• Acute renal failure in cirrhosis: Is it as bad as we think?

      Rye, Kara; Taylor, Nicholas; Li, Ka Kit; Mortimore, Gerri; Johnson, M.; Freeman, Jan G.; Derby City General Hospital (BMJ Publishing Group Ltd., 2007-04)
      Introduction: Acute renal failure (ARF) is associated with a mortality of 50–60% in critically ill patients admitted to the intensive care unit (ICU). Prerenal causes and acute tubular necrosis (ATN) account for more than 85% of cases and are potentially reversible. ARF frequently complicates cirrhosis, is often attributed to hepatorenal syndrome (HRS), which may preclude aggressive treatment with its mortality up to 90%. Aims & Methods: The aim of this study was to identify factors that may predispose to or precipitate ARF in cirrhosis, and determine outcome and mortality. A retrospective review of cirrhotic patients admitted with or developing renal impairment (defined as serum creatinine >130 μmol/l or oliguria <500 ml/24 h) from October 1999–April 2004. Patients with bleeding gastro-oesophageal varices were excluded. Demographic details, cause of ARF, potential early warning features, management and outcome were recorded. Results: Eighty patients, median age 52 years (25–84), 46 male, median MELD 26 (7–43). Alcohol was causal in 88.8%. ARF occurred in 41/80 (51.3%) on admission, or a median of 6 days after admission (1–34). Median serum creatinine at onset of renal impairment 172 μmol/l (60–589). An identifiable precipitant was found in 62/80 (77.5%) and were concurrent in 51%; nephrotoxic drugs 50%, sepsis 45% (culture positive 27/36), recent paracentesis (preceding month) 28.8%, fluid loss 26.3%, and spontaneous bacterial peritonitis 13.3%. HRS occurred in 17.5%. No parenchymal renal disease or obstructive uropathy was seen. 54% were hyponatraemic (serum sodium <130 μmol/l) at onset of ARF. ARF was heralded by a fall in median mean arterial pressure (MAP) of 14.1 mm Hg from admission (p<0.001, CI 6.8–19.7). 71.2% received volume expansion, 91.1% terlipressin, 79.7% salt poor albumin, 93.4% antibiotics, 7.5% MARS/renal support. MAP did not rise significantly 24 h after initiation of treatment (p = 0.56). 28 day mortality was 61%. HRS patients had higher MELD scores than non-HRS patients (30 v 25; p = 0.0152) but 28 day mortality was not significantly different (64.3% v 60.6% respectively, p = 0.797). Conclusion: ARF in cirrhosis is rarely due to HRS but is most commonly pre-renal in origin and multifactorial. Potential early warning features include hyponatraemia and a falling MAP. Current treatment regimes may not be aggressive enough to reverse renal hypoperfusion. Despite this mortality for our cirrhotic cohort was similar to non-cirrhotic patients admitted to ITU with ARF. Development of ARF in a cirrhotic patient should not preclude aggressive treatment.
    • Automonic dysfunction measured by baroreflex sensitivity is markedly abnormal in stable cirrhosis despite minimal systemic haemodynamic changes

      Rye, Kara; Mortimore, Gerri; Austin, Andrew; Freeman, Jan G.; University of Derby (BMJ Publishing Group Ltd., 2009)
      Baroreceptor sensitivity (BRS) is well recognised as a composite marker of the overall integrity of the autonomic nervous system, maintaining cardiovascular status both at rest and during physiological stress. Autonomic dysfunction occurs in 43–80% of cases of cirrhosis, affecting both sympathetic and parasympathetic branches. BRS impairment occurs independently of aetiology and correlates with disease severity and the hyperdynamic circulation. BRS has been studied extensively in advanced disease, especially pre-transplantation but less so in more compensated disease. Impaired BRS is associated with a 5-fold increase in mortality, independent of cirrhosis stage, yet can be improved by drugs and liver transplantation.
    • Automonic dysfunction measured by baroreflex sensitivity is markedly abnormal in stable cirrhosis despite minimal systemic haemodynamic changes

