Esophageal Variceal Bleeding as the First Manifestation of COVID-19 Infection: A Case Report

Liver cirrhosis is a defined liver disease with a wide range of clinical manifestations. Variceal bleeding is the main source of gastrointestinal hemorrhage among cirrhotic patients induced by several factors, such as alcohol consumption or infections. This is a report of a cirrhotic patient presenting with esophageal variceal bleeding in the context of COVID-19 infection. We report the case of a 53-year-old patient with liver cirrhosis and multifocal hepatocellular carcinoma presenting with upper gastrointestinal bleeding as the first manifestation of COVID-19 infection. Upon admission, the patient had no symptoms suggestive of a respiratory tract infection or any contact with positive SARS-CoV-2 individual and upper gastrointestinal endoscopy revealed variceal hemorrhage. After a few hours the patient manifested with fever, cough and dyspnea and a SARS-CoV-2 polymerase chain reaction test obtained was positive. The patient was initially treated with endoscopic band ligation and transferred in the COVID-19 infection clinic, where after a few days of hospitalization he passed away. The devastating pandemic of coronavirus disease 2019 had altered the pathophysiology and clinical presentation of several chronic diseases. This case report suggests that coronavirus disease as a potential triggering factor of variceal bleeding.

Study of endoscopic esophageal variceal ligation cases in Tishreen University Hospital: دراسة لحالات ربط دوالي المري تنظيرياً في مشفى تشرين الجامعي

Objective: The aim of this study is to estimate the effectiveness and complications of performing EVL in cirrhotic patients, and to assess the outcome of rebleeding events after EVL. Patients and Methods: An Observational Descriptive Study conducted for the period from January 2020 to January 2021 at Tishreen University Hospital in Lattakia- Syria, 45 Cirrhotic patients with esophageal varices who underwent 69 EVL sessions whether done as prophylactic or therapeutic followed up for three weeks. Results: The median age was 57 years, 66.70% of patients were male. The most common etiology was cryptogenic cirrhosis (40%), and 44.4% of patients had esophageal varices grade III. The most common indication for performing EVL was primary prophylaxis (46.4%). Initial control of bleeding was achieved in 95.2% of emergency procedures. The mortality rate during follow- up was 2.2%. Chest pain was the most common complication of EVL (31.9%). The incidence of re- bleeding events after EVL was 7.24%, more frequently in emergency procedures. Re- bleeding was significantly associated with alcoholic liver disease, poor liver condition (Child- Paugh C class), emergency procedures, coagulation disorders (low levels of PLT and high levels of INR) and presence of large varices (grade III and IV). Conclusion: EVL is feasible, safe, and effective for the management of esophageal varices in patients with end stage liver disease.

Endoscopic Vacuum-assisted Closure in a Patient with an Overtube-induced Esophageal Perforation

An esophageal perforation is one of the most fatal clinical events, with a mortality rate of up to 21%. This may arise postoperatively or post-endoscopically. In the past, surgical treatment, such as an esophagectomy, was performed these cases. However, the procedure was challenging and had a high risk of postoperative complications. Recently, advancements in endoscopic techniques have been made, and endoscopic procedures became a common treatment modality for patients with esophageal perforation, even in those with underlying diseases. Among the endoscopic procedures, endoscopic vacuum-assisted closure (E-VAC) has been known to be safe and effective. We present the case of a 64-year-old female with advanced liver cirrhosis and an overtube-induced esophageal perforation during esophageal variceal ligation. She was successfully treated with E-VAC.

Assessment of Non-invasive Markers for the Prediction of Esophageal Variceal Hemorrhage

Background: Esophageal variceal (EV) hemorrhage is a life-threatening consequence of portal hypertension in cirrhotic patients. Screening upper endoscopy and endoscopic variceal ligation to identify and treat EVs have contraindications, complications, and high costs. We sought to identify non-invasive tests (NITs) as alternatives to endoscopic EV screening.Methods: In this case-control study, we retrospectively analyzed 286 cirrhotic patients treated for EVs at the Second People's Hospital of Fuyang City, China from January to December 2019. We applied ROC curve analysis to assess the accuracy of various NITs in predicting EV hemorrhage.Results: There were significant differences between the hemorrhage and non-hemorrhage groups in median serum albumin (ALB) (p < 0.001), median bilirubin (TBIL) (p < 0.046), prothrombin (PT) time (p < 0.001), Golgi protein 73 (GP73; p = 0.012) and Child-Pugh (C-P) scores (p < 0.001). For ALB (cutoff <33.2g/L), PT time (cutoff > 14.2 seconds), GP73 (cutoff > 126.4 ng/ml), and C-P scores, the areas under the ROC curves (AUCs) were 73.4% (95% CI: 67.5–79.2), 68.6% (95% CI: 62.4–74.8), 62.2% (95% CI: 52.8–71.5) and 69.8% (95%CI: 63.8–75.8), respectively, with corresponding sensitives of 71.5, 59.8, 69.8, and 92.2% and specificities of 65.6%, 70.1%, 56.5%, and 38.6%. When ALB was combined with GP73, the AUC was 74.3% (95% CI: 66.1–82.5) with a sensitivity of 65.1% and specificity of 76.5%. When ALB, PT, and C-P scores were combined, the AUC was 76.5% (95% CI: 70.9–82.1) with a sensitivity of 79.5% and specificity of 64.3%. When ALB, PT, GP73, and C-P scores were combined, the AUC was 75.2% (95% CI: 67.3–83.1) with a sensitivity of 54.0% and specificity of 86.9%.Conclusion: ALB, TBIL, GP73, and C-P scores, may be used to predict EV hemorrhage in cirrhotic patients. The combination of multiple NITs is better than a single index and can increase diagnostic performance.

