Evaluation of Venous Ammonia Level, Splenic Longitudinal Diameter, Portal Vein and Splenic Vein Diameters as Non-Invasive Indicators for the Presence of Portosystemic Collaterals in Egyptian Cirrhotic Patients

Mohamed F. Montasser, Heba M. Abdella, Amir Helmy Samy

Internal Medicine, Faculty of Medicine, Ain Shams University, Cairo, Egypt.
Tropical Medicine, Faculty of Medicine, Ain Shams University, Cairo, Egypt.

DOI: 10.4236/ojgas.2014.46039                

Abstract

Introduction and Aim of the Work: The identification of cirrhotic patients with esophageal varices or other portosystemic collateral by non-invasive means is appealing in that it could decrease the necessity of endoscopic screening. This study was to evaluate the diagnostic utility of venous ammonia level with other ultrasonographic parameters as non-invasive markers for the presence of portosystemic shunts. Patients and methods: The study included 3 groups of Child Pugh class A and early B patients. Group (A): 25 patients with evidence of both esophageal varices and portosystemic collaterals; group (B) 25 patients with neither evidence of varices nor portosystemic collaterals and group (C): 25 patients with evidence of varices but no collaterals. Measurement of venous ammonia level was done for all patients. Results: serum ammonia level was significantly higher in group A (222.8 ± 54 μg/dL) than that in group B (85 ± 21.1 μg/dL) and group C (148.2 ± 19.6 μg/dL). The cut-off value of serum ammonia level 113 μg/dL was a good predictor for the presence of esophageal varices, while the cut-off value of serum ammonia level at 133 μg/dL was a good predictor for the presence of both esophageal varices and abdominal collaterals. Combination of portal vein diameter > 13mm + splenic vein diameter > 8.9mm + ammonia level > 133 μg/dL gives 100% of sensitivity and 96% of specificity for the prediction of the presence of portosystemic shunts. Conclusion: Determination of serum ammonia level, splenic, portal vein and splenic vein diameters are considered as good predictors for the presence of portosystemic shunts in patients with liver cirrhosis.

Keywords

Serum Ammonia, Potosystemic Collaterals, Portal Hypertension, Esophageal Varices, Splenic Vein Diameter, Portal Vein Diameter, Splenic Longitudinal Diameter

Conflicts of Interest

The authors declare no conflicts of interest.

