Application of the platelet count/spleen diameter ratio to rule out the presence of oesophageal varices in patients with cirrhosis: a validation study based on follow-up

Platelet counts to spleen diameter ratio: A promising noninvasive tool for predicting esophageal varices in cirrhosis patients

BACKGROUND

Liver cirrhosis is the end stage of progressive liver fibrosis as a consequence of chronic liver inflammation, wherein the standard hepatic architecture is replaced by regenerative hepatic nodules, which eventually lead to liver failure. Cirrhosis without any symptoms is referred to as compensated cirrhosis. Complications such as ascites, variceal bleeding, and hepatic encephalopathy indicate the onset of decompensated cirrhosis. Gastroesophageal varices are the hallmark of clinically significant portal hypertension.

AIM

To determine the accuracy of the platelet count-to-spleen diameter (PC/SD) ratio to evaluate esophageal varices (EV) in patients with cirrhosis.

METHODS

This retrospective observational study was conducted at Tikur Anbessa Specialized Hospital and Adera Medical Center from January 1, 2019, to December 30, 2023. Data were collected via chart review and direct patient interviews using structured questionnaires. The data were exported to the SPSS software version 26 for analysis and clearance. A receiver operating characteristic curve was plotted for splenic diameter, platelet count, and PC/SD ratio to obtain sensitivity, specificity, positive predictive value, negative predictive value, positive likelihood ratio, and negative likelihood ratio.

RESULTS

Of the 140 participants, 67% were men. Hepatitis B (38%) was the most common cause of cirrhosis, followed by cryptogenic cirrhosis (28%) and hepatitis C (16%). Approximately 83.6% of the participants had endoscopic evidence of EV, whereas 51.1% had gastric varices. Decompensated cirrhosis and PC were associated with the presence of EV with adjusted odds ratios of 12.63 (95%CI: 3.16-67.58, P = 0.001) and 0.14 (95%CI: 0.037-0.52, P = 0.004), respectively. A PC/SD ratio < 1119 had a sensitivity of 86.32% and specificity of 70% with area under the curve of 0.835 (95%CI: 0.736-0.934, P < 0.001).

CONCLUSION

A PC/SD ratio < 1119 predicts EV in patients with cirrhosis. It is a valuable, noninvasive tool for EV risk assessment in resource-limited settings.

Impact of sustained virologic response in regression of portal hypertension in Egyptian patients with hepatitis C virus-associated cirrhosis and portal hypertension

Background

Portal hypertension (PH) is a common consequence in hepatitis C virus cirrhotic patients. With interferon alpha-based therapy, SVR was linked to improved PH and fibrosis regression. SVR to oral antiviral regimens is linked to reduced portal pressure in patients with clinically significant portal hypertension (CSPH) at baseline. However, CSPH continues in most of the patients. This study aims to assess the reversibility and/or improvement of PH in Egyptian patients with HCV-related cirrhosis and CSPH after achieving SVR with DAAs. The second aim is to evaluate performance of the noninvasive markers of fibrosis in prediction of the presence and/or reversibility of the CSPH in correlation to radiological and endoscopic parameters.

Subjects and methods

We evaluated noninvasive parameters, radiological and endoscopic signs of PH at baseline, and/or SVR 24 and SVR 48 post-DAA therapy in 40 patients with cirrhosis and CSPH (group A) and another 40 patients with cirrhosis only (group B).

Results

In group A, the spleen diameter decreased from baseline (15.74 ± 1.53 cm), and SVR 24 (15.48 ± 1.51), to SVR 48 (15.35 ± 1.49 cm). No ascites detected at SVR 48 in 62.5%. Portal vein diameter and portal vein blood velocity reduced to 13.53 ± 1.07 mm and 14.14 ± 2.2 cm/s at SVR 48, with reversibility of hepatic vein waveform towards the triphasic pattern. Medium to large esophageal varices regressed from 52.5% to 2.5%, and up to 70% of patients showed no EVs at SVR 48. In group A, 24 patients showed complete reversibility of CSPH, and 16 patients showed improvement of CSPH. Child-Pugh score, FIB-4 index, King’s score, and Lok index revealed higher significance for detection of the presence of PH. Child-Pugh score, PC/SD ratio, and Lok index revealed higher significance for detection of reversibility of PH.

Conclusion

We concluded that CSPH improved after SVR with DAAs and completely regressed in some patients. Upon predicting the presence of PH, Child-Pugh score, FIB-4 index, King’s score, and Lok index were the most significant noninvasive scores. While for predicting the reversibility of PH, Child-Pugh score, PC/SD ratio, and Lok index were the most significant scores.

Platelet count/spleen volume ratio has a good predictive value for esophageal varices in patients with hepatitis B liver cirrhosis

Background & aims

Platelet count/spleen longest diameter ratio (PSDR) is widely used in clinical practice due to its good performance in predicting esophageal varices (EV). We obtained spleen volume (SV) by magnetic resonance examination, the purpose of this study was to evaluate the clinical value of platelet count/spleen volume ratio (PSVR) and spleen volume in predicting EV in patients with hepatitis B cirrhosis. Methods: This study was a diagnostic accuracy experiment and retrospective, 199 patients with hepatitis B cirrhosis who met the criteria were selected as the research subjects. All patients were collected blood samples in the morning on an empty stomach within 2 days, and related indicators were tested. Within 10 days, they received electronic gastroscopy and abdominal magnetic resonance examination. According to the Child-Pugh score, the patients were divided into groups with or without EV and with or without high-risk esophageal varices (HRV), then statistical analysis of the two groups was performed.

Results

The area under the curve (AUC) of PSVR in predicting EV or HRV in each group (85.5%-92.6%) was higher than PSDR, SV, spleen diameter, and platelet count. The AUC of PSDR in diagnosing HRV was higher than SV, and the AUC of SV in diagnosing EV was higher than PSDR, but the difference was not significant (P>0.05). In Child-Pugh A patients, Multivariate logistic regression analysis showed PSVR could be a predictor of HRV (P<0.05), SV was a reliable predictor of EV (P<0.05).

Conclusion

PSVR is better than PSDR, spleen diameter, platelet count in predicting EV; in the absence of serological results, SV could be used instead of PSDR. Both can predict EV or HRV of patients with hepatitis B cirrhosis.

