Non-invasive diagnosis of variceal bleeding: choose the right target population and identify the right culprit

摘要

The reference for esophageal varice (EV) diagnosis is endoscopy, but its invasive nature and certain logistic issues constrain its deployment to larger urban health facilities. Resultantly, endoscopy, especially in emergency settings, is generally not available in remote areas, be they in developed or developing countries, and in these latter, the cost of the intervention may further limit its availability to patients. Furthermore, even in developed countries, the recommended screening for varices needing treatment (VNT) is performed in only about one third of cirrhotic patients ( ), thus decreasing the collective life expectancy of this population ( ). To address these issues, non-invasive techniques to diagnose EV have been developed over the last 20 years with the main objective of improving VNT screening in cirrhotic patients with regards to primary prevention of variceal bleeding (VB). That body of research led to the Baveno VI recommendation to screen for VNT in compensated advanced chronic liver diseases (cACLD) using a combination of platelets count and liver stiffness measurement by Fibroscan ( ). Beyond this popular topic, several teams have set their sights on evaluating the non-invasive diagnosis of EV in patients with upper gastrointestinal bleeding (UGIB) with, here, the main objective of improving causal treatment, especially early vasoactive drug delivery for VB. Classically, the prevalence and imputability of EV are considered sufficiently high to justify the use of vasoactive drugs prior to endoscopy in all patients with known or suspected cirrhosis. Endoscopy within 12 hours is considered mandatory ( ) as delays to resulting interventional treatments are responsible for increased mortality ( ). Additionally, the effectiveness of vasoactive drugs in suspected VB before endoscopy has been demonstrated in a randomized trial ( ). However, this policy of early drug administration and endoscopy cannot be applied everywhere for logistic or economic reasons. In their report evaluating several markers or simple fibrosis tests ( ) in a cohort of 2,233 American patients, Rockey, Elliott and Lyles stated that “ ” ( ). In a work performed in Egypt, Hanafy developed a scoring system for EV prediction in 300 critically ill patients with UGIB. They reported high accuracy in derivation and validation populations for their system, but this latter employed a high number of variables, including ultrasonographic and Doppler criteria, limiting its clinical application ( ). In this context, limited by the few available data, a multicenter cross-sectional study was performed by Qi in China in 363 cirrhotic patients of whom 260 had EVs and 180 UGIB ( ). In that study, they found that ascites and platelets were independent predictors for EVs, both in the whole population (plus UGIB as a third independent predictor) and in the subgroup with UGIB. The logistic score they constructed with those variables was named the Liaoning score, after the Chinese province where the study was performed. There were however two main limits to that study: there was no validation population and only patients with cirrhosis were included. Two minor limitations were also present: high risk EV (HREV) were not evaluated and the method to select the score cut-off was not stated.