Gastrointestinal diseases in patients on the waiting list for liver transplantation

The incidence of and risk factors for gastrointestinal diseases in patients awaiting liver transplantation are still a matter of debate. The article by Dr. Bresci and colleagues [1] indicates that cirrhosis is not a predisposing factor for gastrointestinal lesions, except for hypertensive variceal gastropathy and colopathy. We would like to confirm these findings on the basis of analysis of the experience at our transplant center.

We conducted a retrospective analysis to address two questions: (a) Are there any lesions that occur more commonly in these patients than in the general population (with the exception of portal hypertension- and liver disease-related pathology); and (b) Are there any patient characteristics that predict the presence of such lesions? We recorded data from all asymptomatic patients who were successfully placed on the waiting list for liver transplantation. We excluded symptomatic patients and patients who were not listed after routine examinations. Baseline demographic data (sex, age), clinical characteristics (cause of the liver disease, Child status, ascites, splenomegaly), and endoscopic findings were recorded. Between April 2004 and April 2006 we retrospectively evaluated 45 candidates for liver transplantation (Table [1]). The most frequent pathological abnormalities found at upper endoscopy were esophageal varices (73.3 %) and portal hypertensive gastropathy (48.9 %). At colonoscopy the most common abnormal findings were hemorrhoids (22 %) and colonic polyps (17.8 %) (Table [2]). Univariate analysis showed that there was no significant correlation between colonic polyps and patients’ demographic characteristics or other clinical variables (P > 0.05), except a slight correlation with age. Multivariate analysis did not confirm any of the associations.

Table 1 Demographic and clinical characteristics of the study patients Patients, n 45 Sex, M/F 37/8 Mean age ± SD, years 56 ± 5.6 Cause of liver disease, n (%) Hepatitis C Alcohol Hepatitis B PBC/PSC Cryptogenic Caroli disease Metabolic 17 (38 %)12 (26.7 %)8 (17.8 %)8 (17.8 %)4 (8.9 %)4 (8.9 %)1 (2.2 %) Child classification, n (%) A (5-6 points) B (7-9 points) C (10-15 points) 5 (11.1 %)29 (64.4 %)11 (24.4 %) Ascites, n (%) 24 (53.3 %) Splenomegaly, n (%) 37 (82.2 %) PBC, primary biliary cirrhosis; PSC, primary sclerosing cholangitis; SD, standard deviation.

Table 2 Upper and lower endoscopy findings in the 45 study patients Endoscopic finding, n (%) Esophageal varices 33 (73.3 %) Degree of severity of varices 1 2 3 4 15 (33.3 %)14 (31.1 %)3 (6.6 %)1 (2.2 %) Esophagitis 1 (2.2 %) Hiatal hernia 2 (4.3 %) Portal hypertensive gastropathy 22 (48.9 %) Gastritis 8 (17.8 %) Gastric polyps 2 (4.3 %) Gastric ulcer 1 (2.2 %) Duodenitis 5 (11 %) Duodenal ulcer - Colonic polyps 8 (17.8 %) Ulcerative colitis 3 (6.7 %) Portal hypertensive colopathy 4 (8.9 %) Diverticulosis 3 (6.7 %) Hemorrhoids 10 (22 %) Vascular ectasias 2 (4.4 %) Colorectal cancer -

The incidence of gastrointestinal pathology in candidates for liver transplantation was not different from that in the asymptomatic general population, except for cirrhosis-specific complications (esophageal varices, portal hypertensive gastropathy and colopathy). For these reasons, our findings confirm those of Bresci et al. [1]. Furthermore, we also confirm the necessity of performing esophagogastroduodenoscopy in all patients who are candidates for liver transplantation (due to the high prevalence of disease), and that colonoscopy should only be performed as indicated by current guidelines for colorectal cancer screening [2].

Competing interests: None

References

• 1 Bresci G, Parisi G, Capria A. Clinical relevance of colonic lesions in cirrhotic patients with portal hypertension.  Endoscopy. 2006;  38 830-835
• 2 Winawer S, Fletcher R, Rex D. et al . Gastrointestinal Consortium Panel. Colorectal cancer screening and surveillance: clinical guidelines and rationale - update based on new evidence.  Gastroenterology. 2003;  124 544-560