Longitudinal Analysis of the Effect of Repeated Transarterial Chemoembolization for Liver Cancer on Portal Venous Pressure

Objectives

Investigate long-term effects of repeated transarterial chemoembolization (TACE) on portal venous pressure (PVP) using non-invasive surrogate markers of portal hypertension.

Methods

Retrospective, Institutional Review Board-approved study. 99 patients [hepatocellular carcinoma (HCC) group (n=57); liver metastasis group (n=42)] who underwent 279TACEs and had longitudinal pre-/post-therapy contrast-enhanced-MRI (n=388) and complete blood work were included. Outcomes of interest were platelet count (PC), spleen volume, ascites and portosystemic collaterals. Variables included TACE type/number, tumor type, microcatheter location, Child-Pugh, baseline tumor burden (tumor number/total/largest size), vessel invasion, alpha-fetoprotein, Eastern Cooperative Oncology Group (ECOG) performance status, and Model for End-Stage Liver Disease (MELD) score. Generalized Estimating Equations assessed the associations between TACE and outcomes. Power analysis determined the sample size was sufficient.

Results

No significant change in PC over time was observed in either groups, regardless of liver function (P>0.05). Baseline spleen volume was 226 cm³ for metastatic group, and was larger by 204 cm³ for HCC group (P<0.001). Spleen volume increased by 20 cm³ (95%CI: 8-32; P=0.001) for both groups after 1^stTACE and by 16cm³/TACE (P=0.099) over the full follow-up (up to 9TACEs). Spleen volume also tended to increase by 23cm³ (95%CI: -1–48; P=0.064) with higher tumor burden. Odds of developing moderate/severe ascites for metastatic patients was decreased by 0.5 (95%CI: 0.3–0.9; P=0.014), regardless of the Child-Pugh, and increased by 1.5 (95%CI: 1.2–1.9; P<0.001) among HCC patients with unstable Child-Pugh, whereas no change was noted with stable Child-Pugh. HCC patients with unstable Child-Pugh demonstrated a significant increase in portosystemic collaterals number over time (P=0.008). PVP-related complications such as variceal bleeding post-TACE were low (0.4%).

Conclusion

Repeated TACEs did seem to have an impact on PVP. However, the increase in PVP had marginal effects with low portal hypertension-related complications.

Diagnostic performance of platelet count/spleen diameter ratio to detect esophageal varices in patients with cirrhosis

Introduction: The platelet count/spleen diameter (PC/SD) ratio is a noninvasive method for the diagnosis of esophageal varices (EV) used as an alternative to endoscopy in patients with cirrhosis. Objective: To evaluate the diagnostic performance of the PC/SD ratio (cut-off point <909) to detect EV in patients with cirrhosis treated at a tertiary referral hospital in Bogotá D.C., Colombia. Materials and methods: A prospective diagnostic test accuracy study was conducted in 66 patients with cirrhosis treated at the Hospital Universitario de La Samaritana between July and December 2018. A descriptive analysis of the data was performed. In addition, the diagnostic performance of the PC/SD ratio (cut-off point <909) for the detection of EV was compared with the findings reported in the esophagogastroduodenoscopy (gold standard), calculating its sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), positive likelihood ratio (LR+), and negative likelihood ratio (LR-). A significance level of p<0.05 was considered. Results: The mean age of the participants was 65.5 years, 53.03% were female, and the most common causes of cirrhosis were alcohol consumption (40.90%) and autoimmune hepatitis (22.72%). EV was diagnosed in 48 patients (72.72%). The PC/SC ratio showed sensitivity of 60%, specificity of 78%, PPV of 0.88, NPV of 0.42, LR+ of 2.73, and LR- of 0.51. Conclusion: The low sensitivity, specificity, and NPV found in the present study suggest that the PC/SD ratio (cut-off point <909) may not be a useful diagnostic test for detecting EV in patients with cirrhosis.

Role of non-invasive markers in prediction of esophageal varices and variceal bleeding in patients of alcoholic liver cirrhosis from central India

BACKGROUND/AIMS

Alcohol is the leading cause of liver cirrhosis, which results in portal hypertension and subsequently, culminates into esophageal varices and esophgeal variceal bleeding. Esophagogastroduodenoscopy is gold standard for diagnosis of varices. Non-invasive markers based on clinical, laboratory - ultrasonographic parameters can be utilised for prediction of risk of esophageal varices - variceal bleed in alcoholic cirrhosis from central India.

MATERIALS AND METHODS

This was a cross sectional observational study. Child Turcot Pugh scores, MELD, AST ALT Ratio(AAR), AST Platelet Ratio Index(APRI), FIB-4 index and Platelet count-Spleen diameter(PC/SD) ratio were calculated for all patients and correlated with esophagogastroduodenoscopy findings. Short term follow up was done for variceal bleeding.

RESULTS

Total 202 male patients were included with mean age of 43.77±9.95 years. 188(93%) patients had esophageal varices. 61(30.19%) patients had variceal bleeding. On univariate analysis platelet count, APRI, spleen bipolar diameter, and PC/SD ratio were significantly associated with varices. For prediction of esophageal varices, only PC/SD ratio was significant and showed area under the curve of 65.6% at cut-off of <997. CTP score, FIB-4, APRI, and PC/SD ratio were significant for variceal bleeding. At cut-off <985 PC/SD ratio had sensitivity of 82% and specificity of 63% with AUC of 78% for prediction of variceal bleeding. Also, FIB-4 and APRI had diagnostic accuracy of 64% and 61% with AUC of 74% and 72% respectively for bleed.

CONCLUSION

FIB-4 and PC/SD may be useful among armamentarium of non-invasive markers for predicting esophageal varices and risk of variceal bleeding in alcoholic liver cirrhosis.

Screening for esophageal varices in cirrhotic patients - Non-invasive methods

Variceal bleeding is a dramatic complication of cirrhosis. Primary prophylaxis against variceal bleeding is indicated for patients with high-risk varices. In order for these patients to be identified, endoscopic screening for esophageal varices has been traditionally recommended at the time of the diagnosis of cirrhosis. Considering that many patients do not have esophageal varices in the early stages of cirrhosis and, therefore, are submitted to endoscopy unnecessarily, non-invasive methods for variceal screening have been studied. Among these non-invasive methods, the most extensively studied probably are platelet count/spleen diameter ratio, liver stiffness, spleen stiffness and an association between liver stiffness and platelet count, referred to as the Baveno VI criteria. The Baveno VI criteria has recently been recommended by different medical associations for variceal screening. This is a critical review on the non-invasive methods for variceal screening, in which the performances of the different methods are presented and the limitations of the existing evidence is discussed. Despite reasonable performances of some of these methods, especially platelet count/spleen diameter ratio and the association between liver stiffness and platelet count, we understand that the available evidence still has relevant limitations and that physicians should decide on screening cirrhotic patients for esophageal varices with endoscopy or non-invasive methods on a case-by-case basis.

