Gallbladder Wall Thickening as a Non-Invasive Screening Parameter for Esophageal Varices Compared to Upper GI Endoscopy
Authors: Abdelwahab Khaled Mohamed , Mohamed Azza Emam , Yousry Wael Ahmed , Elmonshed Hossam Hassan Sayed Saleh 
Published: August 2023

Abstract

Background
Variceal hemorrhage is considered a life threatening complication of esophageal varices (EV).The main cause of esophageal varices is liver Cirrhosis and subsequent Portal hypertension. Current Guidelines recommend screening via Upper GI Endoscopy which is an invasive procedure which has its own hazards, complications and disadvantages. Gallbladder wall thickening is an early finding in patients with liver cirrhosis that occurs even before other manifestations of portal hypertension. In this study, the utility and efficiency of sonographic measurement of gallbladder wall thickness will be analyzed as a non-invasive screening alternative for upper endoscopy for assessment of EV.

Objective
To assess possibility of using the Gallbladder wall thickness as a non invasive screening parameter for esophageal varices in cirrhotic patients.

Patients and Methods
150 patients were enrolled in this study. The laboratory tests, sonographic and endoscopy findings of 150 CLD patients to assess their correlation to esophageal varices. The Patients were classified into two groups according to the presence of varices and ascites into EV Group of 75 cirrhotic patients with esophageal varices regardless of ascites, and Non EV: Group of 75 patients with chronic liver disease and no ascites on sonography as a control group. The esophageal varices group were further subclassified into 3 groups according to the grade of varices present. Patients with grade I varices were assigned to Group (EV 1). Patients with grade II varices (EV 2). Patients with grade III varices were included in (EV 3) group.

Results
On Comparison of the lab finding, Sonography, and Child score of the EV and Non EV group, it was found a statistical significance in most variables. On using the multi variate assessment, the following parameters were significant as independent predictors for varices being, platelet count, AFP, Liver Span, and GBWT. The platelet levels seem to be of statistical significance with a mean of 109 with an interquartile range of 79 to 146 in the EV group. while the Non EV group, the median is 195 with IQR from 178 to 234. Alpha feto protein shows statistical significance with a median of 4.5 with IQR of 2.7 to 6.7 in the EV group, and median of 2.1 with an IQR of 1.5 to 4.9 in the Non EV group. The mean liver span in the EV group is 127.56 ± 16.19 with values ranging from 84 to 175. While the mean liver span in the Non EV group in 146.88 ± 14.47 with values ranging from 114 to 184.The mean spleen diameter in the EV group was 161.18±20.73 with values ranging from 118 to 213. The mean splenic diameter in the Non EV group is 141.84±12.34 with measurements ranging from 114 to 167. AUROC curve was drawn with a best cutoff value at 3.8 mm with AUC of 0.810 showing a sensitivity of 76%, specificity at 76 %, PPV at 76 % and NPV of 76%. At a cut off value of 4 mm sensitivity was at 62% specificity 81.3%, PPV 77% and a NPV 68%. PC/ SD was assessed with AUROC with a cutoff of 1006.29 with AUC of 0.879 with a sensitivity of 76%, specificity of 96 %, PPV of 95% and NPV of 80%.Noteworthy that GBWT showed statistical significance between grades of varices with a P-value of 0.003 and mean thickness in EV1, EV2, and EV 3 as follows 4.04 ± 0.8, 4.46 ± 0.68, and 5.27 ± 1.75.

Conclusion
GBWT seems to be a good predictor of varices which could be used as a screening modality for varices.