Abnormal Gastroesophageal Flap Valve: A Predictor of Recurrent Variceal Hemorrhage

Background: Esophageal variceal bleeding is affected by various risk factors. We hypothesized that increased exposure to gastric acid in patients with abnormal gastroesophageal flap valve (GEFV) might increase esophageal variceal bleeding.

Goal: To investigate the relationship between GEFV and esophageal variceal bleeding episodes.

Methods: In this cross-sectional, retrospective study, 300 consecutive patients with esophageal varices and a documented GEFV during esophagogastroduodenoscopy were included. Patients were divided into two groups according to: the Hill’s grade of flap valve (grade 1 and 2: normal and grade 3 and 4: abnormal), size of varices: large (>5 mm) and small (<5 mm), and the number of bleeding episodes into: Group A with ≤1 and Group B with ≥2 bleeding episodes. We compared GEFV and various other factors to the number of variceal bleeding episodes.

Results: A total of 224 patients (74.60%) had a normal and 76 (25.40%) had an abnormal GEFV. Clinical variables were statistically significant in the abnormal GEFV group (p < 0.0.5). Propensity score matching was done to reduce the significant differences in the clinical background at baseline between the two groups. In total, 152 patients (76 in each group) were analyzed after propensity score matching. A significant difference between the two groups disappeared except for number of bleeding episodes ([Table 1]). Binary logistic Cox regression analysis was applied using the clinical variables to assess their role in predicting recurrent variceal bleeding. On univariate analysis, abnormal GEFV and large varices were significantly associated with recurrent esophageal variceal bleed (p = 0.001). On multivariate analysis, abnormal GEFV (OR: 7.25, 95% CI: 3.27– 16.08, p = 0.001) and large varices (OR: 5.70, 95% CI: 2.45–13.20, p = 0.001) were independent predictors for recurrent esophageal variceal bleeding ([Fig. 1]) ([Table 2]).

Conclusion: Abnormal GEFV and large varices are independent risk factors for recurrent esophageal variceal hemorrhage.

Table 1

Parameter	All	Normal GEFV	Abnormal GEFV	p-Value
Number	152	76	76	–
Agea (years)	47.77 ± 11.36	47.79 ± 10.12	47.75 ± 12.54	0.150
Malea	105 (69.07%)	54 (71.05%)	51 (67.10%)	0.726
Duration of diseaseb (days)	90 (30,900)	60 (15,897)	165 (30,900)	0.626
CTPa	7.52 ± 1.74	7.51 ± 1.76	7.52 ± 1.74	0.985
MELDa	15.15 ± 6.25	15.10 ± 6.60	19.23 ± 6.86	0.757
Large varicesa	96 (63.15%)	45 (59.21%)	51 (67.10%)	0.401
Number of bleeding episodesa	1.48 ± 1.40	0.95 ± 0.815	2 ± 1.66	0.008
Etiology	ALD 74 (48.70%)AIH 13 (8.60%)NAFLD 9 (5.9%)NCPF 13 (8.6%)HBV 20 (13.2%)Others 32 (21.05%)	ALD 35 (46.05%)AIH 7 (9.21%)NAFLD 7 (9.21%)NCPF 6 (7.89%)HBV 8 (10.52%)Others 13 (17.10%)	ALD 39 (51.31%)AIH 6 (7.89%)NAFLD 2 (2.63%)NCPF 7 (9.21%)HBV 12 (15.78%)Others 10 (13.15%)	0.208

Note: a - expressed in mean; b - expressed in median

Fig. 1

Table 2

Univariate analysis					Multivariate analysis
Parameter	p-Value	OR	95% CI		p-Value	OR	95% CI
			Lower	Upper			Lower	Upper
Age (years)	0.600	1.01	0.97	1.04	–	–	–	–
Gender	0.544	0.76	0.32	1.81	–	–	–	–
Duration of disease (days)	0.390	1.00	1.00	1.00	–	–	–	–
CTP	0.769	1.03	0.82	1.30	–	–	–	–
MELD	0.648	1.01	0.95	1.08	–	–	–	–
Size of varices	0.001	4.63	2.20	9.71	0.001	5.70	2.45	13.20
GEFV	0.001	5.76	2.86	11.65	0.001	7.25	3.27	16.08
Etiology	0.120	1.13	0.99	1.29	–	–	–	–

Publication History

Article published online:
22 April 2024