Course of oesophageal varices and performance of noninvasive predictors following Hepatitis C Virus clearance in compensated advanced chronic liver disease

BACKGROUND

In patients with hepatitis C virus (HCV) and compensated advanced chronic liver disease (cACLD), there is evidence that sustained virological response (SVR) to direct-acting antivirals (DAA) may ameliorate portal hypertension, although both the course of oesophageal varices and the performance of their noninvasive predictors following DAA-induced SVR are less defined. In this study, our aim was to assess the variation in oesophageal varices status in HCV patients with cACLD who obtained an SVR to DAAs and to evaluate the diagnostic performance of noninvasive predictors of varices after HCV cure.

MATERIAL AND METHODS

Sixty-three HCV patients with cACLD and SVR to DAAs were prospectively followed up, and oesophageal varices surveillance was carried out according to the Baveno VI indications. Appearance and disappearance of varices, accuracy performance of their noninvasive predictors (Baveno/expanded Baveno VI criteria, platelet count/spleen diameter ratio) and number of endoscopies spared with their application were calculated.

RESULTS

Following SVR, varices developed or disappeared in 12.1% and 17.4% of patients, respectively. The negative predictive value for varices of the Baveno VI, expanded Baveno VI criteria and platelet count/spleen diameter ratio following SVR was 88.2% (65.6-96.7), 83.3% (66.3-92.7) and 80.7% (67.1-89.5), respectively. Their application would have saved 30.4%, 42.9% and 55.4% of endoscopies, with no varices needing treatment missed using both Baveno VI criteria.

CONCLUSIONS

In HCV patients with cACLD, following SVR to DAA, the expanded Baveno VI criteria provide the best balance between utility (diagnostic accuracy and endoscopies avoided) and safety (varices needing treatment missed) for varices surveillance.

Usefulness of noninvasive methods including assessment of liver stiffness by 2-dimensional shear wave elastography for predicting esophageal varices

BACKGROUND

The aim of this study was to predict the presence of esophageal varices (EVs) by noninvasive tools combined with 2-dimensional shear wave elastography (2D-SWE), and to compare the diagnostic capabilities of 2D-SWE with those of transient elastography (TE).

METHODS

Between January 2015 and December 2017, 289 patients with compensated advanced chronic liver disease (cACLD) who underwent consecutive 2D-SWE and EGD were enrolled. Capabilities for predicting the presence of EVs of 2D-SWE and models combining 2D-SWE with other noninvasive tools (modified LS-spleen-diameter-to-platelet-ratio score [mLSPS], platelet-spleen ratio score) were compared. A subgroup analysis was performed on 177 patients who also underwent simultaneous TE.

RESULTS

The area under receiver operating characteristics (AUROCs) for detecting EVs for 2D-SWE alone vs. mLSPS, which included 2D-SWE, were 0.757 (95% confidence interval [CI], 0.701-0.810) and 0.813 (95% CI, 0.763-.857), respectively. The AUROCs for predicting varices needing treatment (VNT) for 2D-SWE and mLSPS were 0.712 (95% CI, 0.621-0.738) and 0.834 (95% CI, 0.785-0.875), respectively. For the 195 patients who underwent simultaneous TE and 2D-SWE, no differences in diagnostic performance were observed.

CONCLUSIONS

The diagnostic performance of 2D-SWE is similar to that of TE for predicting the presence of EVs. The mLSPS, which includes 2D-SWE, seemed to be useful for predicting EVs.

Non-invasive markers as predictors of oesophageal varices in cirrhotic patient in a teaching hospital in Ghana

Introduction

Oesophageal variceal (OV) bleeding is a potentially fatal consequence of portal hypertension in patients with liver cirrhosis. Upper GI endoscopy is recommended for screening for varices in cirrhotics for early detection and treatment, however, this is invasive. The purpose of this study was to assess the predictive values of the noninvasive tests in detecting the presence of OV.

Methods

A cross-sectional hospital-based study involving 149 patients with liver cirrhosis was carried out at the Korle-Bu Teaching Hospital from 1^st November 2015 to 25^th November 2016. Relevant clinical parameters assessed included Child-Pugh class, ascites and splenomegaly. Full blood count and liver function tests, abdominal ultrasound and gastroscopy were done for all the participants. Receiver operating characteristic curve was generated to determine the cut-off values for the best sensitivity, specificity, negative and positive predictive values of the variables (serum albumin, platelet count (PC), aspartate aminotransferase (AST)/alanine aminotransferase (ALT), PC/Spleen diameter( SD)) with regard to the presence of OV.

Results

On gastroscopy, 135 (90.60%) had OV and 14 patients (9.40%) had no OV. One hundred and eleven of the varices (82.22%) were large varices and the rest (17.78%) small varices. The overall mean of serum albumin, PC and PC/SD were not significant predictors of the presence of OV. However, the overall mean of AST/ALT significantly predicted the presence of OV. A PC/SD cut off value of ≤833.3 had 72.62% diagnostic accuracy for diagnosing all OV.

Conclusion

PC/SD cut-off could be used to screen cirrhotics for OV and treatment initiated in geographical areas lacking endoscopy facilities

Funding

None declared

The relationship between fibrosis and nodule structure and esophageal varices

BACKGROUND/AIMS

The aim of the present study was to evaluate the histopathological findings of cirrhosis together with clinical and laboratory parameters, and to investigate their relationship with esophageal varices that are portal hypertension findings.

MATERIALS AND METHODS

A total of 67 (42 male and 25 female) patients who were diagnosed with cirrhosis were included in the study. The mean age of the patients was 51.6±19.0 (1-81) years. The biopsy specimens of the patients were graded in terms of fibrosis, nodularity, loss of portal area, central venous loss, inflammation, and steatosis. The spleen sizes were graded ultrasonographically, and the esophageal varices were graded endoscopically.