      Rye, Kara; Mortimore, Gerri; Austin, Andrew; Freeman, Jan G.; Derby City General Hospital (BMJ Publishing Group Ltd., 2009-04)
      Introduction: Baroreceptor sensitivity (BRS) is well recognised as a composite marker of the overall integrity of the autonomic nervous system, maintaining cardiovascular status both at rest and during physiological stress. Autonomic dysfunction occurs in 43–80% of cases of cirrhosis, affecting both sympathetic and parasympathetic branches. BRS impairment occurs independently of aetiology and correlates with disease severity and the hyperdynamic circulation. BRS has been studied extensively in advanced disease, especially pre-transplantation but less so in more compensated disease. Impaired BRS is associated with a 5-fold increase in mortality, independent of cirrhosis stage, yet can be improved by drugs and liver transplantation. Aims and Methods: The aim of this study was to determine the prevalence of BRS abnormalities in a stable population of cirrhotics. We studied 16 cirrhotic patients with stable disease for >6 months. Systemic haemodynamics and BRS were assessed non-invasively in the supine position on two different days using the Finometer® (TNO instruments, Amsterdam). Data were downloaded to a PC-based analysis program (Beatscope®). Spontaneous BRS was assessed using software studying the relationship between inter-beat variability and beat-to-beat changes in systolic blood pressure. Portal pressure was assessed by measurement of the hepatic venous pressure gradient (HVPG). Results: Median age 47 (30 to 67) years, 63% male, median Child–Pugh (CP) score 6 and MELD 11. 94% alcoholic aetiology, 69% abstinent. 9/16 (56%) concomitant spironolactone. Median haemodynamic data as follows: systolic BP 147 (115 to 169) mm Hg, diastolic BP 82 (65 to 103) mm Hg, MAP 104 (87 to 131) mm Hg, HR 89 (54 to 117) bpm, SV 89 (36 to 164) ml, CO 7.0 (3.5 to 12.0) lpm, PVR 0.98 (0.45 to 2.14) MU, HVPG 18 (7 to 25) mm Hg. 12/16 (75%) had abnormal BRS (normal 8 to 10 ms/mm Hg) with median BRS 3.38 (1.14 to 11.19) ms/mm Hg. Sequential BRS readings were not significantly different (3.38 vs 3.98 ms/mm Hg, p = 0.87). Systemic haemodynamics were not significantly different in patients with impaired BRS compared with those with normal BRS. BRS did not correlate with disease severity (CP A 2.96 vs CP B 3.80 ms/mm Hg, p = 1.0), systemic haemodynamics, serum sodium or variceal size. There was a significant negative correlation between BRS and HVPG (r = −0.523, p = 0.045). Conclusion: Autonomic function as assessed by BRS is frequently abnormal in stable cirrhotic patients. Abnormalities of BRS are not associated with marked haemodynamic changes, suggesting that it is predominantly the vagal aspect that is impaired in stable disease. Abnormalities of BRS are associated with HVPG which may suggest that portal pressure itself plays a pivotal role in its causation. The significance of impaired BRS in this stable group needs to be determined by assessing long-term outcome.
    • Autonomic dysfunction measured by baroreflex sensitivity in markedly abnormal in stable cirrhosis despite minimal haemodynamic changes.

