Non-Invasive Risk Stratification in NAFLD/NASH Patients for Screening EGD.

Abstract

1Division of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, SC, USA; 2Division of Gastroenterology and Hepatology, Central Virginia VA Health Care System, Richmond, VA, USA; 3Department of Internal Medicine, University Hospital, Knappschaftskrankenhaus, RuhrUniversity Bochum, Bochum, Germany; 4Division of Gastroenterology and Hepatology, Virginia Commonwealth University, Richmond, VA, USA; 5Section of Gastroenterology, Ralph H Johnson VAMC, Charleston, SC, USA; 6Department of Physiology, Faculty of Medicine and Nursing, University of the Basque Country, Universidad del Pa S Vasco/Euskal Herriko Univertsitatea (UPV/EHU), Leioa, Spain Portal hypertension is a major complication of cirrhosis, as it predisposes patients to manifestations of hepatic decompensation, including the development of esophageal variceal bleeding, hepatic encephalopathy, and ascites. Esophageal varices are present in approximately 50% of patients with cirrhosis. The mortality during a variceal bleeding event is high, with estimates ranging from 15% to 20%, being largely dependent upon whether patients have received the standard of care with endoscopic band ligation, vasoactive drugs, and antibiotics. The hepatic venous pressure gradient (HVPG) is considered the gold standard in ascertaining the presence of portal hypertension (PH). Clinically significant portal hypertension (CSPH), which is associated with the development of the aforementioned manifestations of decompensation, has been defined as an HVPG greater than or equal to 10 mmHg. After a diagnosis of cirrhosis, current guidelines recommend screening for esophageal varices with esophagogastroduodenoscopy (EGD). This procedure is carried out to identify patients who are at risk for variceal hemorrhage and would benefit from starting prophylactic therapy with beta blockade. This procedure carries risks, which include any type of respiratory or cardiac suppression from anesthesia, infection, bleeding, and perforation. In addition, a significant majority of patients with varices who are indeed at high risk for bleeding do not have any symptoms from the varices themselves, making EGD a non-ideal screening test. Previous studies suggest that non-invasive blood-based markers are useful to identify patients with liver damage (fibrosis or cirrhosis) and may identify those who will develop complications such as liver cancer. Examples of these markers include the Fibrosis-4 Index (FIB-4), which is a non-invasive estimate of liver scarring in HCV and HBV patients; the NAFLD (Non-Alcoholic Fatty Liver Disease) Fibrosis Score (NFS), which is used to estimate the amount of scarring in the liver based on several laboratory tests; the BARD score, based upon BMI, AST/ALT ratio, and the presence or absence of diabetes; and the AST to Platelet Ratio Index (APRI). We evaluated whether these non-invasive markers and/or any other clinical parameters may be used to identify patients with liver cirrhosis who are likely to have large esophageal varices, and therefore would benefit most from screening EGD. We retrospectively evaluated a cohort of non-alcoholic fatty liver disease (NAFLD)/non-alcoholic steatohepatitis (NASH) patients at two tertiary care Veterans Affairs (VA) Hospitals between January 1st 2017 and February 15th 2021. A total of 1476 patients was initially investigated; however, 1221 patients Correspondence: John Romano Division of Gastroenterology and Hepatology, Medical University of South Carolina, Strom Thurmond Gazes Cardiac Research Institute 30 Courtenay Drive Suite: 249, Charleston, SC, USA Email Romanoj@musc.edu