Liver stiffness measurement for diagnosis of portal hypertension-related digestive bleeding in the ICU

Introduction

Without past history or clinical signs of cirrhosis, the diagnosis of portal hypertension (PHT)-related digestive haemorrhage (DH) is often delayed until upper intestinal endoscopy performance, thus delaying specific medical treatment such as vasoactive drugs. As the liver stiffness measurement (LSM) is correlated to hepatic fibrosis [1] and PHT, it could be therefore useful for the diagnosis of cirrhosis in this situation. The aim of this study was to assess the predictive value of LSM by FIBROSCAN^® for the diagnosis of cirrhotic PHT-related DH.

Methods

Between January and May 2006, all consecutive patients referred for DH in two ICUs were prospectively included. In all patients a LSM and an upper gastrointestinal endoscopy were performed simultaneously at admission, each operator blinded to the result of the other examination. Exclusion criteria were the presence of ascitis or portal thrombosis without cirrhosis.

Results

Sixty-two patients were included (mean age: 60.2 ± 14.2 years; males: 40/62 (65%); BMI: 24.0 ± 11.3 kg/m²; SAPS II: 26.0 ± 19.3): 27/62 (44%) had non PHT-related DH (gastroduodenal ulcer, 16 cases; oesophagitis, seven cases; others, four cases); 35/62 (56%) had PHT-related DH (oesophageal varicose, 100%). All of these 35 patients had cirrhosis, either previously known or clinically obvious (18/35, 51%) or biopsy-proven later. The median LSM was significantly higher in patients with PHT-related DH (54.6 kPa (45.0–65.7) vs 5.2 kPa (4.3–6.3), P < 10^-6). The AUROC for the diagnosis of PHT-related DH was 0.97 ± 0.03. A threshold of 13.7 kPa was chosen with specificity and a positive predictive value at 100% (sensitivity, 93%; negative predictive value, 94%).

Conclusion

LSM is a powerful noninvasive tool for the instant diagnosis of PHT-related DH. Performed at admission, it could allow the rapid onset of specific medical management. The prognostic value assessment of LSM in these patients is ongoing.