      Rye, Kara; Mortimore, Gerri; Austin, Andrew; Freeman, Jan G.; University of Derby; Derby Hospitals NHS Foundation Trust (British Association for the Study of Liver (BASL), 2008)
      Introduction: Autonomic dysfunction occurs in 43-80% of cases of cirrhosis, but is usually asymptomatic. The baroreflex arc is an important component of the autonomic nervous system main- taining cardiovascular status both at rest and during physio- logical stress. Baroreceptor sensitivity (BRS) is impaired in cirrhosis and correlates with disease severity. It has been stud- ied extensively in advanced disease, especially pre-transplan- tation, where impairment of BRS correlates with the presence of ascites, encephalopathy, and the hyperdynamic circulation. Impaired BRS is associated with a five-fold increase in mortal- ity predominantly from sepsis and variceal bleeding, inde- pendent of the stage of liver disease. Manipulation by ACE inhibitors, aldosterone antagonists and liver transplantation all improve BRS. The aim of this study was to determine the preva- lence of BRS abnormalities in a stable population with well compensated disease. Methods: We studied 11 stable cirrhotic patients. Spontaneous BRS was assessed in the supine position on two different days using software studying the relationship between inter-beat variability and beat-to-beat changes in sys- tolic blood pressure. Systemic haemodynamics (heart rate (HR), mean arterial pressure (MAP), cardiac output (CO), stroke vol- ume (SV), peripheral vascular resistance (PVR)) were assessed non-invasively using the Finometer®. Portal pressure was assessed by measurement of the hepatic venous pressure gra- dient (HVPG). Results: Median age 46 (30-67) years, 64% male, median Child-Pugh (CP) score 6 and MELD 11. Median haemodynamic data as follows: systolic BP 147 (115-169) mmHg, diastolic BP 82 (73-103) mmHg, MAP 103 (87-131) mmHg, HR 90 (63-110) bpm, SV 87 (38-141) ml, CO 8.0 (3.5-10.1) lpm, PVR 0.96 (0.64-2.14) MU, HVPG 18 (12-26)mmHg. 9/11 (82%) had abnormal BRS (normal 8- 10ms/mmHg) with median BRS 2.58 (1.14-9.46) ms/mmHg. Sequential BRS readings were not significantly different (2.58 vs 3.26 ms/mmHg, p=0.8). BRS did not correlate with disease severity (CP A 2.58 vs CP B 3.80 ms/mmHg, p=0.9), systemic haemodynamics, HVPG or serum sodium. Systemic haemody- namics were not significantly different in patients with impaired BRS compared to those with normal BRS. Conclusions: Auto- nomic function as assessed by BRS is markedly abnormal in sta- ble well compensated cirrhosis. Abnormalities are not specific to advanced disease as previously thought and in our group are not associated with marked hyperdynamic changes. Our data suggest that it is predominantly the vagal aspect that is impaired in well compensated disease. The long-term outcome of these patients needs to be assessed.
    • Autonomic dysfunction measured by baroreflex sensitivity in markedly abnormal in stable cirrhosis despite minimal haemodynamic changes.

      Rye, Kara; Mortimore, Gerri; Austin, Andrew; Freeman, Jan G.; University of Derby; Derby Hospitals NHS Foundation Trust (Wiley, 2008-09-24)
      Introduction: Autonomic dysfunction occurs in 43-80% of cases of cirrhosis, but is usually asymptomatic. The baroreflex arc is an important component of the autonomic nervous system main- taining cardiovascular status both at rest and during physio- logical stress. Baroreceptor sensitivity (BRS) is impaired in cirrhosis and correlates with disease severity. It has been stud- ied extensively in advanced disease, especially pre-transplan- tation, where impairment of BRS correlates with the presence of ascites, encephalopathy, and the hyperdynamic circulation. Impaired BRS is associated with a five-fold increase in mortal- ity predominantly from sepsis and variceal bleeding, inde- pendent of the stage of liver disease. Manipulation by ACE inhibitors, aldosterone antagonists and liver transplantation all improve BRS. The aim of this study was to determine the preva- lence of BRS abnormalities in a stable population with well compensated disease. Methods: We studied 11 stable cirrhotic patients. Spontaneous BRS was assessed in the supine position on two different days using software studying the relationship between inter-beat variability and beat-to-beat changes in sys- tolic blood pressure. Systemic haemodynamics (heart rate (HR), mean arterial pressure (MAP), cardiac output (CO), stroke vol- ume (SV), peripheral vascular resistance (PVR)) were assessed non-invasively using the Finometer®. Portal pressure was assessed by measurement of the hepatic venous pressure gra- dient (HVPG). Results: Median age 46 (30-67) years, 64% male, median Child-Pugh (CP) score 6 and MELD 11. Median haemodynamic data as follows: systolic BP 147 (115-169) mmHg, diastolic BP 82 (73-103) mmHg, MAP 103 (87-131) mmHg, HR 90 (63-110) bpm, SV 87 (38-141) ml, CO 8.0 (3.5-10.1) lpm, PVR 0.96 (0.64-2.14) MU, HVPG 18 (12-26)mmHg. 9/11 (82%) had abnormal BRS (normal 8- 10ms/mmHg) with median BRS 2.58 (1.14-9.46) ms/mmHg. Sequential BRS readings were not significantly different (2.58 vs 3.26 ms/mmHg, p=0.8). BRS did not correlate with disease severity (CP A 2.58 vs CP B 3.80 ms/mmHg, p=0.9), systemic haemodynamics, HVPG or serum sodium. Systemic haemody- namics were not significantly different in patients with impaired BRS compared to those with normal BRS. Conclusions: Auto- nomic function as assessed by BRS is markedly abnormal in sta- ble well compensated cirrhosis. Abnormalities are not specific to advanced disease as previously thought and in our group are not associated with marked hyperdynamic changes. Our data suggest that it is predominantly the vagal aspect that is impaired in well compensated disease. The long-term outcome of these patients needs to be assessed.
    • Do H63D homozygote patients have clinically significant iron overload?

