presence and size of varices. J Clin Gastroenterol. 2007;41:609–15.

    Article  PubMed  Google Scholar 

  25. Chalasani N, Imperiale T, Ismail A. Predictors of large esophageal varices in cirrhosis. Am J Gastroenterol. 1999;94(11):3103–5.

    Article  Google Scholar 

  26. Giannini E, Botta F, Borro P, Risso D, Romagnoli P, Fasoli A, et al. Platelet count/spleen diameter ratio: proposal and validation of a non-invasive parameter to predict the presence of oesophageal varices in patients with liver cirrhosis. Gut. 2003;52(8):1200–5.

    Article  CAS  PubMed  Google Scholar 

  27. Giannini EG, Zaman A, Kreil A, Floreani A, Dulbecco P, Testa E, et al. Platelet count/spleen diameter ratio for the noninvasive diagnosis of esophageal varices: results of a multicenter, prospective, validation study. Am J Gastroenterol. 2006;101(11):2511–9.

    Article  PubMed  Google Scholar 

  28. Sandrin L, Fourquet B, Hasquenoph JM, Yon S, Fournier C, Mal F, et al. Transient elastography: a new noninvasive method for assessment of hepatic fibrosis. Ultrasound Med Biol. 2003;29(12):1705–13.

    Article  PubMed  Google Scholar 

  29. Kazemi F, Kettaneh A, N’kontchou G, Pinto E, Ganne-Carrie N, Trinchet JC, et al. Liver stiffness measurement selects patients with cirrhosis at risk of bearing large oesophageal varices. J Hepatol. 2006;45(2):230–5.

    Article  PubMed  Google Scholar 

  30. Foucher J, Chanteloup E, Vergniol J, Castéra L, Le Bail B, Adhoute X, et al. Diagnosis of cirrhosis by transient elastography (FibroScan): a prospective study. Gut. 2006;55(3):403–8.

    Article  CAS  PubMed  Google Scholar 

  31. Vizzutti F, Arena U, Romanelli RG, Rega L, Foschi M, Colagrande S, et al. Liver stiffness measurement predicts severe portal hypertension in patients with HCV-related cirrhosis. Hepatology. 2007;45(5):1290–7.

    Article  PubMed  Google Scholar 

  32. Castéra L, Le Bail B, Roudot-Thoraval F, Bernard PH, Foucher J, Merrouche W, et al. Early detection in routine clinical practice of cirrhosis and oesophageal varices in chronic hepatitis C: comparison of transient elastography (FibroScan) with standard laboratory tests and non-invasive scores. J Hepatol. 2009;50(1):59–68.

    Article  PubMed  Google Scholar 

  33. Berzigotti A, Seijo S, Arena U, Abraldes JG, Vizzutti F, García-Pagán JC, et al. Elastography, spleen size, and platelet count identify portal hypertension in patients with compensated cirrhosis. Gastroenterology. 2013;144(1):102–11.

    Article  PubMed  Google Scholar 

  34. Colecchia A, Montrone L, Scaioli E, Bacchi-Reggiani ML, Colli A, Casazza G, et al. Measurement of spleen stiffness to evaluate portal hypertension and the presence of esophageal varices in patients with HCV related cirrhosis. Gastroenterology. 2012;143(3):646–54.

    Article  PubMed  Google Scholar 

  35. Stefanescu H, Grigorescu M, Lupsor M, Procopet B, Maniu A, Badea R. Spleen stiffness measurement using Fibroscan for the noninvasive assessment of esophageal varices in liver cirrhosis patients. J Gastroenterol Hepatol. 2011;26(1):164–70.

    Article  PubMed  Google Scholar 

  36. Thabut D, Trabut JB, Massard J, Rudler M, Muntenau M, Messous D, et al. Noninvasive diagnosis of large oesophageal varices with FibroTest in patients with cirrhosis: a preliminary retrospective study. Liver Int. 2006;26(3):271–8.

    Article  PubMed  Google Scholar 

  37. Madhotra R, Mokhashi M, Willner I, Hawes RH, Reuben A. Prospective evaluation of a 3.1-mm battery-powered esophagoscope in screening for esophageal varices in cirrhotic patients. Am J Gastroenterol. 2003;98(4):807–12.

    Article  PubMed  Google Scholar 

  38. Eisen GM, Eliakim R, Zaman A, Schwartz J, Faigel D, Rondonotti E, et al. The accuracy of PillCam ESO capsule endoscopy versus conventional upper endoscopy for the diagnosis of esophageal varices: a prospective three-center pilot study. Endoscopy. 2006;38(1):31–5.

    Article  CAS  PubMed  Google Scholar 

  39. Lapalus MG, Dumortier J, Fumex F, Roman S, Lot M, Prost B, et al. Esophageal capsule endoscopy versus esophagogastroduodenoscopy for evaluating portal hypertension: a prospective comparative study of performance and tolerance. Endoscopy. 2006;38(1):36–41.