RESULTS

In the multivariate regression analysis, there was a correlation between the advanced disease stage (Child-Pugh score odds ratio (OR): 1.47, 95% confidence interval (CI): 1.018-2.121, p=0.040), presence of micronodularity (OR: 0.318, 95% CI: 0.120-0.842, p=0.021), grade of central venous loss (OR: 5.231, 95% CI: 1.132-24.176, p=0.034), and presence of esophageal varicose veins.

CONCLUSION

Although thrombocytopenia and splenomegaly may predict the presence of large esophageal varices, cirrhosis histopathology is the main factor in the presence of varices.

Oesophageal varices in patients with liver cirrhosis attending a major tertiary hospital in Ghana

Introduction

Oesophageal variceal bleeding is a potentially fatal consequence of portal hypertension in cirrhotic patients. In Ghana, bleeding oesophageal varices (OV) are a significant cause of acute upper gastrointestinal bleeding with comparatively high mortality. This study was to determine the prevalence of OV and its clinical correlate in cirrhotic patients.

Methods

This was a cross sectional hospital based study of 149 subjects with liver cirrhosis from 5^thNovember, 2015 to 4^th November, 2016. Demographic and other clinical data were collected using standardized questionnaire. Liver function, full blood count, HBsAg and anti-HCV Ab tests were done for all patients. All patients underwent an abdominal ultrasound to assess liver and document ascites. Upper GI endoscopy (UGIE) was done to screen for and grade varices.

Results

A total of 149 patients with a mean age of 45 ± 12.28 years were evaluated. There were 77.85% and 22.15% men and women respectively, with a male to female ratio of 3.5:1. By Child-Pugh Classification, 12 (8.16%) patients were in class A, 64 (43.54%) in class B and 71 (48.3%) in class C at presentation. On UGIE, 135 (90.60%) had varices and 14 patients (9.40%) had no varices. One hundred and eleven of the varices (82.22%) were large varices and the rest (17.78%) small varices.

Conclusion

Majority of cirrhotic patients present late with advance disease to this referral centre. Most have large varices on their first screening endoscopy. Prophylactic treatment should be considered for all cirrhotics especially patients with decompensated liver cirrhosis when UGIE cannot be done immediately.

Long-term Nucleos(t)ides Analogues for Chronic Hepatitis B Improve Liver and Spleen Size: A Noninvasive Sonographic Study

Background:

Histological improvement and regression of liver fibrosis after long-term use of nucleos(t)ides analogues (NUCs) have been documented. The aim of the present investigation was to evaluate the usefulness of traditional sonography to detect hepatic and splenic changes during NUC therapy in chronic hepatitis B (CHB) patients.

Methods:

A total of 181 CHB patients receiving NUC treatment were enrolled in this study. The study population was divided into three groups 72 cirrhotic, 58 noncirrhotic CHB, and 51 nonreplicative hepatitis B virus carriers. All patients had blood chemistries taken and sonography at baseline and during the NUC treatment period. The changes in liver size, liver edge, spleen size, platelet count, and platelet count/spleen diameter (PC/SD) ratio were compared among the three groups of patients.

Results:

CHB Patients with and without cirrhosis have improved clinical features during NUC therapy with lower aspartate aminotransferase, alanine aminotransferase, international normalized ratio, hepatitis B virus DNA, and spleen size and higher platelet, liver edge, liver size, and PC/SD ratio compared with the baseline data (p < 0.05). The differences in liver edge, liver size, spleen size, and PC/SD ratio are higher in the cirrhosis group than in the non-cirrhotic group (p < 0.001). A decrease in spleen size exhibited a linear relationship with treatment duration (R² = 0.905).

Conclusions:

Traditional sonography is helpful to monitor changes in liver fibrosis of CHB patients under NUC therapy.

Abbreviations: AFP, α-fetoprotein; ALT, alanine transaminase; AST, aspartate transaminase; CHB, chronic hepatitis B; Hb, hemoglobin; HBV, hepatitis B virus; INR, international normalized ratio; NUCs, nucleos(t)ides analogues; PC/SD, platelet count/spleen diameter; WBC, white blood cells.

Noninvasive prediction of portal pressure with MR elastography and DCE-MRI of the liver and spleen: Preliminary results

BACKGROUND

Portal hypertension (PH), defined by hepatic venous pressure gradient (HVPG) ≥5 mmHg and clinically significant PH, defined by HVPG ≥10 mmHg, are complications of chronic liver disease.

PURPOSE

To assess the diagnostic performance of MR elastography (MRE) and dynamic contrast-enhanced MRI (DCE-MRI) of the liver and spleen for the prediction of PH and clinically significant PH, in comparison with a qualitative PH imaging scoring system.

STUDY TYPE

IRB-approved prospective study.

POPULATION

In all, 34 patients with chronic liver disease who underwent HVPG measurement.

FIELD STRENGTH/SEQUENCE

1.5/3T examination including 2D-GRE MRE (n = 33) and DCE-MRI of the liver/spleen (n = 28).

ASSESSMENT

Liver and spleen stiffness were calculated from elastogram maps. DCE-MRI was analyzed using model-free parameters and pharmacokinetic modeling. Two observers calculated qualitative PH imaging scores based on routine images.

STATISTICAL TESTS

Imaging parameters were correlated with HVPG. Receiver operating characteristic (ROC) analysis was performed for prediction of PH and clinically significant PH.

RESULTS

There were significant correlations between DCE-MRI parameters (liver time-to-peak, r = 0.517 / P = 0.006, liver distribution volume, r = 0.494 / P = 0.009, liver upslope, r = -0.567 / P = 0.002), liver stiffness (r = 0.478 / P = 0.016), PH imaging score (r = 0.441 / P = 0.009), and HVPG. ROC analysis provided significant area under the ROC (AUROCs) for PH (liver upslope 0.765, liver stiffness 0.809, spleen volume/diameter 0.746-0.731, PH imaging score 0.756) and for clinically significant PH (liver and spleen perfusion parameters 0.733-0.776, liver stiffness 0.742, PH imaging score 0.742). The ratio of liver stiffness to liver upslope had the highest AUROC for diagnosing PH (0.903) and clinically significant PH (0.785).