      White, Jonathan; Scott, Robert; Mortimore, Gerri; Lawson, Adam; Freeman, Jan G.; Austin, Andrew; Derby Digestive Diseases Centre (2011-03-13)
      Homozygosity H63D is present in 2% of the normal Caucasian population and is thought to carry a small risk of iron overload. The authors aim to characterise patients referred with evidence of iron overload found to be H63D homozygous.
    • Non-invasive assessment and prediction of clinically significant portal hypertension

      Rye, Kara; Mortimore, Gerri; Austin, Andrew; Freeman, Jan G.; Royal Derby Hospital (BMJ Publishing Group Ltd., 2011-03-13)
      Hepatic venous pressure gradient (HVPG) predicts variceal development, bleeding, clinical decompensation and death. Measurement is invasive, time-consuming and performed in few centres. Reduction of HVPG to ≥12 mm Hg or by >20% significantly reduces bleeding risk and mortality. Detection of non-responders requires repeated HVPG measurement as conventional non-invasive assessment is not accurate in predicting haemodynamic response. Cirrhotics have a hyperdynamic circulation and impaired baroreceptor sensitivity (BRS). The authors assessed whether non-invasive measurement of systemic haemodynamics and BRS detected clinically significant portal hypertension (CSPH, HVPG ≥12 mm Hg).
    • Non-invasive measurement of Systemic Haemodynamics by Finometry in patients with Cirrhosis

      Freeman, Jan G.; Rye, Kara; Mortimore, Gerri; Austin, Andrew; University of Derby (2015-01)
    • P16 Non-invasive detection of oesophageal varices: comparison of non-invasive assessment of systemic haemodynamics with laboratory parameters and predictive scores

      Rye, Kara; Mortimore, Gerri; Austin, Andrew; Freeman, Jan G.; Derby Hospitals NHS Foundation Trust (BMJ Publishing Group Ltd., 2010)
      Endoscopic screening for varices (OV) is advised in cirrhosis, repeated every 1–3 years, with primary prophylaxis given to large OV. This is costly to endoscopy units, unpleasant for patients and multiple procedures may affect compliance. Cirrhosis is characterised by a hyperdynamic circulation; novel tools make non-invasive assessment possible.
    • P24 Presence of impaired baroreceptor sensitivity is a poor prognostic marker in cirrhosis

      Rye, Kara; Mortimore, Gerri; Austin, Andrew; Freeman, Jan G.; University of Derby (BMJ Publishing Group Ltd., 2011)
      Autonomic function is essential for blood pressure control and baroreceptor sensitivity (BRS) acts as a composite marker of overall function. Both sympathetic and parasympathetic function is impaired in cirrhosis. Impaired BRS predicts death in cardiovascular diseases and chronic kidney disease.
    • P35 Long-term remission is achievable in autoimmune hepatitis using Tacrolimus or Mycophenolate mofetil and results in regression of fibrosis

      Scott, Robert; White, Jonathan; Atwal, Gurprit Suni; Taylor, Nicholas; Mortimore, Gerri; Freeman, Jan G.; Lawson, Adam; Austin, Andrew; University of Derby (BMJ Publishing Group Ltd., 2011-09-06)
      Introduction 10–20% of patients do not respond to conventional treatment of autoimmune hepatitis, or are intolerant of azathioprine. There is no established second line treatment. Experience with transplant immunosuppressive agents such as Tacrolimus (TAC) and mycophenolate mofetil (MMF) is limited to small numbers and short-term follow-up. Aim To describe the progress of all patients who had failed conventional therapy and were treated with second line agents with at least 12-month follow-up. Method An audit of patients identified who received second line agents for at least 12 months on maintenance dose <10 mg prednisolone. Patient records were reviewed and treatment endpoints based on aminotransferase changes defined as; Complete response (CR) - sustained normalisation for at least 12 months, partial response (PR) - improvement by >50% but not always normal over a 12-month period. Where applicable, interval histology was reviewed by a single pathologist to assess ISHAK fibrosis scores at the start and at least 18 months after commencing second line agents. Results A total of 26 patients were identified. 9 were treated with TAC for a median 81 months (21–137), 16 with MMF for a median 81 months (30–114) and one on a combination of TAC and MMF. Median age is 56 (28–68) and 64 (40–79) respectively. The median dose of TAC is 3.5 mg/day (1–6) and MMF 1 g/day (1–2). All patients on TAC achieved CR. Two patients discontinued treatment; one renal impairment and one rationalising treatment after 27 months CR. 11/16 patients on MMF achieved CR, 5/16 achieved PR. Five patients no longer take MMF; two due to toxicity (recurrent chest infections at 60 months, GI disturbance at 78 months), one successfully withdrew treatment after 39 months CR, one switched to TAC as a treatment failure of MMF after 103 months and one was withdrawn after a diagnosis of larynx SCC. The combination patient achieved CR and has received 50 months dual treatment with confirmed histological remission. Four patients on TAC and five on MMF had interval biopsies. 3/4 patients on TAC (median 87 months) exhibited stable or reduced grades of fibrosis compared to 2/5 patients on MMF (median 101 months). Conclusion Effective long-term maintenance of remission at 10 years is achievable on MMF and TAC in the absence of significant toxicity. Achieving prolonged CR seems to confer disease control and can result in histological regression of fibrosis.
    • P37 identifying cirrhotics at risk of paracentesis-induced circulatory dysfunction (PICD): The significance of an early fall in stroke volume

