LARGE SILENT GASTRIC FUNDAL VARICES IN CIRRHOTIC PATIENTS: ROLE OF ABDOMINAL MULTIDETECTOR TRIPHASIC COMPUTED TOMOGRAPHY.

Background:- Gastric varices have been recognized as a major cause of gastrointestinal bleeding, reaching 33% in patients with portal hypertension mostly secondary to liver cirrhosis. Compared with esophageal variceal bleeding, haemorrhage caused by fundal varices, although less frequent, is more severe and haemostatic control is more difficult. The diagnosis and treatment of gastrointestinal bleeding are based mainly on endoscopic examinations however; radiological studies such as computed tomography (CT) studies have proved useful in clinical practice. Spiral imaging has dramatically improved CT in the evaluation of focal hepatic lesion. The aim of this study is to investigate the role of abdominal Multidetector triphasic CT scan done for early detection of hepatocellular carcinoma (HCC) as a predictor and diagnostic tool for silent large gastric fundal varices in patients with liver cirrhosis. Methods:- A total of 145 patients were enrolled in this study. All patients were referred for early detection of HCC with suspected focal hepatic lesion or elevated ? fetoprotein above 50 and below 400 IU/dl. All patients underwent full clinical and laboratory investigations. Abdominal US was performed for all patients. Abdominal Multidetector triphasic CT scan was done by a single experienced radiologist for evaluation for the presence of hypervascular focal hepatic lesions, splenomegaly, epigastric and hilar collaterals, portal vein thrombosis and the presence of esophageal or gastric fundal varices. All patients underwent standard upper GIT endoscopy and according to the endoscopic findings the studied patients were further classified to three groups: group I (GI) 79 patients (54.48%) with no or small esophageal and/or gastric varices, group II (GII) 42 patients (28.97%) with large esophageal varices, and group III (GIII) 24 patients (16.55%) with large gastric fundal varices Results:- There was a statistically significant increase in portal vein diameter, splenic size (long axis span), splenic vein diameter, presence of gastro-renal collaterals, portal vein thrombosis and HCC in patients with large gastric fundal varices in relation to other groups. platelet/splenic ratio as calculated by dividing platelet count over long axis of the spleen was determined for each patient which had significant lower values in relation to presence of large gastric varices Step-wise regression analysis was done for all the above mentioned variables revealing that only three predictors namely the presence of large fundal varices by abdominal CT, presence of splenic hilar or splenorenal collaterals and platelet/splenic ratio were found to have highly significant independent predictive value for the presence of those varices being 1312.64, 19.11 and 16.99 respectively (P< 0.001). Out of 24 patients with gastric fundal varices diagnosed by Upper GIT endoscopy, 22 cases were diagnosed by Multidetector triphasic CT with 91.67% sensitivity and 100% specificity and area under the ROC curve 0.96 (P?0.001). On the other hand, out of 42 patients diagnosed by Upper GIT endoscopy with large esophageal varices, only 29 cases were diagnosed by Multidetector triphasic CT with 69.05% sensitivity and 100% specificity (P?0.001). Decrease in platelet/splenic ratio had sensitivity of 75% and specificity of 67.77% (P?0.001). Moreover, detection of HCC by Multidetector triphasic CT was confirmed in 31 cases and portal vein thrombosis in 20 patients Conclusions:- Triphasic CT is a reliable noninvasive, highly tolerable examination in evaluation of gastric varices with ability to detect other portosystemic collaterals; in addition, the detection of other associated pathologies.