DATA CONCLUSION

These preliminary results suggest that the combination of liver stiffness and perfusion metrics provide excellent accuracy for diagnosing PH, and fair accuracy for clinically significant PH. Combined MRE and DCE-MRI outperformed qualitative imaging scores for prediction of PH.

LEVEL OF EVIDENCE

1 Technical Efficacy: Stage 2 J. Magn. Reson. Imaging 2018;48:1091-1103.

Noninvasive Methods of Predicting Large Esophageal Varices in Children With Intrahepatic Portal Hypertension

OBJECTIVE

Esophageal variceal bleeding is a severe complication of portal hypertension. The standard diagnostic screening test and therapeutic procedure for esophageal varices (EV) is endoscopy, which is invasive in pediatric patients. This study aimed to evaluate the role of noninvasive parameters as predictors of large varices in children with intrahepatic portal hypertension.

METHODS

Participants included in this cross-sectional study underwent a screening endoscopy. Variceal size, red marks, and portal gastropathy were assessed and rated. Patients were classified into two groups: Group 1 (G1) with small or no varices and Group 2 (G2) with large varices. The population consisted of 98 children with no history of gastrointestinal (GI) bleeding, with a mean age of 8.9 ± 4.7 years. The main outcome evaluated was the presence of large varices.

RESULTS

The first endoscopy session revealed the presence of large varices in 32 children. The best noninvasive predictors for large varices were platelets (Area under the ROC Curve [AUROC] 0.67; 95% CI 0.57-0.78), the Clinical Prediction Rule (CPR; AUROC 0.65; 95% CI 0.54-0.76), and risk score (AUROC 0.66; 95% CI 0.56-0.76). The logistic regression model showed that children with a CPR value under 114 were 8.59 times more likely to have large varices. Risk scores higher than -1.2 also increased the likelihood of large varices (OR 6.09; P = 0.014), as did a platelet count/spleen size z score lower than 25 (OR 3.99; P = 0.043). The combination of these three tests showed a high negative predictive value.

CONCLUSIONS

The CPR, the risk score, and the platelet count/spleen size z score could be helpful in identifying cirrhotic children who may be eligible for endoscopy.

Screening of Esophageal Varices by Noninvasive Means in Chronic Liver Disease

Introduction

Noninvasive assessment of esophageal varices (EV) decreases the medical and financial burden related to screening and helps in the management of patients with chronic liver diseases (CLDs). In this study, our aim was to assess the utility of the platelet count/spleen diameter index for the noninvasive evaluation of EV.

Materials and methods

In this cross-sectional observational study, a total of 100 CLD patients underwent screening endoscopy for EV in Medicine and Gastroenterology Department, Sylhet MAG Osmani Medical College Hospital, Sylhet, Bangladesh. Platelet count/spleen diameter ratio was assessed in all patients and its diagnostic implication was calculated.

Results

Upper gastrointestinal endoscopy revealed that 45 (45.0%) patients had medium EV followed by 27 (27.0%) that had small EV and 19 (19.0%) patients had large EV. Receiver operator characteristic (ROC) curve was constructed using platelet count/spleen index, which gave a cut-off value of >905. The validity of platelet count/spleen index evaluation of CLD was: Sensitivity 92.3%, specificity 66.7%, accuracy 90.0%, positive predictive value (PPV) and negative predictive value (NPV) were 96.6 and 46.2% respectively. True positive was 84 cases, false positive 3 cases, false negative 7 cases, and true negative 6 cases. If we consider cut-off value as 909 in the evaluation of EV in CLD, then true positive was 85 cases, false positive 3 cases, false negative 6 cases, and true negative 6 cases. From this, by calculation, sensitivity was 93.4%, specificity 66.7%, accuracy 91%, PPV 96.6%, and NPV 50%.

Conclusion

The platelet count/spleen index may be proposed to be a safe and reliable mean of screening of EV in CLD patients; however, case-control study would be required to validate this.

How to cite this article: Hossain E, Ahammed F, Saha SK, Foez SA, Rahim MA, Noor-e-Alam SM, Abdullah AS. Screening of Esophageal Varices by Noninvasive Means in Chronic Liver Disease. Euroasian J Hepato-Gastroenterol 2018;8(1):18-22.

[Splenic thickness combined with routine clinical markers predicts esophageal varices in patients with liver cirrhosis]

OBJECTIVE

To explore the noninvasive indicators for predicting the occurrence of esophageal varices (EV) in patients with liver cirrhosis.

METHODS

A total of 202 patients with liver cirrhosis caused by hepatitis B or C or alcoholic hepatic disease were enrolled in this study. EV and high risk esophageal varices (HREV) were confirmed in these patients by gastroscopy. The hematological, serum biochemical and ultrasonic parameters of the patients were analyzed, and a model for predicting EV was established by stepwise logistic regression analysis.

RESULTS

The areas under receiver operating characteristics curve (AUROC) of splenic thickness (SPT) for detecting EV and HREV were 0.827 and 0.766, respectively. The combined index USWA (SPT, US, WBC and albumin [ALB]) showed an AUROC of 0.873 for detecting EV, and the index SPA (combining SPT and ALB) showed an AUROC of 0.777 for detecting HREV. The direct combination of SPT with USWA or with platelet/splenic thickness ratio (PSA) was capable of completely excluding a definite diagnosis of EV, while the sequential combination of SPT with USWA or with platelet was capable of a diagnosis of EV and clarifying the condition of EV in approximately half of the cirrhotic patients in the absence of gastroscopic findings. The combination of SPT and SPA allowed for a definite diagnosis of the condition of HREV in 10% of the cirrhotic patients.

CONCLUSION

SPT combined with SPT derived indexes or platelet status allows for a definite diagnosis of EV in patients with liver cirrhosis to offer a noninvasive option for diagnosis.

Platelet count, spleen length, and platelet count-to-spleen length ratio for the diagnosis of oesophageal varices in people with chronic liver disease or portal vein thrombosis

BACKGROUND

Current guidelines recommend screening of people with oesophageal varices via oesophago-gastro-duodenoscopy at the time of diagnosis of hepatic cirrhosis. This requires that people repeatedly undergo unpleasant invasive procedures with their attendant risks, although half of these people have no identifiable oesophageal varices 10 years after the initial diagnosis of cirrhosis. Platelet count, spleen length, and platelet count-to-spleen length ratio are non-invasive tests proposed as triage tests for the diagnosis of oesophageal varices.