    Article  PubMed  Google Scholar 

  40. Pena LR, Cox T, Koch AG, Bosch A. Study comparing oesophageal capsule endoscopy versus EGD in the detection of varices. Dig Liver Dis. 2008;40(3):216–23.

    Article  CAS  PubMed  Google Scholar 

  41. de Franchis R, Eisen GM, Laine L, Fernandez-Urien I, Herrerias JM, Brown RD, et al. Esophageal capsule endoscopy for screening and surveillance of esophageal varices in patients with portal hypertension. Hepatology. 2008;47(5):1595–603.

    Article  PubMed  Google Scholar 

  42. Frenette CT, Kuldau JG, Hillebrand DJ, Lane J, Pockros PJ. Comparison of esophageal capsule endoscopy and esophagogastroduodenoscopy for diagnosis of esophageal varices. World J Gastroenterol. 2008;14(28):4480–5.

    Article  PubMed  Google Scholar 

  43. Lapalus MG, Ben Soussan E, Gaudric M, Saurin JC, D’Halluin PN, Favre O, et al. Esophageal capsule endoscopy vs. EGD for the evaluation of portal hypertension: a French prospective multicenter comparative study. Am J Gastroenterol. 2009;104(5):1112–8.

    Article  CAS  PubMed  Google Scholar 

  44. Lu Y, Gao R, Liao Z, Hu LH, Li ZS. Meta-analysis of capsule endoscopy in patients diagnosed or suspected with esophageal varices. World J Gastroenterol. 2009;15(10):1254–8.

    Article  PubMed  Google Scholar 

  45. Nakos G, Karagiannis S, Ballas S, Galanis P, Alevizopoulos G, Nakos A, et al. A study comparing tolerability, satisfaction and acceptance of three different techniques for esophageal endoscopy: sedated conventional, unsedated peroral ultra thin, and esophageal capsule. Dis Esophagus. 2009;22(5):447–52.

    Article  CAS  PubMed  Google Scholar 

  46. Kim YJ, Raman SS, Yu NC, To’o KJ, Jutabha R, Lu DS. Esophageal varices in cirrhotic patients: evaluation with liver CT. AJR Am J Roentgenol. 2007;188(1):139–44.

    Article  PubMed  Google Scholar 

  47. Kim SH, Kim YJ, Lee JM, Choi KD, Chung YJ, Han JK, et al. Esophageal varices in patients with cirrhosis: multidetector CT esophagography—comparison with endoscopy. Radiology. 2007;242(3):759–68.

    Article  PubMed  Google Scholar 

  48. Perri RE, Chiorean MV, Fidler JL, Fletcher JG, Talwalkar JA, Stadheim L, et al. A prospective evaluation of computerized tomographic (CT) scanning as a screening modality for esophageal varices. Hepatology. 2008;47(5):1587–94.

    Article  PubMed  Google Scholar 

  49. Finn JP, Kane RA, Edelman RR, Jenkins RL, Lewis WD, Muller M, et al. Imaging of the portal venous system in patients with cirrhosis: MR angiography vs duplex Doppler sonography. AJR Am J Roentgenol. 1993;161(5):989–94.

    Article  CAS  PubMed  Google Scholar 

  50. Matsuo M, Kanematsu M, Kim T, Hori M, Takamura M, Murakami T, et al. Esophageal varices: diagnosis with gadolinium-enhanced MR imaging of the liver for patients with chronic liver damage. AJR Am J Roentgenol. 2003;180(2):461–6.

    Article  PubMed  Google Scholar 

  51. Talwalkar JA, Yin M, Venkatesh S, Rossman PJ, Grimm RC, Manduca A, et al. Feasibility of in vivo MR elastographic splenic stiffness measurements in the assessment of portal hypertension. AJR Am J Roentgenol. 2009;193(1):122–7.

    Article  PubMed Central  PubMed  Google Scholar 

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Authors and Affiliations

  1. First Division of Gastroenterology, Fondazione IRCCS Cá Granda Ospedale Maggiore Policlinico, via F. Sforza 35, Milan, 20122, Italy

    Massimo Primignani M.D.

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  1. Massimo Primignani M.D.
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Correspondence to Massimo Primignani M.D. .

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  1. Luigi Sacco University Hospital, University of Milan, Milan, Italy

    Roberto de Franchis

  2. Ospedale Universitario Luigi Sacco, Universitá degli Studi di Milano, UOC Gastroenterologia, Milano, Italy

    Alessandra Dell’Era

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Primignani, M. (2014). Diagnosis of Esophageal Varices. In: de Franchis, R., Dell’Era, A. (eds) Variceal Hemorrhage. Springer, New York, NY. https://doi.org/10.1007/978-1-4939-0002-2_3

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  • DOI: https://doi.org/10.1007/978-1-4939-0002-2_3

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