      Grant, Claire; Rye, Kara; Scott, Robert; White, Jonathan; Mortimore, Gerri; Freeman, Jan G.; Austin, Andrew; University of Derby (Elsevier, 2014-04)
    • Patient experience of day case liver biopsy: Prospective audit

      Li, Ka Kit; Mortimore, Gerri; Jackson, Michelle; Clarke, Dominic; Freeman, Jan G.; Austin, Andrew; Royal Derby Hospital (Wiley, 2006-10-01)
      Background: Percutaneous liver biopsy remains an important toolin the diagnosis and staging of chronic liver disease. There is oftenreluctance to use wider bore needles because of potentially highercomplication rates. There are no good prospective studies of thepatient experience and morbidity associated with the procedure.Aims: To describe the patient experience and compare two differ-ent biopsy needles. Patients and Methods: Data collected prospec-tively was available for 83 ultrasound-sited percutaneous biopsiesfor chronic liver disease. Subjects were regularly offered analgesiaand asked to rate pain on a visual analogue scale (0-10). Patientswere contacted 30 days post-biopsy. Results: Indications for bi-opsy were alcoholic liver disease (21%), NAFLD (21%), HCV(14%), HBV (8%), haemachromatosis (10%), autoimmune hepatitis(8%), other (22%). Data are expressed as mean (CI) and comparedusing t-test and ANOVA. Within the first 6 hours, 28 took parac-etamol only, 8 required codeine-based analgesia, and 1 receivedpethidine. There were no episodes of bradycardia, hypotension orpyrexia and only one re-admission (for recurrent ascites). Therewere no serious adverse events in either group. Conclusions: Themajority of patients experienced only mild discomfort after liverbiopsy and 45% did not require analgesia. A small difference inpain scores was detected at one hour but did not persist to sixhours and may reflect the greater use of lignocaine by one group.
    • Prospective audit of liver biopsy practice: Is bigger better?

      Li, Ka Kit; Mortimore, Gerri; Jackson, Michelle; Semeraro, David; Clarke, Dominic; Freeman, Jan G.; Austin, Andrew; Royal Derby Hospital (Wiley, 2006-10)
      Background: Percutaneous liver biopsy remains an important toolin the diagnosis and staging of chronic liver disease. For reliableand reproducible interpretation, a specimen containing a minimum of six portal tracts and ideally more than ten is required.There is often reluctance to use wider bore needles because ofpotentially higher complication rates. Aims: To compare the ad-equacy of samples obtained using two different biopsy needles.Patients and Methods: Data was collected prospectively for 128ultrasound-sited percutaneous biopsies for chronic liver diseaseover a 10 month period using a proforma. Results: Indications forbiopsy were alcoholic liver disease (21%), NAFLD (21%), HCV(14%), HBV (8%), haemachromatosis (10%), autoimmune hepatitis(8%), other (22%). There were no serious adverse events in eithergroup. Biopsy characteristics are compared in Table 1. Data areexpressed as mean (CI) or median (range) and compared using ttest, Mann-Whitney U test or Chi-squared. Conclusions: Liverbiopsy samples obtained with a 15G Menghini needle are superiorto those obtained using an 18G Trucut needle. The latter are ofteninadequate for assessment using accepted criteria.
    • PTU-066 Non-invasive assessment of systemic haemodynamics to determine variceal bleeding risk in cirrhotic patients: Abstract PTU-066