CT-Based Radiomics Score Can Accurately Predict Esophageal Variceal Rebleeding in Cirrhotic Patients

Purpose: This study aimed to develop a radiomics score (Rad-score) extracted from liver and spleen CT images in cirrhotic patients to predict the probability of esophageal variceal rebleeding.Methods: In total, 173 cirrhotic patients were enrolled in this retrospective study. A total of 2,264 radiomics features of the liver and spleen were extracted from CT images. Least absolute shrinkage and selection operator (LASSO) Cox regression was used to select features and generate the Rad-score. Then, the Rad-score was evaluated by the concordance index (C-index), calibration curves, and decision curve analysis (DCA). Kaplan–Meier analysis was used to assess the risk stratification ability of the Rad-score.Results: Rad-scoreLiver, Rad-scoreSpleen, and Rad-scoreLiver−Spleen were independent risk factors for EV rebleeding. The Rad-scoreLiver−Spleen, which consisted of ten features, showed good discriminative performance, with C-indexes of 0.853 [95% confidence interval (CI), 0.776–0.904] and 0.822 (95% CI, 0.749–0.875) in the training and validation cohorts, respectively. The calibration curve showed that the predicted probability of rebleeding was very close to the actual probability. DCA verified the usefulness of the Rad-scoreLiver−Spleen in clinical practice. The Rad-scoreLiver−Spleen showed good performance in stratifying patients into high-, intermediate- and low-risk groups in both the training and validation cohorts. The C-index of the Rad-scoreLiver−Spleen in the hepatitis B virus (HBV) cohort was higher than that in the non-HBV cohort.Conclusion: The radiomics score extracted from liver and spleen CT images can predict the risk of esophageal variceal rebleeding and stratify cirrhotic patients accordingly.

THE EFFECTIVENESS OF SPLENORENAL SHUNT IN TREATMENT OF PREHEPATIC PORTAL HYPERTENSION IN CHILDREN

Objective. To evaluate the results of treatment of prehepatic portal hypertension (PPH) in children by method of side-to-side splenorenal bypass. Methods. A retrospective, monocentric analysis of 114 patients with prehepatic portal hypertension was carried out in the period from 2000 to 2018. The age of the patients was from 6 months up to 18 years, the average age 10,1±3,8 years (M±σ). All patients underwent side-to-side splenorenal shunt. In the postoperative period, on the 7^th day, ultrasound examination of the abdominal organs with Doppler sonography (US) was performed to assess the volume of the spleen, the rate of portohepatic perfusion, the rate of blood flow along the side-to-side splenorenal shunt, as well as to assess its diameter. Control US was performed after the 1^st, 3^rd, 6^th, 12^th months; to assess the regression of esophageal and gastric varicose veins, the control esophagogastroduodenoscopy (EYD) was performed after 3^rd , 6^th, 12^th months and then once a year. Subsequently, the control examination of the patients was carried out once a year. The follow-up was 2-18 years. Results. Out of 114 patients who underwent side - to - side splenorenal shunt, 5 (4,4%) patients had recurrent bleeding from the esophageal variceal vein at the follow-up period (2-18 years). One patient had intra-abdominal arrosive bleeding from side-to-side splenorenal shunt provoked by severe postoperative pancreatitis. The average diameter of the shunt was 12±1.9 mm. The spleen volume decreased by 39.7±10.3%. Portohepatic perfusion reduced by 39% in comparison with the indicators before surgery. The blood flow rate along the side -to-side splenorenal shunt was 2403±557.3 ml/min. in 95,4% of patients the regression of variceal vein was noted. Hypersplenism syndrome was arrested in 73.6% of children. Conclusion. Side -to- side splenorenal shunt is considered to be an effective method of portal decompression with the effectiveness inpreventingboth esophageal and gastricvariceal veins bleeding in 95,4% of patients. What this paper adds The results of treatment of the prehepatic portal hypertension by method of side-to-side splenorenal shunt have been firstly analyzed, and the effect of this variant of portosystemic shunt on portohepatic perfusion has been assessed. It has been established that this option of shunt is effective for the portal system decompression and occupies an intermediate position between selective and total variant of portosystemic shunt.