Secondary gastric varices in hepatic cirrhosis

Secondary gastric varices in hepatic cirrhosis

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  ORIGINAL ARTICLE Secondary Gastric Varices in Hepatic Cirrhosis Shaikh Samiullah1, Muhammad Sadik Memon2, Hanif Ghani Memon1 and Amir Ghori2 ABSTRACT Objective: To determine the frequency of secondary gastric varices after esophageal variceal eradication in patients with cirrhosis of liver and factors associated with their development. Study Design: Observational study. Place and Duration of Study: The Department of Gastroenterology, Liaquat University Hospital, Jamshoro and Isra University Hospital Hyderabad, from September 2007 to July 2009. Methodology: Consecutive patients with decompensated cirrhosis of liver were subjected to endoscopy for management of varices. Endoscopic variceal band ligation was done in all patients. Secondary gastric varices were noted at surveillance. Receiver-operating characteristic (ROC) curves were used to determine the cut off values of secondary gastric varices and various factors influencing the development of gastric varices after eradication with the best sensitivity and specificity. Results: Of the 162 patients; 46 (28.3%) were females and 116 (71.7%) males. The mean age was 45 ±13 years. Fundal varices were present before eradication in 12 (7.4%) patients and after eradication of varices in 38 (23.5%) patients. A strong association was found between gastric varices after eradication and Child Pugh class (p=0.001), grade of varices at the time of presentation (p=0.024), increasing number of sessions for eradication of esophageal varices (p=0.001) and presence of gastric varix at the time of first presentation (p=0.009). Conclusion: Secondary gastric varices are common in cirrhosis. A significant association with Child-Pugh class, presenting grade, increasing number of ligation session and prior existence was seen in the studied group. Key words: Cirrhosis. Fundal varices. Band ligation. Secondary gastric. INTRODUCTION 5-33% in patients who have portal hypertension, with an Gastro-esophageal varices occur in 50% of cirrhotic overall incidence of bleeding ranging from 3% to 30%.4 patients at a rate of 10% per year. The clinical course of Gastroesophageal varices continuing as extension chronic liver disease is complicated by variceal along the lesser curvature of stomach (GOV1) hemorrhage in 30% of cases. With each episode of disappears in about 58% and 70% after EST and EVL of variceal bleeding the mortality is 20 - 30%; around 70% esophageal varices respectively.5,6 Secondary gastric of survivors have recurrent bleeding after their first varices occur at the rate of 9.7-15.3% patients after variceal hemorrhage.1 eradication of esophageal varices.7 Bleeding from gastric varices occurs repeatedly from esophageal Endoscopic sclerotherapy (EST) and band ligation of varices and is associated with decreased survival. The esophageal varices (EVL) has been accepted as the mortality from gastric varices can reach as high as 52% treatments of choice for eradication of esophageal at the end of one year. Gastric varices also leads to varices and prevention of variceal re-bleeding.2,3 hepatic encephalopathy due to presence of porto- However, variceal eradication may result in gastric systemic shunt more frequently as compared to hemodynamic changes resulting in blockage of shunting esophageal varices. Because of certain anatomical in palisade zone leading to dilatation and formation of features, the gastric varices rupture is less frequent but new or secondary gastric varices. Gastric varices are the calibre of gastric varix is so large that if it ruptures it classified as primary when they occur primarily in bleeds massively which is difficult to control.8,9 Due to continuation with esophageal varices whereas high frequency of spontaneous gastrorenal shunts, secondary gastric varices occur after obliteration of gastric varices bleed at < 12 mmHG portosystemic esophageal varices. The prevalence of gastric varices is pressure gradient which is less than expected and 1 Department of Medicine, Liaquat University of Medical and predict bleeding gastric varices has always been a Health Sciences, Jamshoro/Hyderabad. challenge to clinicians.10 2 Department of Medicine, Isra University Hospital, Hyderabad. The purpose of this study was to determine the Correspondence: Dr. Samiullah Shaikh, House No. 55, frequency of secondary gastric varices after esophageal Green Homes, Qasimabad, Hyderabad. variceal eradication in patients with cirrhosis of liver and E-mail: [email protected] the factors associated with the development of Received September 06, 2010; accepted September 09, 2011. secondary gastric varices. Journal of the College of Physicians and Surgeons Pakistan 2011, Vol. 21 (10): 593-596 593
