Predictors of Bleeding from Esophageal Varices: The Role of Factor VII and von Willebrand Factor (vWF)

Ali Abdelrahman Ghweil, Usama Ahmed Arafa, Ashraf Khodeary, Ahmed N. Salem

Clinical Pathology, Sohag University, Sohag, Egypt.
Internal Medicine, Sohag University, Sohag, Egypt.
Tropical Medicine and Gastroenterology, South Valley University, Qena, Egypt.

DOI: 10.4236/ojgas.2014.44023                

Abstract

Objectives: Bleeding from gastroesophageal varices is the most serious and life-threatening complication of cirrhosis and accounts for 10% of all cases of bleeding from the upper GI tract. It is essential to identify and treat those patients at the highest risk because each episode of variceal hemorrhage carries a 20 percent to 30 percent risk of death, and up to 70 percent of patients who do not receive treatment die within one year of the initial bleeding episode. The aim of this study is to determine the clinical predictors of bleeding esophageal varices and study the role of F VII (factor VII) and vWF (von willebrand factor) in predicting bleeding in patients with eosphogeal varices. Methods: A case control study was done on all patients with esophageal varices admitted at Sohag and Qena faculty of medicine hospitals from January 2012 to August 2013. Various clinical, laboratory and endoscopic variables were tested to determine the predictors of esophageal bleeding. Results: Among 300 patients with esophageal varices, 80 percent was due to hepatitis C virus (HCV), 18 percent was due to hepatitis B virus (HBV), and 2 percent had both HCV and HBV. As an etiologic factor for their liver disease, hemoglobin was 10.12 ± 2.26 g/l, platelet count 135.55 ± 65.94 × l09/l, prothrombin time 14.1 ± 0.92 second, albumin 2.88 ± 0.71 g/dl, ALT 48.25 ± 24.15 u/l, total bilirubin 1.92 ± 1.36 mg/dl. Factor VII was 27.4 ± 8.92 percent and vWF was 188.33 ± 13.66 IU/dl. Splenomegaly was reported 79.6 percent, 90.3 percent had ascites. 35 percent had grade III esophageal varices, 29 percent had four-column esophageal varices on endoscopy, 13.7 percent had concomitant gastric varices and 38.3 percent had portal hypertensive gastropathy. Platelet count, presence of red color sign, the number of columns of esophageal varices, presence of portal gastropathy on eosphagogastroduodenoscopy (EGD) showed a significant positive correlation with bleeding. There is a significant decrease of FVII and a significant increase of vWF in bleeding group in comparison with non bleeding group. Conclusion: Thrombocytopenia, presence of encephalopathy and endoscopic findings of large varices, presence of red color sign, and portal hypertensive gastropathy were found to be predictors of esophageal variceal bleeding. Increase of vWF and decrease of FVII are laboratory predictors of esophageal variceal bleeding.

Keywords

Esophageal Varices; FVII; von Willebrand Factor

Conflicts of Interest

The authors declare no conflicts of interest.

