Prediction of Esophageal Varices and Variceal Hemorrhage in Patients with Acute Upper Gastrointestinal Bleeding

Abstract

In patients with upper gastrointestinal bleeding (UGIB), identifying those with esophageal variceal hemorrhage prior to endoscopy would be clinically useful. This retrospective study of a large cohort of patients with UGIB used logistic regression analyses to evaluate the platelet count, aspartate aminotransferase (AST) to platelet ratio index (APRI), AST to alanine aminotransferase (ALT) ratio (AAR) and Lok index (all non-invasive blood markers) as predictors of variceal bleeding in (1) all patients with UGIB and (2) patients with cirrhosis and UGIB. 2233 patients admitted for UGIB were identified; 1034 patients had cirrhosis (46%) and of these, 555 patients (54%) had acute UGIB due to esophageal varices. In all patients with UGIB, the platelet count (cut-off 122,000/mm3), APRI (cut-off 5.1), AAR (cut-off 2.8) and Lok index (cut-off 0.9) had area under the curve (AUC)s of 0.80 0.82, 0.64, and 0.80, respectively, for predicting the presence of varices prior to endoscopy. To predict varices as the culprit of bleeding, the platelet count (cut-off 69,000), APRI (cut-off 2.6), AAR (cut-off 2.5) and Lok Index (0.90) had AUCs of 0.76, 0.77, 0.57 and 0.73, respectively. Finally, in patients with cirrhosis and UGIB, logistic regression was unable to identify optimal cut-off values useful for predicting varices as the culprit bleeding lesion for any of the non-invasive markers studied. For all patients with UGIB, non-invasive markers appear to differentiate patients with varices from those without varices and to identify those with a variceal culprit lesion. However, these markers could not distinguish between a variceal culprit and other lesions in patients with cirrhosis.

Non-invasive assessment of large esophageal varices with liver cirrhosis ; a study conducted in Pakistan

“…Low platelet counts, high bilirubin level, presence of ascites, severity of cirrhosis (CTP-A, and CTP-B) were found to have predictive ability on univariate analysis. Earlier studies (2,4,(15)(16)(17) have also shown an independent predictive ability of low platelet count in liver cirrhosis patients to predict LEVx.…”

Liver stiffness and serum markers for excluding high-risk varices in patients who do not meet Baveno VI criteria

“…Previous studies have found that serum markers of liver fibrosis have moderate value for predicting liver cirrhosis in patients with HBV infection[29,30]. However, there is disagreement on the performance of serum markers of liver fibrosis in EV or HRV prediction[8,19,31]. In this study, we found that APRI and FIB-4 could not predict HRV.…”

“…Serum markers of liver fibrosis such as PLT count, aspartate aminotransferase (AST)-to-PLT ratio index (APRI), Fibrosis-4 (FIB-4), and the Lok index are useful in predicting severe liver fibrosis or cirrhosis[16-18], EV risk, and variceal bleeding risk in patients with HBV infection[19]. It remains unknown whether these serum markers of liver fibrosis can identify patients without HRV among those who do not meet the Baveno VI criteria.…”

S2k-Leitlinie Gastrointestinale Blutung

“…Es ist sehr schwierig, bei Patienten mit oberer gastrointestinaler Blutung aufgrund der Anamnese und anderer nicht-invasiver Indikatoren zwischen variköser und nicht-variköser Blutungsquelle zu unterscheiden. In einer großen retrospektiven Analyse von 2233 stationär aufgenommenen Patienten mit oberer gastrointestinaler Blutung, davon 1034 Patienten mit Leberzirrhose, waren Thrombozytopenie, AST-Thrombozyten-Ratio (APRI-Score), AST-ALT-Ratio (AAR) und der Lok-Index (nicht-invasive Labortests) hinweisend auf das Vorhandensein von Varizen sowie mit niedrigerer Sensitivität und Spezifität auch hinweisend auf eine Varizenblutung [6]. Leider war keiner der untersuchten Parameter in multivariaten Untersuchungen in der Lage, bei Patienten mit bekannter Leberzirrhose sicher zwischen nicht-varikösen und varikösen Blutungen zu unterscheiden [6].…”

“…In einer großen retrospektiven Analyse von 2233 stationär aufgenommenen Patienten mit oberer gastrointestinaler Blutung, davon 1034 Patienten mit Leberzirrhose, waren Thrombozytopenie, AST-Thrombozyten-Ratio (APRI-Score), AST-ALT-Ratio (AAR) und der Lok-Index (nicht-invasive Labortests) hinweisend auf das Vorhandensein von Varizen sowie mit niedrigerer Sensitivität und Spezifität auch hinweisend auf eine Varizenblutung [6]. Leider war keiner der untersuchten Parameter in multivariaten Untersuchungen in der Lage, bei Patienten mit bekannter Leberzirrhose sicher zwischen nicht-varikösen und varikösen Blutungen zu unterscheiden [6]. Derzeit werden weitere Verfahren evaluiert; beispielsweise scheinen sowohl die Lebersteifigkeit, gemessen über transiente Elastografie (Fibroscan ® , Fa.…”