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  Shaikh Samiullah, MuhammadSadik Memon, Hanif Ghani Memon and Amir Ghori METHODOLOGY accuracy if the c-statistic was 0.5 and excellent This study was conducted in the Department of Gastro- diagnostic accuracy if the c-statistic was > 0.5. All enterology, Liaquat University Hospital, Jamshoro and calculations were done using SPSS version 16 Isra University Hospital, Hyderabad, from September (Chicago, IL, USA). 2007 to July 2009. Patients of either gender suffering from cirrhosis of liver with history of bleeding RESULTS esophageal varices were included. Patients suffering This study included 162 consecutive patients of whom from hepatocellular carcinoma and those who had re- 46 (28.3%) were females and 116 (71.7%) males. The bleeding during surveillance were excluded from study. mean age of patients was 45 ±13 years. The mean Patient's information about medical history, complete albumin was 2.84±0.83 g/dl; platelet count was 3 physical examination and routine laboratory test were 1.72 x 10 ± 0.45; hemoglobin level was 8.49 ± 2.41 g/dl enrolled in well-designed proforma. The diagnosis of and serum creatinine was 1.01± 0.37 mg/dl. Twenty- decompensated cirrhosis was based on clinical, three (14.2) were in Child-Pugh class A, 35 (21.6) in laboratory, and radiological signs of cirrhosis with at class B and 104 (64.2) in class C. Grade 1 varices were least one sign of liver decompensation (ascites, variceal present in 14 (8.6%), grade 2 in 16 (9.9%) and grade 3 bleeding, hepatic encephalopathy and/or non- in 132 (81.5%) patients. Fundal varices before obstructive jaundice). The severity of each patient was eradication were present in 12 (7.4%) patients and graded by Child-Pugh (range 5-15) classification into A, during follow-up after eradication in 38 (23.5%). Number B and C class.11 The standard coagulation parameters - of sessions needed for eradication of a varices were platelet count, prothrombin time (PT), activated partial 1-3 for 41(25.2%), 4-5 for 71 (43.8%) and > 5 sessions thromboplastin time (APTT) were determined for each for 50 (31%) patients. Table I shows the baseline patient. characteristics of the patients. Endoscopy was done in all patients and presence of A strong association was found between gastric varices variceal bleeding was confirmed if an actively bleeding after eradication and Child-Pugh class (p=0.001), grade varix or varix with adherent clot was found. During of varices at the time of presentation (p=0.024), endoscopy, each varix was assessed for size, color increasing number of sessions for eradication of and location, and the presence of red sign. The size esophageal varices (p=0.001) and presence of gastric of varices was classified as small (F1, varices varix at the time of first presentation (p= 0.009). Child’s compressible by the endoscope); medium (F2, non- class had a sensitivity of 92.1%, specificity of 45%, PPV compressible varices) and large (F3, varices confluent Table I: Baseline characteristics of patients. around the circumference of the esophagus).12 Continuous Mean Std. deviation Age (years) 45.10 13.112 Endoscopic variceal band ligation done in all patients Hemoglobin (G/dl) 8.49 2.415 and repeated every third week till the varices were Platelet count 103/cumm 1.72 45.4 eradicated and called for surveillance endoscopy after Albumin (G/dl) 2.84 0.834 6 months. At surveillance secondary isolated gastric Categorical variable Frequency Percentage varices (IGV-1) were noted.13 The degree of fundal Child class varices (FV) was classified as F0 (absent), F1 (winding) Class A 23 14.2% and F2 (nodule-beaded or tumor-like). Class B 35 21.6% Continuous variables such as age, bilirubin, hemo- Class C 104 64.2% globin, platelet count and serum albumin were Grade of varices Grade 1 14 8.6% expressed as mean with standard deviation. Categorical Grade 2 16 9.9% variables such as gender, Child-Pugh class, grades of Grade 3-4 132 81.5% esophageal varices, gastric varices before eradication, Gasric varices before eradication gastric varices after eradication and sessions of band No 150 92.6% ligation were expressed as frequency and percentage. Mild 8 4.9% Receiver-operating characteristic (ROC) curves were Moderate 4 2.5% used to determine the cut off values of secondary gastric Gasric varices after eradication varices and various factors influencing the development No 124 76.5% of gastric varices after eradication with the best Mild 12 07.5% sensitivity and specificity. The validity of the models was Moderate 16 10% measured by the concordance c-statistic (equivalent to Severe 10 06% the area under the ROC curve), and the c-statistic of Sessions of band ligation models were compared using chi-square test.14 A 1-3 Sessions 41 25.3% p-value of 0.05 or less was considered as statistically 3-5 Sessions 71 43.7% significant. A model was considered to have diagnostic 5 sessions 50 31% 594 Journal of the College of Physicians and Surgeons Pakistan 2011, Vol. 21 (10): 593-596
