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Grading Varices
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Grading Varices

Well I finally got the endoscopy that I put off for months.  I had already been diagnosed with varices from a CT last August.  I figured after failing to clear the virus during my first course of treatment I needed to get a better idea of where things stood so I went in for the endoscopy.  Pretty relaxing and pain free experience by the way.  My results included "Portal Hypertension gastropathy of the entire stomach" and  "Grade II quiescent varices-esophagus".  Was able to quickly find information on the Portal HTN Gastropathy, but I haven't found anything on the grading of varices.  Gauf, Hector, or other cirrhosis experienced folks - anyone have any details on varice grading?  I was put on Propranolol to help lower the PHTN.
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446474_tn?1404424777
For a "nice" extensive treatment" of varices size, color, mortality, tec. whose pics some may find offensive. Maybe this will help make people treat before progressing to cirrhosis! ;-) (Not to be viewed while eating!). Follow this link...

http://sadieo.ucsf.edu/course/things/pre-2005/Jensen.pdf

"Endoscopic Screening for Varices in Cirrhosis: Findings, Implications, and Outcomes
DENNIS M. JENSEN - GASTROENTEROLOGY 2002;122:1620–1630
CURE Digestive Diseases Research Center, University of California Los Angeles School of Medicine, and the Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California"
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Endoscopy is the criterion standard for evaluating esophageal varices and assessing the bleeding risk. This procedure is performed by a surgeon or a gastroenterologist with the patient under light sedation. The procedure involves using a flexible endoscope inserted into the patient's mouth and through the esophagus to inspect the mucosal surface. When esophageal varices are discovered, they are graded according to their size, as follows:
·Grade 1 - Small straight varices
·Grade 2 - Enlarged tortuous varices occupying less than one third of the lumen
·Grade 3 - Large coil-shaped varices occupying more than one third of the lumen

The varices also are inspected for red wheals, which are dilated intra-epithelial veins under tension and which carry a significant risk for bleeding. The grading of varices and identification of red wheals by endoscopy predict a patient's bleeding risk, on which treatment is based.

CT and MRI are identical in their usefulness in diagnosing and evaluating the extent of esophageal varices. These modalities have an advantage over endoscopy because CT and MRI can help in evaluating the surrounding anatomic structures, both above and below the diaphragm. CT and MRI are also valuable in evaluating the liver and the entire portal circulation.

These modalities are used in preparation for a transjugular intrahepatic portosystemic shunt (TIPS) procedure or liver transplantation and in evaluating for a specific etiology of esophageal varices. These modalities also have an advantage over both endoscopy and angiography because they are noninvasive. CT and MRI do not have strict criteria for evaluating the bleeding risk, and they are not as sensitive or specific as endoscopy. CT and MRI may be used be alternative methods in making the diagnosis if endoscopy is contraindicated (eg, in patient with a recent myocardial infarction or any contraindication to sedation).

In the past, angiography was considered the criterion standard for evaluation of the portal venous system. However, current CT and MRI procedures have become equally sensitive and specific in the detection of esophageal varices and other abnormalities of the portal venous system. Although the surrounding anatomy cannot be evaluated as they can be with CT or MRI, angiography is advantageous because its use may be therapeutic as well as diagnostic. Angiography may be performed if CT or MRI findings are inconclusive.
Ultrasonography, excluding EUS, and nuclear medicine studies are of minor significance in the evaluation of esophageal varices.

Limitations of Techniques
Although endoscopy is the criterion standard in diagnosing and grading esophageal varices, the anatomy outside of the esophageal mucosa cannot be evaluated with this technique. Therefore, imaging modalities such as CT, MRI, and EUS are also performed for a more complete evaluation.
Barium swallow examination is not a sensitive test, and it must be performed carefully with close attention to the amount of barium used and the degree of esophageal distension. Barium swallow images may help in detecting only 50% of varices.
On CT scans and MRIs, varices are difficult to see at times. However, in severe disease, varices may be prominent. CT and MRI are useful in evaluating other associated abnormalities and adjacent anatomic structures in the abdomen or thorax. On MRIs, surgical clips may create artifacts that obscure portions of the portal venous system. Disadvantages of CT include the possibility of adverse reactions to the contrast agent and an inability to quantitate portal venous flow, which is an advantage of MRI and ultrasonography.

Cheers!
Hector

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Avatar_m_tn
Thanks for the great and timely information.  I wish the best for both of you in your ongoing battles.  I can't imagine what you are going through Elaine, I would go through this a thousand times to spare my children and from your posts I know you feel the same.  God bless you and stay strong.  I will say a prayer for Nick.
Bill
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Avatar_f_tn
Had my first endoscopy last week. I have been sick as a dog with nausea off and on since January and being a stage 4 figured I could no longer put it off either. Lucked out, varicies were stage 1, but there was no obvious reason for my nausea. Hep doc says it has nothing to do with my liver or hep c.

