No abstract

Current guidelines recommend that all cirrhotic patients should undergo screening endoscopy at diagnosis to identify patients with varices at high risk of bleeding who will benefit from primary prophylaxis. This approach places a heavy burden upon endoscopy units and the repeated testing over time may have a detrimental effect on patient compliance. Noninvasive identification of patients at highest risk for oesophageal varices would limit investigation to those most likely to benefit. Upper GI endoscopy is deemed to be the gold standard against which all other tests are compared, but is not without its limitations. Multiple studies have been performed assessing clinical signs and variables relating to liver function, variables relating to liver fibrosis, and also to portal hypertension and hypersplenism. Whilst some tests are clearly preferable to patients, none appear to be as accurate as upper GI endoscopy in the diagnosis of oesophageal varices. The search for noninvasive tests continues.

Background and Aim: Cirrhosis and portal hypertension are characterised by a hyperdynamic circulation, which is independently associated with portal pressure and variceal size. Measurement is invasive and performed in limited centres; non-invasive techniques are available. We assessed whether non-invasive measurement of systemic haemodynamics can identify the hyperdynamic circulation and its associations with portal pressure and variceal size. Methods:We studied 29 cirrhotic patients. Systemic haemodynamics were studied non-invasively using the Finometer® (cardiac output/index CO/CI, heart rate HR, peripheral vascular resistance PVR). Gastroscopy assessed variceal presence, size and bleeding risk. Portal pressure was assessed by hepatic venous pressure gradient (HVPG).Results: A significant negative correlation was seen between CO and PVR (r= -0.95, p<0.001). Significant positive correlations were seen between CI, HR, HVPG and ChildPugh score (r=0.36, r=0.37 and r=0.58 respectively). HVPG correlated positively with HR and CI (r=0.62, p<0.001 and r=0.53, p=0.05 respectively). Significant differences in haemodynamic parameters were seen according to variceal size. Conclusion:Assessment of systemic haemodynamics by finometry can identify the hyperdynamic circulation in cirrhosis and may aid non-invasive diagnosis of portal hypertension and oesophageal varices. 2/6haemodynamics, had their drugs discontinued 14 days prior to any haemodynamic measurements. Each patient gave informed written consent and our local research ethics committee approved the study. Methods:At the first visit detailed clinical assessment age, sex, body mass index, aetiology of liver disease, alcohol intake, presence of stigmata of chronic liver disease, complications of cirrhosis and calculation of Child-Pugh and MELD scores, laboratory assessment bilirubin, albumin, platelet count, Prothrombin time, AST, ALT, and sodium were undertaken. Subsequently non-invasive systemic haemodynamic studies and endoscopy were undertaken. On the second visit non-invasive measurements were repeated, portal pressure was assessed and if possible abdominal ultrasound performed to assess bipolar spleen size.After calibration, a 20 minute continuous measurement of beat-to-beat blood pressure using the Finometer® was taken with the patient lying at 45° and under steady state conditions. The same arm and middle finger were used for both finometer readings taken on different days and at different times. For the first recordings patients were fasted whereas for the second reading patients were allowed to eat and drink freely. Set up of the equipment was by a single operator trained in the technique. The results of the recordings were blinded to the endoscopist and the measurement of portal pressure From the Finometry the following haemodynamic variables were calculated: systolic and diastolic blood pressure SBP, DBP, mean arterial pressure MAP, heart rate HR, stroke volume SV, cardiac output CO, cardiac index CI, and peripheral resistance PVR.One experienced e...

The economic burden of end stage liver disease is set to increase due to the rising prevalence of cirrhosis secondary to alcohol, viral hepatitis and fatty liver disease. Screening for liver disease has been advocated, as most cases of cirrhosis are preventable with early interventions. Liver function tests (LFTs) are routinely used as a first line investigation to screen for liver diseases but can be normal despite significant underlying liver fibrosis, hepatitis, steatohepatitis or even cirrhosis. Their relationships are far from linear and with little predictive value in some cases. Newer non-invasive modalities are emerging but currently their roles are largely experimental. This review will discuss the role of serum biomarkers and imaging techniques as new modalities to screen for liver disease.

Non-invasive assessment of systemic haemodynamics using finometry could aid the identification of patients who do not immediately require variceal surveillance reducing the numbers of endoscopies and ensuring services are provided to those most likely to benefit.