A portal into hemodynamics: utility of portal vein ultrasound in predicting variceal etiology of upper gastrointestinal hemorrhage in the emergency department

Abstract Rapid differentiation between variceal and non-variceal upper gastrointestinal hemorrhage (UGIH) in the emergency department (ED) is critical for guiding vasoactive therapy, antibiotic use, and timely endoscopy. However, endoscopy is often delayed, deferring these key management decisions and potentially impacting patient outcomes. We aimed to study the utility of portal vein ultrasound by the emergency physician for the prediction of variceal etiology in UGIH. We also studied the diagnostic accuracy of laboratory markers and fibrosis scores for differentiating between variceal and non-variceal hemorrhage. In our prospective observational study, we enrolled patients with UGIH presenting to the ED. Portal vein indices were studied using bedside point-of-care ultrasound (POCUS) by the emergency physician. Laboratory results were noted, and fibrosis scores were calculated. The upper gastrointestinal endoscopy findings were noted for the presence and grade of varices. Out of 181 patients included in the study, 106 patients (58.56%) had varices. Multivariable logistic regression analysis identified spleen diameter, platelet count, PT, ascites, and portal vein flow velocity (PVFV) were significant predictors of variceal etiology. SCoPE score (Splenomegaly, Coagulopathy, PVFV Evaluation) which is a composite that includes spleen diameter, PT, and PVFV is a useful ED-based tool for early identification of variceal bleed (AUC = 0.843, OR = 1.633). Fibrosis scores (AAR, APRI, Fib-4, King, Lok) were also useful in identifying variceal hemorrhage ( p  < 0.001). Integrating POCUS parameters and laboratory markers into clinical decision algorithms may enhance the ability of emergency physicians to predict variceal etiology of UGIH. Novel ED-based composite SCoPE score can help the physicians predict varices and enable them to tailor the management plan and optimize resuscitation strategies.