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  Secondary gastric varicesin hepatic cirrhosis of 31.9% and NPV of 31.96% while the session of band varices in EVL group whereas 13 patients in the EST ligation required for eradication of varices had a group had fundal varices before variceal eradication.13 sensitivity of 53%, specificity of 76%, PPV of 42.66% After variceal eradication, secondary gastric varices was and NPV of 58.13% for diagnosing gastric varices detected in 46 patients in EVL group and in 19 patients development (Table II). On ROC curve, a greater in EST group, an increase in gastric varices by about relationship of fundal varices with Child-Pugh class 10% after eradication.13 According to Mumtaz in a large (AuC 0.690) and number of session required for the retrospective study comprising 1436 patients gastric eradication of esophageal varices (AuC 0.685) was varices was present in 220 (15%) patients.17 In this found with grade of esophageal varices (AuC 0.64) study, secondary gastric varices was found in 23% of before eradication and presence of fundal varices before patients within 6 months after eradication of esophageal variceal eradication (AuC 0.62) as shown in Figure 1. varices. Korula and colleagues found secondary gastric varices in 15.3% cases,18 whereas Hashizume and co- Table II: Sesitivity, specificity, PPV, NPV of various variables with the development of secondary gastric varices. workers found the same in 9.7% cases.19 Variables Area Sensitivity Specificity PPV NPV p-value There were various predisposing risk factors for the Child's class 0.690 92.1 45 68.76 31.96 0.001 development of gastric varices. In this study, Child-Pugh Grade of varices 0.62 100 25 69.92 30.8 0.024 class, grade of varices at the time of presentation, Gastric varices before increasing number of sessions for eradication of eradication 0.64 79 82 50.66 49.97 0.009 esophageal varices and presence of gastric varix at the Sessions of band time of first presentation were the factors associated with the development of gastric varices. Kim et al. ligation 0.685 53 76 42.66 58.13 0.001 Abbreviations: PPV = Positive predictive value; NPV =Negative predictive value. followed 1,392 cirrhotic patients and detected variceal size and Child-Pugh score as important predictors of bleeding from gastric varices.20 These prognostic factors have been seen by Akiyoshi as well who in 145 patients with cirrhosis and fundal vacices found hemorrhage from FV, concomitant hepatocellular carcinoma and poor hepatic functional reserve an important prognostic factors for survival.21 This study could have been extended to identify those patients who are at the risk of bleeding from the gastric varices on the basis of location of gastric varices, size of fundal varices, severity of liver failure and endoscopic presence of variceal red spots.22 This study is limited to observe the frequency of gastric varices after obliteration of esophageal varices by EVL. Further studies are needed to compare the development Figure 1: Relationship of fundal varices with child-pugh class, grade of of gastric varices by other methods of obliteration such varices, fundal varices and session of band ligation. as EST. Management of patients, who bleed from secondary DISCUSSION gastric varices by different means, is our next step which There was an increase in the frequency of gastric will make this as interventional study. This will enable us varices after endoscopic variceal eradication. This study to decide about the options for stopping the gastric showed gastric varices in 7.4% cases before varices. eradication. Sarin prospectively followed 1128 patients and found gastric varices in 20% of patients at first CONCLUSION endoscopy in patients with portal hypertension.15 Secondary gastric varices are not uncommon and Hosking in a study of 114 patients reported gastric develop following obliteration of main variceal columns. varices in 17% of cases.16 The lower percentage in this Secondary gastric varices are common in cirrhosis. A study was probably because of selection of patients with significant association with Child-Pugh class, presenting mild to moderate severity of liver disease. An increase in grade, increasing number of ligation session and prior frequency of gastric varices was also noted in this study after eradication of oesophageal varices. Osman et al. in existence was seen in the studied group. a series of 114 consecutive patients with cirrhosis and REFERENCES portal hypertension, who underwent elective EVL or 1. Mehta G, Abraldes JG, Bosch J. Developments and controversies EST for obliteration of esophageal varices, found gastric in the management of oesophageal and gastric varices. Gut varices in 37 patients before eradication of esophageal 2010; 59:701-5. Journal of the College of Physicians and Surgeons Pakistan 2011, Vol. 21 (10): 593-596 595
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