References

[1]	Madhotra, R., Mulcahy, H.E., Willner, I. and Reuben, A. (2002) Prediction of Esophageal Varices in Patients with Cirrhosis. Journal of Clinical Gastroenterology, 34, 81-85. http://dx.doi.org/10.1097/00004836-200201000-00016
[2]	Alempijevic, T., Bulat, V., Djuranovic, S., Kovacevic, N., Jesic, R., Tomic, D., Krstic, S. and Krstic, M. (2007) Right Liver Lobe/Albumin Ratio: Contribution to Non-Invasive Assessment of Portal Hypertension. World Journal of Gastroenterology, 28, 13.
[3]	Primignani, M., Carpinelli, L., Preatoni, P., Battaglia, G., Carta, A., Prada, A., Cestari, R., Angeli, P., Gatta, A., Rossi, A., Spinzi, G. and De Franchis, R. (2000) Natural History of Portal Hypertensive Gastropathy in Patients with Liver Cirrhosis. The New Italian Endoscopic Club for the Study and Treatment of Esophageal Varices (NIEC). Gastroenterology, 119, 181-187.
[4]	Riggio, O., Efrati, C., Catalano, C., Pediconi, F., Mecarelli, O., Accornero, N., Nicolao, F., Angeloni, S., Masini, A., Ridola, L., Attili, A.F. and Merli, M. (2005) High Prevalence of Spontaneous Portal-Systemic Shunts in Persistent Hepatic Encephalopathy: A Case-Control Study. Hepatology, 42, 1158-1165. http://dx.doi.org/10.1002/hep.20905
[5]	Nicolao, F., Efrati, C., Masini, A., Merli, M., Attili, A.F. and Riggio, O. (2003) Role of Determination of Partial Pressure of Ammonia in Cirrhotic Patients with and without Hepatic Encephalopathy. Journal of Hepatology, 38, 441-446. http://dx.doi.org/10.1016/S0168-8278(02)00436-1
[6]	Ong, J.P., Aggarwal, A., Krieger, D., Easley, K.A., Karafa, M.T., Van Lente, F., Arroliga, A.C. and Mullen, K.D. (2003) Correlation between Ammonia Levels and the Severity of Hepatic Encephalopathy. American Journal of Medicine, 114, 188-193. http://dx.doi.org/10.1016/S0002-9343(02)01477-8
[7]	Child, C. and Turcotte, J. (1964) Surgery and Portal Hypertension. Major Problems in Clinical Surgery, 1, 1-85.
[8]	Bosch, J., Navasa, M., Garcia-Pagán, J.C., DeLacy, A.M. and Rodés, J. (1989) Portal Hypertension. Medical Clinics of North America, 73, 931-953.
[9]	Butterworth, R.F., Giguère, J.F., Michaud, J., Lavoie, J. and Layrargues, G.P. (1987) Ammonia: Key Factor in the Pathogenesis of Hepatic Encephalopathy. Molecular and Chemical Neuropathology, 6, 1-12. http://dx.doi.org/10.1007/BF02833598
[10]	Tarantino, G., Citro, V., Esposito, P., Giaquinto, S., de Leone, A., Milan, G., Tripodi, F.S., Cirillo, M. and Lobello, R. Blood Ammonia Levels in Liver Cirrhosis: A Clue for the Presence of Portosystemic Collateral Veins. BMC Gastroenterology, 17, 9-21.
[11]	Garcia-Tsao, G., Groszmann, R.J., Fisher, R.L., Conn, H.O., Atterbury, C.E. and Glickman, M. (1985) Portal Pressure, Presence of Gastroesophageal Varices and Variceal Bleeding. Hepatology, 5, 419-424. http://dx.doi.org/10.1002/hep.1840050313
[12]	Pagliaro, L., D’Amico, G., Pasta, L., et al. (1994) Portal Hypertension in Cirrhosis: Natural History. In: Bosch, J. and Groszmann, R.J., Eds., Portal Hypertension. Pathophysiology and Treatment, Blackwell Scientific, Oxford, 72-92.
[13]	Garcia-Tsao, G., D’Amico, G., Abraldes, J., et al. (2006) Predictive Models in Portal Hypertension. In: de Franchis, R., Ed., Portal Hypertension IV. Proceedings of the Fourth Baveno International Consensus Workshop on Methodology of Diagnosis and Treatment, Blackwell, Oxford, 47-100.
[14]	Sarangapani, A., Shanmugam, C., Kalyanasundaram, M., Rangachari, B., Thangavelu, P. and Subbarayan, J.K. (2010) Noninvasive Prediction of Large Esophageal Varices in Chronic Liver Disease Patients. Saudi Journal of Gastroenterology, 16, 38-42. http://dx.doi.org/10.4103/1319-3767.58767
[15]	Schepis, F., Cammà, C., Niceforo, D., Magnano, A., Pallio, S., Cinquegrani, M., D’amico, G., Pasta, L., Craxì, A., Saitta, A. and Raimondo, G. (2001) Which Patients with Cirrhosis Should Undergo Endoscopic Screening for Esophageal Varices Detection? Hepatology, 33, 333-338. http://dx.doi.org/10.1053/jhep.2001.21410
[16]	Cottone, M., D’Amico, G., Maringhini, A., Amuso, M., Sciarrino, E., Traina, M., Marcenò, M.P., Fusco, G., Dardanoni, G. and Pagliaro, L. (1986) Predictive Value of Ultrasonography in the Screening of Non-Ascitic Cirrhotic Patients with Large Varices. Journal of Ultrasound in Medicine, 5, 189-192.
[17]	Prihatini, J., Lesmana, L.A., Manan, C. and Gani, R.A. (2005) Detection of Esophageal Varices in Liver Cirrhosis Using Non-Invasive Parameters. Acta Medica Indonesiana, 37, 126-131.
[18]	Sarwar, S., Khan, A.A., Alam, A., Butt, A.K., Shafqat, F., Malik, K., Ahmad, I. and Niazi, A.K. (2005) Non-Endoscopic Prediction of Presence of Esophageal Varices in Cirrhosis. Journal of the College of Physicians and Surgeons-Pakistan, 15, 528-531.
[19]	Thomopoulos, K.C., Labropoulou-Karatza, C., Mimidis, K.P., Katsakoulis, E.C., Iconomou, G. and Nikolopoulou, V.N. (2003) Non-Invasive Predictors of the Presence of Large Oesophageal Varices in Patients with Cirrhosis. Digestive and Liver Disease, 35, 473-478. http://dx.doi.org/10.1016/S1590-8658(03)00219-6
[20]	Chang, M.H., Sohn, J.H., Kim, T.Y., Son, B.K., Kim, J.P., Jeon, Y.C. and Han, D.S. (2007) Non-Endoscopic Predictors of Large Esophageal Varices in Patients with Liver Cirrhosis. Korean Journal of Gastroenterology, 49, 376-383.
[21]	Tarzamni, M.K., Somi, M.H., Farhang, S. and Jalilvand, M. (2008) Portal Hemodynamics as Predictors of High Risk Esophageal Varices in Cirrhotic Patients. World Journal of Gastroenterology, 14, 1898-1902. http://dx.doi.org/10.3748/wjg.14.1898