OBJECTIVES

Primary objectives To determine the diagnostic accuracy of platelet count, spleen length, and platelet count-to-spleen length ratio for the diagnosis of oesophageal varices of any size in paediatric or adult patients with chronic liver disease or portal vein thrombosis, irrespective of aetiology. To investigate the accuracy of these non-invasive tests as triage or replacement of oesophago-gastro-duodenoscopy. Secondary objectives To compare the diagnostic accuracy of these same tests for the diagnosis of high-risk oesophageal varices in paediatric or adult patients with chronic liver disease or portal vein thrombosis, irrespective of aetiology.We aimed to perform pair-wise comparisons between the three index tests, while considering predefined cut-off values.We investigated sources of heterogeneity.

SEARCH METHODS

The Cochrane Hepato-Biliary Group Controlled Trials Register, the Cochrane Hepato-Biliary Group Diagnostic Test Accuracy Studies Register, the Cochrane Library, MEDLINE (OvidSP), Embase (OvidSP), and Science Citation Index - Expanded (Web of Science) (14 June 2016). We applied no language or document-type restrictions.

SELECTION CRITERIA

Studies evaluating the diagnostic accuracy of platelet count, spleen length, and platelet count-to-spleen length ratio for the diagnosis of oesophageal varices via oesophago-gastro-duodenoscopy as the reference standard in children or adults of any age with chronic liver disease or portal vein thrombosis, who did not have variceal bleeding.

DATA COLLECTION AND ANALYSIS

Standard Cochrane methods as outlined in the Cochrane Handbook for Diagnostic Test of Accuracy Reviews.

MAIN RESULTS

We included 71 studies, 67 of which enrolled only adults and four only children. All included studies were cross-sectional and were undertaken at a tertiary care centre. Eight studies reported study results in abstracts or letters. We considered all but one of the included studies to be at high risk of bias. We had major concerns about defining the cut-off value for the three index tests; most included studies derived the best cut-off values a posteriori, thus overestimating accuracy; 16 studies were designed to validate the 909 (n/mm3)/mm cut-off value for platelet count-to-spleen length ratio. Enrolment of participants was not consecutive in six studies and was unclear in 31 studies. Thirty-four studies assessed enrolment consecutively. Eleven studies excluded some included participants from the analyses, and in only one study, the time interval between index tests and the reference standard was longer than three months. Diagnosis of varices of any size. Platelet count showed sensitivity of 0.71 (95% confidence interval (CI) 0.63 to 0.77) and specificity of 0.80 (95% CI 0.69 to 0.88) (cut-off value of around 150,000/mm3 from 140,000 to 150,000/mm3; 10 studies, 2054 participants). When examining potential sources of heterogeneity, we found that of all predefined factors, only aetiology had a role: studies including participants with chronic hepatitis C reported different results when compared with studies including participants with mixed aetiologies (P = 0.036). Spleen length showed sensitivity of 0.85 (95% CI 0.75 to 0.91) and specificity of 0.54 (95% CI 0.46 to 0.62) (cut-off values of around 110 mm, from 110 to 112.5 mm; 13 studies, 1489 participants). Summary estimates for detection of varices of any size showed sensitivity of 0.93 (95% CI 0.83 to 0.97) and specificity of 0.84 (95% CI 0.75 to 0.91) in 17 studies, and 2637 participants had a cut-off value for platelet count-to-spleen length ratio of 909 (n/mm3)/mm. We found no effect of predefined sources of heterogeneity. An overall indirect comparison of the HSROCs of the three index tests showed that platelet count-to-spleen length ratio was the most accurate index test when compared with platelet count (P < 0.001) and spleen length (P < 0.001). Diagnosis of varices at high risk of bleeding. Platelet count showed sensitivity of 0.80 (95% CI 0.73 to 0.85) and specificity of 0.68 (95% CI 0.57 to 0.77) (cut-off value of around 150,000/mm3 from 140,000 to 160,000/mm3; seven studies, 1671 participants). For spleen length, we obtained only a summary ROC curve as we found no common cut-off between studies (six studies, 883 participants). Platelet count-to-spleen length ratio showed sensitivity of 0.85 (95% CI 0.72 to 0.93) and specificity of 0.66 (95% CI 0.52 to 0.77) (cut-off value of around 909 (n/mm3)/mm; from 897 to 921 (n/mm3)/mm; seven studies, 642 participants). An overall indirect comparison of the HSROCs of the three index tests showed that platelet count-to-spleen length ratio was the most accurate index test when compared with platelet count (P = 0.003) and spleen length (P < 0.001). DIagnosis of varices of any size in children. We found four studies including 277 children with different liver diseases and or portal vein thrombosis. Platelet count showed sensitivity of 0.71 (95% CI 0.60 to 0.80) and specificity of 0.83 (95% CI 0.70 to 0.91) (cut-off value of around 115,000/mm3; four studies, 277 participants). Platelet count-to-spleen length z-score ratio showed sensitivity of 0.74 (95% CI 0.65 to 0.81) and specificity of 0.64 (95% CI 0.36 to 0.84) (cut-off value of 25; two studies, 197 participants).

AUTHORS' CONCLUSIONS

Platelet count-to-spleen length ratio could be used to stratify the risk of oesophageal varices. This test can be used as a triage test before endoscopy, thus ruling out adults without varices. In the case of a ratio > 909 (n/mm3)/mm, the presence of oesophageal varices of any size can be excluded and only 7% of adults with varices of any size would be missed, allowing investigators to spare the number of oesophago-gastro-duodenoscopy examinations. This test is not accurate enough for identification of oesophageal varices at high risk of bleeding that require primary prophylaxis. Future studies should assess the diagnostic accuracy of this test in specific subgroups of patients, as well as its ability to predict variceal bleeding. New non-invasive tests should be examined.

