Clinically-Evident (CE) Varices and Variceal Hemorrhage

(1)

Clinically-Evident (CE) Varices and Variceal Hemorrhage Liver Transplant (Date/age):

Case Report Form #: ______ Death (Date/age):

Pt case #:

DOB:

Gender: M/F

HPE(Date/age):

Date of upper endoscopy __/__/__

Repeat for every upper endoscopy performed post-HPE and pre-LT/death A. Indication for upper endoscopy (check

one) Evaluation for 1^st time GI hemorrhage

Repeat evaluation of GI hemorrhage Screening endoscopy

Surveillance endoscopy

B. Documented finding of esophageal

and/or gastric varices on endoscopy? Yes à Continue to section C No à stop

C. Documented evidence of variceal

hemorrhage on endoscopy? Yes à Go to section D No à Go to section E

D. Intervention performed during

endoscopy secondary to variceal hemorrhage?

Sclerotherapy Band Ligation

None performedàaborted procedure Other ______________

Go to Section F

E Intervention performed during

endoscopy secondary to findings of non-hemorrhaging varices?

Sclerotherapy Band Ligation None performed Other ______________

(2)

Operational Research Definition(s):

CE varices: Documented finding of esophageal and/or gastric varices on endoscopic evaluation

Patient meets definition for CE varices if he/she meets all of the below:

1. ‘Yes’ to Section B

Yes, patient met definition for CE varices during their post-HPE disease course on this date __/__/__

Patient meets definition for variceal hemorrhage if he/she meets all of the below:

1. ‘Yes’ to Section C

Yes, patient met definition for variceal hemorrhage during their post-HPE disease course on this date __/__/__

*Variceal hemorrhage may recur multiple times throughout a patient’s course Go to Section F

F Follow-up within 6 weeks of

endoscopic procedure? Repeat endoscopy à 1) Go to end and 2) complete new CRF for follow-up endoscopy (CRF# ____)

TIPS

Liver transplantation Death

F Did the patient require blood

products within 72 hours prior to endoscopic procedure?

Yes

Date __/__/___ _______ cc/kg No