References

[1]	Paunescu, V., Grigorean, V. and Popescu, C. (2004) Risk Factors for Immediate Outcome of Gastrointestinal Bleeding in Patients with Cirrhosis. Chirurgia [Bucur], 99, 311-322.
[2]	Alao, A., Sharara, M.D. and Don, C. and Rockey, M.D. (2001) Medical Progress Gastroesophageal Variceal Hemorrhage. New England Journal of Medicine, 345, 30.
[3]	Goh, S.H., Tan, W.P. and Lee, S.W. (2005) Clinical Predictors of Bleeding Esophageal Varices in the ED. American Journal of Emergency Medicine, 23, 531-535.
[4]	Green, G., Poller, L., Thomson, J.M., et al. (1976) Factor VII as a Marker of Hepatocellular Synthetic Function in Liver Disease. Journal of Clinical Pathology, 29, 971-975.
[5]	Deitcher, S.R. (2002) Interpretation of the International Normalised Ratio in Patients with Liver Disease. Lancet, 359, 47-48.
[6]	Hallen, A. and Nilsson, I.M. (1964) Coagulation Studies in Liver Disease. Thrombosis et Diathesis Haemorrhagica, 11, 51-63.
[7]	Kupfer, H.G., Gee, W., Ewald, A.T., et al. (1964) Statistical Correlation of Liver Function Tests with Coagulation Factor Deficiencies in Laennec’s Cirrhosis. Thrombosis et Diathesis Haemorrhagica, 10, 317-331.
[8]	Kerr, R. (2003) New Insights into Haemostasis in Liver Failure. Blood Coagulation & Fibrinolysis, 14, S43-S45.
[9]	Beer, J.H., Clerici, N., Baillod, P., von Felten, A., Schlappritzi, E. and Buchi, L. (1995) Quantitative and Qualitative Analysis of Platelet GPIb and von Willebrand Factor in Liver Cirrhosis. Thrombosis and Haemostasis, 73, 601-609.
[10]	Ferro, D., Quintarelli, C., Lattuada, A., Leo, R., Alessandroni, M., Mannucci, P.M., et al. (1996) High Plasma Levels of von Willebrand Factor as a Marker of Endothelial Perturbation in Cirrhosis: Relationship to Endotoxemia. Hepatology, 23, 1377-1383.
[11]	Arguedas, M.R., Heudebert, G.R., Eloubeidi, M.A., Abrams, G. and Fallon, M.B. (2002) Cost-Effectiveness of Screening, Surveillance, and Primary Prophylaxis Strategies for Esophageal Varices. American Journal of Gastroenterology, 97, 2441-2452.
[12]	Paunescu, V., Grigorean, V. and Popescu, C. (2004) Risk Factors for Immediate Outcome of Gastrointestinal Bleeding in Patients with Cirrhosis. Chirurgia [Bucur], 99, 311-322.
[13]	De Franchis, R. and Primignani, M. (1992) Why Do Varices Bleed? Gastroenterology Clinics of North America, 21, 85-101.
[14]	Burroughs, A.K. and McCormick, P.A. (1992) Preventin of Variceal Rebleeding. Gastroenterology Clinics of North America, 21, 119-147.
[15]	Koch, H., Henning, H., Grimm, H. and Soehendra, N. (1986) Prophylactic Sclerosing of Oesophageal Varices-Results of a Prospective Controlled Study. Endoscopy, 18, 40-43.
[16]	Limquiaco, J., Eulenia, R.N., Maria, L.O., Venancio, I.G., Ernesto, O.D., Virgilio, P.B., Felix, M.Z., Melflor, A.A., Peter, P.S., Labio, E. and Antonio, C.C. (2006) Clinical Predictors of Bleeding from Esophageal Varices. A Retrospective Study Phil Journal of Gastroenterology, 2, 103-111.
[17]	Benedeto-Stojanov, D., et al. (2006) Predictive Factors of Bleeding from Esophageal Varicies in Patient with Liver Cirrhosis and Portal Hypertension. Medicine and Biology, 13, 164-167.
[18]	Watanabe, K. and Kimujra, K. (1988) Portal Hemodynamics in Patients with Gastric Varices. Gastroenterology, 95, 434-440.
[19]	Ferlitsch, M., Reiberger, T., Hoke, M., Salzl, P., Schwengerer, B., Ulbrich, G., Payer, B.A., Trauner, M., Peck-Radosavljevic, M. and Ferlitsch (2012) A von Willebrand Factor as New Noninvasive Predictor of Portal Hypertension, Decompensation and Mortality in Patients with Liver Cirrhosis. Hepatology, 56, 1439-1447.
[20]	Iwakiri, Y. and Groszmann, R.J. (2007) Vascular Endothelial Dysfunction in Cirrhosis. Journal of Hepatology, 46, 927-933.
[21]	Franchini, M., Montagnana, M., Targher, G., Zaffanello, M. and Lippi, G. (2008) The Use of Recombinant Factor VIIa in Liver Diseases. Blood Coagulation & Fibrinolysis, 19, 341-348.