Platelet Count to Spleen Diameter Ratio for the Diagnosis of Gastroesophageal Varices in Liver Cirrhosis: A Systematic Review and Meta-Analysis

Platelet count to spleen diameter ratio (PSR) was studied extensively as a noninvasive method of diagnosis for varices. The present study aimed to systematically assess the performance of PSR in the diagnosis of varices. PubMed, EMBASE, and article references were searched. The summary receiver operating characteristic curves (AUSROCs), sensitivities, specificities, positive and negative likelihood ratio, and diagnostic odds ratio were calculated. The heterogeneity, quality, and publication bias of studies were evaluated. Subgroup and sensitivity analyses were performed. A total of 49 papers were included. The AUSROCs of PSR for any varices and high-risk varices were 0.8719 and 0.8132, respectively. The summary sensitivities of PSR for any varices and high-risk varices were 0.84 and 0.78, respectively. The summary specificities of PSR for any varices and high-risk varices were 0.78 and 0.67, respectively. The AUSROC of PSR for any varices at the threshold of 909 was 0.8867. The AUSROC of PSR for any varices in viral liver cirrhosis was 0.8675. The overall quality of studies was moderate. Significant heterogeneity and publication bias existed in the study. In conclusion, PSR can be used to identify varices in liver cirrhosis. PSR had a high sensitivity in viral liver cirrhosis.

The Relationship between Inflammatory Marker Levels and Hepatitis C Virus Severity

Background. Red cell distribution width (RDW) and platelet-lymphocyte ratio (PLR) have been studied in a variety of etiological diseases. We aim to investigate the relationship between RDW and PLR and the severity of hepatitis C virus- (HCV-) related liver disease. Methods. We included fifty-two chronic HCV and 42 HCV-related cirrhosis patients and 84 healthy controls. Hematological and virological parameters and liver function biomarkers of HCV-related patients at admission were recorded. Results. RDW, RDW-to-platelet (RPR), and 1/PLR values in HCV-related cirrhosis patients were significantly higher than in chronic HCV patients and healthy controls (all P < 0.001). The aspartate aminotransferase (AST)/alanine aminotransferase (ALT) ratio (AAR), AST-to-platelet ratio index (APRI), and fibrosis index based on the four factors (FIB-4) scores in HCV-related cirrhosis patients were significantly higher than in chronic HCV patients (all P < 0.001). The areas under the curve of the RDW, RPR, and 1/PLR for predicting cirrhosis were 0.791, 0.960, and 0.713, respectively. Bivariate logistic regression analysis showed that RDW could independently predict the presence of cirrhosis in chronic HCV patients. Conclusions. RDW, RPR, and PLR may be potential markers for estimating HCV severity.

Noninvasive tools and risk of clinically significant portal hypertension and varices in compensated cirrhosis: The "Anticipate" study

In patients with compensated advanced chronic liver disease (cACLD), the presence of clinically significant portal hypertension (CSPH) and varices needing treatment (VNT) bears prognostic and therapeutic implications. Our aim was to develop noninvasive tests-based risk prediction models to provide a point-of-care risk assessment of cACLD patients. We analyzed 518 patients with cACLD from five centers in Europe/Canada with paired noninvasive tests (liver stiffness measurement [LSM] by transient elastography, platelet count, and spleen diameter with calculation of liver stiffness to spleen/platelet score [LSPS] score and platelet-spleen ratio [PSR]) and endoscopy/hepatic venous pressure gradient measurement. Risk of CSPH, varices, and VNT was modeled with logistic regression. All noninvasive tests reliably identified patients with high risk of CSPH, and LSPS had the highest discrimination. LSPS values above 2.65 were associated with risks of CSPH above 80%. None of the tests identified patients with very low risk of all-size varices, but both LSPS and a model combining TE and platelet count identified patients with very low risk (<5%) risk of VNT, suggesting that they could be used to triage patients requiring screening endoscopy. LSPS values of <1.33 were associated with a <5% risk of VNT, and 26% of patients had values below this threshold. LSM combined with platelet count predicted a risk <5% of VNT in 30% of the patients. Nomograms were developed to facilitate point-of-care risk assessment.

CONCLUSION

A significant proportion of patients with a very high risk of CSPH, and a population with a very low risk of VNT can be identified with simple, noninvasive tests, suggesting that these can be used to individualize medical care. (Hepatology 2016;64:2173-2184).

Can platelet count/spleen diameter ratio be used for cirrhotic children to predict esophageal varices?

AIM

To determine the laboratory and radiologic parameters, including the platelet count (PC)-to-spleen diameter (SD) ratio as a non-invasive marker that may predict the presence of esophageal varices (EV) in children with cirrhosis.

METHODS

Eighty-nine patients with cirrhosis, but without a history of variceal bleeding were prospectively included. The children were grouped into 6-12 and 12-18 years of age groups. These groups were also divided into 2 sub-groups (presence and absence of EV). All of the patients underwent a complete biochemical and radiologic evaluation. The PC (n/mm³)-to-SD (mm) ratio was calculated for each patient.

RESULTS

Sixty-nine of 98 (70.4%) patients had EV. The presence of ascites in all age groups was significantly associated with the presence of EV. There were no differences in serum albumin levels, PC, SD and the PC-to-SD ratio between the presence and absence of EV groups in both age groups (P > 0.05).

CONCLUSION

Laboratory and radiologic parameters, including the PC-to-SD ratio as a non-invasive marker (except for the presence of ascites), was inappropriate for detecting EV in children with cirrhosis.

Transient Elastography for Spleen Stiffness Measurement in Patients With Cirrhosis: Role in Degree of Thrombocytopenia

OBJECTIVES

The purpose of our study was to evaluate the relationship between spleen stiffness measured by transient elastography and the degree of thrombocytopenia in patients with liver cirrhosis.

METHODS

A total of 67 patients with liver cirrhosis were prospectively enrolled in the study. All patients underwent single-day hematologic and biochemical tests, sonography, and transient elastography of the liver and spleen. Thrombocytopenia was categorized as mild (platelet count, 75,000-150,000/μL), moderate (50,000-75,000/μL), and severe (<50,000/μL).

RESULTS

The degree of thrombocytopenia was significantly correlated with spleen stiffness (P = .001) and spleen size (P = .002) but not with liver stiffness (P = .086). In patients without splenomegaly, spleen stiffness values were significantly higher in patients with thrombocytopenia than in those without thrombocytopenia (P = .035). In patients with splenomegaly, spleen stiffness values were significantly higher in patients with moderate to severe thrombocytopenia than in those with a normal platelet count or mild thrombocytopenia (P = .007). Compared to liver stiffness, spleen stiffness showed a better and statistically significant correlation with platelet count and spleen size in patients with cirrhosis.

CONCLUSIONS

The degree of thrombocytopenia was directly correlated with spleen stiffness, irrespective of the presence of splenomegaly. The clinical phenomenon of unexpected thrombocytopenia may be explained by a subtle or irreversible change in spleen stiffness.