      Rye, Kara; Mortimore, Gerri; Austin, Andrew; Freeman, Jan G.; Royal Derby Hospital (BMJ Publishing Group Ltd., 2015-09-23)
      Variceal bleeding is one of the most severe complications of portal hypertension. Universal endoscopic variceal screening is recommended and primary prophylaxis given based on oesophageal variceal size. Risk of bleeding also relates to other factors such as portal pressure, liver disease severity, and red wale markings at endoscopy. Currently there is no non-invasive way of measuring portal pressure or bleeding risk. The aim of this study was to evaluate whether non-invasive assessment of systemic haemodynamics in cirrhosis can identify bleeding risk in portal hypertension.
    • Tissue advanced glycation endproducts in two populations associated with increased oxidative stress: Normal in cirrhosis but elevated in haemodialysis patients

      Rye, Kara; Mortimore, Gerri; John, Stephen G.; Jefferies, Helen; Korsheed, Shvan; Owen, Paul; Fluck, Richard; McIntyre, Christopher W.; Austin, Andrew; Freeman, Jan G.; et al. (BMJ Publishing Group Ltd., 2009-04)
      Introduction: Advanced glycation endproducts (AGE) result from non-enzymatic glycation between reducing sugars and proteins and are a measure of cumulative metabolic stress. Tissue and serum AGE are known to predict cardiovascular mortality in end stage renal disease. Serum AGE levels are elevated in euglycaemic cirrhotics and correlate with disease severity yet cirrhosis appears to be protective against coronary atherosclerosis. Tissue AGE has not been assessed in cirrhosis. Aims and Methods: We aimed to assess tissue AGE in two populations with increased oxidative stress: cirrhosis and haemodialysis (HD) and determine whether skin AF is a non-invasive marker of liver disease severity. We studied 56 patients (28 cirrhotics, 28 age and sex matched HD patients) and compared with a normal control database (NC). Tissue AGE was measured using UV autofluorescence (AF) (AGE Reader, DiagnOptics, The Netherlands). Three sequential readings were taken from the palmar aspect of the forearm, approximately 10 cm below the elbow, avoiding pigmentation or vascular structures. History of diabetes mellitus (DM) and ischaemic heart disease (IHD) was noted and Child–Pugh (CP) and Model for End Stage Liver Disease (MELD) scores calculated. Results: Mean age 56±15 years, 64% male. 71% alcoholic cirrhosis, median CP score 8, MELD 12. DM and IHD prevalence was similar in both groups; no cirrhotic patient had renal impairment. Compared with NC, mean AF was significantly higher in both HD (3.264 vs 2.218, CI 0.691 to 1.402, p = <0.0001) and cirrhosis (2.632 vs 2.218, CI 0.082 to 0.746, p = 0.016). When cirrhotic patients with DM and IHD were excluded, this became insignificant (2.352 vs 2.157, CI to 0.116 to 0.506, p = 0.209). Mean AF was significantly higher in HD compared with cirrhosis (3.264 vs 2.632, CI 0.180 to 1.084, p = 0.007). Conclusion: Despite high levels of cumulative metabolic stress in both HD and cirrhosis, tissue AGE is only increased in HD. Both conditions are associated with elevated serum AGE levels but the mechanism underlying the differential tissue deposition is unknown. One hypothesis that may explain the reduced cardiovascular risk in cirrhosis is that soluble RAGE acts as a decoy receptor preventing AGE-RAGE interaction and the resulting endothelial dysfunction. Skin AF measurement is unhelpful as a non-invasive tool to detect cirrhosis.
    • Towards noninvasive detection of oesophageal varices

      Rye, Kara; Scott, Robert; Mortimore, Gerri; Lawson, Adam; Austin, Andrew; Freeman, Jan G.; University of Derby; Liver Unit, Royal Derby Hospital, Uttoxeter Road, Derby DE22 3NE, UK; Liver Unit, Royal Derby Hospital, Uttoxeter Road, Derby DE22 3NE, UK; Liver Unit, Royal Derby Hospital, Uttoxeter Road, Derby DE22 3NE, UK; et al. (Hindawi Publishing Corporation, 2012)
      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.