The doc spoke with me after the procedure and said moderate gastritis due to cirrhosis and told me to take Prilosec. Lab results said reactive for gastophy with a little asterisk that said this is usually due to overuse of nsaids, alcohol consumption or bile backing up from the small intestine. Nothing about Portal HTN Gastropathy, so thanks for posting this info. Possibly it would have come up at my follow up.

Meanwhile in spite of Prilosec twice a day, I am still sick. Next step is ultrasound to see what my gallbladder looks like (even though it isn't behaving like typical gall bladder issues, low fat or high fat foods create the same amount of distress). Gallstones were visible on CT over the last couple of years, so you never know. Maybe I'm special :)

Any of you cirrhotics out there ever have ongoing pain and severe nausea?
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446474_tn?1404424777
Glad to hear your varices are not too bad.
"Any of you cirrhotics out there ever have ongoing pain and severe nausea?"
Luckily not. That's something I'm thankful for.
Sorry I am not familiar with cirrhosis being related to nausea. You mention pain...What is the pain like?

Glad you are following through to get to the bottom of this.
Let us know what happens.
Hector
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Avatar_f_tn
Yeah, Googling nausea and cirrhosis you come up with zilch and basically that is what my doc says..the two are not related. I just thought I would give a shout out to see if by chance anyone else had experienced this, since we have such a large community here. Actually, I recall Goofy Dad having some gastric issues a few weeks back. I'll do some digging and read that thread again.

We will see what the ultrasound reveals. Pain is a spasmy ache in my stomache and good ol URQ. Sometimes feels like someone has kicked me in the kidney area on the backside of liver, sometimes a burning sensation in the URQ. Ocassionally it feels like some kind of faucet has been turned on and a gurgling, bubbling sensation (like a water cooler going glub, glub) in URQ and RELIEF follows.

Andiamo had his gallbladder cause him major grief but I believe his symptoms were textbook. I hate the hassle of tests and missing work but I feel so crappy that I won't be able to work if I don't get this figured out (not to mention the thought of starting tx feeling this way).

Thanks for your two cents and we'll see if anyone else has had any "glub, glub" action.

Foo
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Avatar_n_tn
i also have cirrhosis and nausea though it is not severe. i also have mild upper right quadrant pain which seems to get worse when my ALT and AST are high.   i find that ginger tea helps the nausea. my favorite is the traditional medicinals organic golden ginger.
eric
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Avatar_m_tn
Several weeks ago I was having pretty serious bouts of nausea after every meal.  I was also having some pain in my upper right abdomen.  I thought this was related to stopping treatment and was seriously considering starting treatment again just to relieve the nausea.  Then I had a gall bladder attack that had me in the ER seeking relief from the pain.  My primary doc told me it was classic symptoms of gall bladder disease and sure enough I had several stones show up on ultrasound.  My doc set me up for a surgical consult for gall bladder removal but the surgeon would not do the surgery because of the increased risk associated with operating on someone with cirrhosis.  So I went to see the hepatologist at UW and they agreed with the surgeon.  I changed my diet slightly to avoid the foods that upset me gall bladder and I have been free of the nausea and pain since then.  Mostly foods high in fat are what need to be avoided.
As an interesting footnote, I talked to my GI about the almost constant itching I am experiencing (likely caused by an elevated bilirubin count) and he prescribed me Ursodiol (AKA Actigal).  I had been prescribed that drug previosuly as a menas to minimize the itching and it helped.  Anyway, one of the primary uses for Actigal is to dissolve gall stones.  If your issue is gall bladder related, maybe this drug would help.
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Avatar_f_tn
I wish it were just high fat foods that caused me grief. It can be anything...stuff with no fat at all. And it isn't all the time. I will have a week or so and feel okay. So I don't know what to think. Maybe a stone is lodged somewhere and causing my intermittent problems.

Interesting to hear that they don't want to do surgery. My doc's PA response to any concern is, "Why do you think you can't have surgery--why do you think you can't wait to treat--why do you think your platelets will cause a problem"...and on and on. I wouldn't have gone to see him again (I have an appointment with a new doc on June 23), but I felt so crummy I had to go.

And now I will bring the endoscopy results to my appointment with the new guy (I know he would have wanted that anyway--should have been done two years ago).

Good to know about the Actigal for a plan B. Thanks!
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