Abdominal Imaging

, Volume 39, Issue 2, pp 251–256 | Cite as

Esophageal varices on computed tomography and subsequent variceal hemorrhage

  • Ma Somsouk
  • Katherine To’o
  • Mujtaba Ali
  • Eric Vittinghoff
  • Benjamin M. Yeh
  • Judy Yee
  • Alex Monto
  • John M. Inadomi
  • Rizwan Aslam



Endoscopy is recommended to screen for esophageal varices in patients with cirrhosis. The objective of this study was to identify features on abdominal CT imaging associated variceal hemorrhage (VH).


A case–control study was performed among patients with cirrhosis who had a CT scan. Consecutive patients who experienced VH were included as cases, and patients without VH served as controls. Two radiologists recorded the maximal esophageal varix diameter in addition to other measures of portal hypertension at CT.


The most powerful CT parameter associated with VH was the esophageal varix diameter (5.8 vs. 2.7 mm, p < 0.001; adjusted OR 1.84 per mm, p = 0.009). 63% of individuals with VH had a maximal varix diameter ≥5 mm compared to 7.5% of cirrhotic patients without VH (p < 0.001). In contrast, the proportion of individuals whose largest varix was <3 mm was 7.4% among VH cases compared to 54.7% among controls (p = 0.001). The varix diameter powerfully discriminated those with and without VH (C-statistic 0.84).


A large esophageal varix diameter is strongly associated with subsequent VH. A threshold of <3 and ≥5 mm appears to identify patients with cirrhosis at low and high risk for hemorrhage.

Key words:

Portal hypertension Variceal hemorrhage CT Cirrhosis 



This work was supported by the American Society for Gastrointestinal Endoscopy Endoscopic Research Award (MS) and from the National Institute of Diabetes and Digestive and Kidney Diseases (K24 DK080941, JI). The funding agencies did not have any role in the design, interpretation, or preparation of the manuscript.


All authors do not have any actual or potential conflict of interest including any financial, personal, or other relationships that could inappropriately influence this work.

Supplementary material

261_2013_57_MOESM1_ESM.doc (72 kb)
Supplementary material 1 (DOC 72 kb)


  1. 1.
    Stokkeland K, Brandt L, Ekbom A, Hultcrantz R (2006) Improved prognosis for patients hospitalized with esophageal varices in Sweden 1969–2002. Hepatology 43(3):500–505PubMedCrossRefGoogle Scholar
  2. 2.
    Graham DY, Smith JL (1981) The course of patients after variceal hemorrhage. Gastroenterology 80(4):800–809PubMedGoogle Scholar
  3. 3.
    Garcia-Tsao G, Sanyal AJ, Grace ND, Carey WD (2007) Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis. Am J Gastroenterol 102(9):2086–2102PubMedCrossRefGoogle Scholar
  4. 4.
    The North Italian Endoscopic Club for the Study and Treatment of Esophageal Varices (1988) Prediction of the first variceal hemorrhage in patients with cirrhosis of the liver and esophageal varices. A prospective multicenter study. N Engl J Med 319(15):983–989CrossRefGoogle Scholar
  5. 5.
    Assy N, Rosser BG, Grahame GR, Minuk GY (1999) Risk of sedation for upper GI endoscopy exacerbating subclinical hepatic encephalopathy in patients with cirrhosis. Gastrointest Endosc 49(6):690–694PubMedCrossRefGoogle Scholar
  6. 6.
    Vasudevan AE, Goh KL, Bulgiba AM (2002) Impairment of psychomotor responses after conscious sedation in cirrhotic patients undergoing therapeutic upper GI endoscopy. Am J Gastroenterol 97(7):1717–1721PubMedCrossRefGoogle Scholar
  7. 7.
    Eisen GM, Baron TH, Dominitz JA, et al. (2002) Complications of upper GI endoscopy. Gastrointest Endosc 55(7):784–793PubMedCrossRefGoogle Scholar
  8. 8.
    Perri RE, Chiorean MV, Fidler JL, et al. (2008) A prospective evaluation of computerized tomographic (CT) scanning as a screening modality for esophageal varices. Hepatology 47(5):1587–1594PubMedCrossRefGoogle Scholar
  9. 9.
    Yu NC, Margolis D, Hsu M, Raman SS, Lu DS (2011) Detection and grading of esophageal varices on liver CT: comparison of standard and thin-section multiplanar reconstructions in diagnostic accuracy. Am J Roentgenol 197(3):643–649. doi: 10.2214/AJR.10.5458197/3/643 CrossRefGoogle Scholar
  10. 10.
    Shen M, Zhu KS, Meng XC, et al. (2010) Evaluation of esophageal varices and predicting the risk of esophageal varices bleeding with multi-detector CT in patients with portal hypertension. Zhonghua Yi Xue Za Zhi 90(41):2911–2915PubMedGoogle Scholar
  11. 11.
    Kamath PS, Wiesner RH, Malinchoc M, et al. (2001) A model to predict survival in patients with end-stage liver disease. Hepatology 33(2):464–470PubMedCrossRefGoogle Scholar
  12. 12.
    Kim WR, Biggins SW, Kremers WK, et al. (2008) Hyponatremia and mortality among patients on the liver-transplant waiting list. N Engl J Med 359(10):1018–1026PubMedCrossRefGoogle Scholar
  13. 13.
    Kim YJ, Raman SS, Yu NC, et al. (2007) Esophageal varices in cirrhotic patients: evaluation with liver CT. Am J Roentgenol 188(1):139–144CrossRefGoogle Scholar
  14. 14.
    de Franchis R, Eisen GM, Laine L, et al. (2008) Esophageal capsule endoscopy for screening and surveillance of esophageal varices in patients with portal hypertension. Hepatology 47(5):1595–1603PubMedCrossRefGoogle Scholar
  15. 15.
    Lapalus MG, Ben Soussan E, Gaudric M, et al. (2009) Esophageal capsule endoscopy vs. EGD for the evaluation of portal hypertension: a French prospective multicenter comparative study. Am J Gastroenterol 104(5):1112–1118PubMedCrossRefGoogle Scholar
  16. 16.
    Spiegel BM, Esrailian E, Eisen G (2007) The budget impact of endoscopic screening for esophageal varices in cirrhosis. Gastrointest Endosc 66(4):679–692PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2013

Authors and Affiliations

  • Ma Somsouk
    • 1
  • Katherine To’o
    • 2
  • Mujtaba Ali
    • 3
  • Eric Vittinghoff
    • 4
  • Benjamin M. Yeh
    • 2
  • Judy Yee
    • 2
  • Alex Monto
    • 5
  • John M. Inadomi
    • 6
  • Rizwan Aslam
    • 2
  1. 1.Division of Gastroenterology, Department of MedicineUniversity of California, San FranciscoSan FranciscoUSA
  2. 2.Department of Radiology and Biomedical ImagingUniversity of California, San FranciscoSan FranciscoUSA
  3. 3.Department of RadiologyUniversity of Colorado HospitalAuroraUSA
  4. 4.Department of Epidemiology and BiostatisticsUniversity of California, San FranciscoSan FranciscoUSA
  5. 5.Division of Gastroenterology and Hepatology, Department of MedicineSan Francisco Veterans Affairs Medical CenterSan FranciscoUSA
  6. 6.Division of Gastroenterology and Hepatology, Department of MedicineUniversity of WashingtonSeattleUSA

Personalised recommendations