This prospective study was conducted in Sohag University Hospital, Faculty of Medicine, Sohag University, during the period from July 2016 to December 2018.
The study included 60 cirrhotic patients and 20 healthy volunteers, aged > 18 years, who accepted participation in this study. Exclusion criteria included presence of hepatic encephalopathy grade 3 or grade 4, left-sided portal hypertension (this entity is due to pancreatic disease with normal liver), presence of a contraindication to perform upper gastrointestinal endoscopy (EGD), or presence of hepatocellular carcinoma. Patients with advanced cardiac, renal, or pulmonary disease were also excluded. Diagnosis of liver cirrhosis was based upon clinical evaluation, liver function tests, abdominal ultrasonography, and hepatitis markers or PCR. All volunteers were healthy and free from any disease affecting the liver.
All patients and control volunteers were subjected to abdominal ultrasound examination, Doppler examination, and real-time Shear wave elastography using (Toshiba Aplio 500) at our Radiology Department. All cirrhotic patients were subjected to EGD at the endoscopy unit of the Internal Medicine Department.
The current study was approved by the Institutional Committee in our University Faculty of Medicine. Written informed consent was obtained from all patients and volunteers.
Shear wave elastography (SWE)
The patient is placed in a supine position with the right arm placed in maximum abduction to enlarge the space between the ribs. The convex probe is placed between the ribs, using the best acoustic window available for liver evaluation. The SWE box has to be placed in a uniform zone, away from the sub-capsular region to avoid reverberation artifacts that are often found beneath the capsule (Fig. 1). Similarly, perivascular areas were avoided because they may alter liver stiffness estimate. The patient has to hold breath in the expiration phase to acquire a stable image. The color map is not dependable to assess liver stiffness because it is operator dependent and not quantitative. So, we depended on liver stiffness measurement in kPa.
The elastography acquisition was repeated three to five times for each patient. For each acquisition, real-time SWE 2D color map of the stiffness (in kPa) was frozen after a stabilization of at least 3 s. The size of the SWE color box was about 3 × 4 cm. The measurements were performed in a 1.6- to 3-cm-diameter region of interest (ROI) (Fig. 2). For each patient, stiffness was defined as the median of several SWE successful measurements.
Upper gastrointestinal endoscopy (EGD) protocol
Upper GIT endoscopy (EGD) was performed after overnight fasting under conscious sedation and nasal oxygen using EG-2985 scope, Pentax, Tokyo, Japan. Patients were placed in the left lateral position, and the endoscope was inserted into the esophagus and passed to the stomach down to the second part of the duodenum.
Endoscopic findings of esophageal varices (EV) and gastric varices (GV) were classified according to the criteria proposed by the Japanese Society for Portal Hypertension [16]. The form (F) of GV or EV was classified as straight small-calibered varices (F1); moderately enlarged, beady varices (F2); or markedly enlarged, nodular, or tumor-shaped varices (F3). According to location, EV were classified as varices at the lower 1/3 of the esophagus (Li), at the middle 1/3 of the esophagus (Lm), or at the upper 1/3 of the esophagus (Ls). According to location, GV were classified as adjacent to the cardiac orifice (Lg-c), distant from the cardiac orifice (Lg-f), or extending from the cardiac orifice to the fornix (Lg-cf). Varices were also classified according to its bluish (Cb) or whitish (Cw) color and if the varices were associated with red color sign (RC) or not. All endoscopic procedures were performed by a single operator with 10 years of experience in endoscopic management of gastro-esophageal varices. Endoscopic management of the detected varices was performed according to guideline recommendations.
Statistical analysis
The analysis of data was made using SPSS version 16. Continuous data were expressed. Quantitative data was represented as mean, standard deviation, median, and range. P value was considered significant if it was less than 0.05.