Diagnostic non-invasive model of large risky esophageal varices in cirrhotic hepatitis C virus patients

AIM

To build a diagnostic non-invasive model for screening of large varices in cirrhotic hepatitis C virus (HCV) patients.

METHODS

This study was conducted on 124 post-HCV cirrhotic patients presenting to the clinics of the Endemic Medicine Department at Mansoura University Hospital for evaluation before HCV antiviral therapy: 78 were Child A and 46 were Child B (score ≤ 8). Inclusion criteria for patients enrolled in this study was presence of cirrhotic HCV (diagnosed by either biopsy or fulfillment of clinical basis). Exclusion criteria consisted of patients with other etiologies of liver cirrhosis, e.g., hepatitis B virus and patients with high MELD score on transplant list. All patients were subjected to full medical record, full basic investigations, endoscopy, and computed tomography (CT), and then divided into groups with no varices, small varices, or large risky varices. In addition, values of Fibrosis-4 score (FIB-4), aminotransferase-to-platelet ratio index (APRI), and platelet count/splenic diameter ratio (PC/SD) were also calculated.

RESULTS

Detection of large varies is a multi-factorial process, affected by many variables. Choosing binary logistic regression, dependent factors were either large or small varices while independent factors included CT variables such coronary vein diameter, portal vein (PV) diameter, lieno-renal shunt and other laboratory non-invasive variables namely FIB-4, APRI, and platelet count/splenic diameter. Receiver operating characteristic (ROC) curve was plotted to determine the accuracy of non-invasive parameters for predicting the presence of large esophageal varices and the area under the ROC curve for each one of these parameters was obtained. A model was established and the best model for prediction of large risky esophageal varices used both PC/SD and PV diameter (75% accuracy), while the logistic model equation was shown to be (PV diameter × -0.256) plus (PC/SD × -0.006) plus (8.155). Values nearing 2 or more denote large varices.

CONCLUSION

This model equation has 86.9% sensitivity and 57.1% specificity, and would be of clinical applicability with 75% accuracy.

Ratio of platelet count/spleen diameter predicted the presence of esophageal varices in patients with schistosomiasis liver cirrhosis

AIM

To examine the platelet count (PC)/spleen diameter (SD) ratio in predicting the presence of esophageal varices (EV) in patients with schistosomiasis liver cirrhosis.

MATERIALS AND METHODS

A total of 95 consecutive patients with EV induced by schistosomiasis liver cirrhosis were enrolled in this trial. A total of 141 schistosomiasis liver cirrhosis patients without EV were enrolled as controls. All patients were diagnosed by endoscopy. Demographic, laboratory, and Doppler ultrasound parameters were collected and analyzed. Binary logistic regression analysis was carried out to identify independent risk factors associated with EV occurrence. Receiver operating curves were generated to obtain the PC/SD ratio cutoff values for the optimal sensitivity and specificity with respect to EV.

RESULTS

The accuracy was increased in diagnosing for EV using the ratio of PC/SD compared with the SD alone [area under the curve: 0.891 95% confidence interval (CI): 0.844-0.928 vs. 0.764 95% CI: 0.705-0.817; P<0.01]. The optimal cutoff value was 1004, with a 77.1% (95% CI: 67.9-84.8%) positive-predictive value and an 89.3% (95% CI: 82.7-94.0%) negative-predictive value. Using a cutoff of 1004, it was determined that 117/141 (83.0%) patients without EV could avoid undergoing unnecessary endoscopy, whereas 14/95 (14.7%) patients with EV would be misdiagnosed. In contrast, when the ratio was set at 909, the positive-predictive and negative-predictive values were 79.5% (95% CI: 69.5-87.4%) and 83.1% (95% CI: 76.1-88.8%), respectively. A ratio of 909 would accurately predict the absence of EV in 123/141 (87.2%) patients; however, 24/95 (25.3%) patients with EV would miss the necessary screening endoscopy.

CONCLUSION

The ratio of PC/SD was a useful marker in predicting the presence of EV in patients with schistosomiasis liver cirrhosis.

Recombinant HBV vaccine enhances the rate of sustained virological response when early initiated after anti-HCV combination therapy

The overall SVR rate for chronic hepatitis C genotype 4 using the Standard of care is 54.3%. HBV infection can be prevented by the administration of effective and safe vaccine. Evaluation of the vaccination-induced anti-HBs response rates in a cohort of HCV Egyptian patients after being exposed to antiviral combination therapy and the magnitude of its effect on the rate of SVR through its putative role in induction of crossed immunity. (A) 500 HCV patients who had completed the course of antiviral therapy and achieved ETR were retrospectively analyzed and received 20 μg of recombinant DNA vaccine for hepatitis B at time intervals (0, 1, and 4 months). The first dose of the vaccine was initiated one month post treatment. (B) Laboratory analysis: Included routine preliminary investigations to anti viral therapy and specific investigations as determination of anti-HBs antibodies 2 months following the third dose of vaccine. 433 patients showed protective response (86.6%), 67 patients were non-responders (13.4%) (P = 0.003). Adding HBV vaccine 1 month post-treatment increased SVR (400 patients, 80%) (χ(2)  = 40.3, P = 0.000). Diabetes affect response to HBV vaccine (P = 0.0001). Adding HBV vaccine to the post treatment care of patients with HCV after termination of antiviral therapy gain two benefits; protection from HBV and significant increase in rates of SVR.

Use of eltrombopag in thrombocytopenia of liver disease

Second generation thrombopoietin agonists including eltrombopag and romiplostim act on the thrombopoietin receptor to increase the megakaryocyte production. These agents were needed as use of first generation recombinant products was associated with formation of autoantibodies. Eltrombopag is an oral thrombopoietin agonist found effective in raising platelet counts in patients with immune thrombocytopenia. The drug has now been found to be useful in raising platelet counts in thrombocytopenia related to liver disease including cirrhosis and chronic viral hepatitis. Although the drug may help enable adequate interferon therapy in patients with HCV infection and help carry out invasive procedures in patients with cirrhosis, concerns have been raised of possible thrombotic complications including portal vein thrombosis. Randomized trials have shown that use of eltrombopag concomitant with pegylated interferon and ribavirin increased the chances of sustained virologic response while decreasing the dose reductions of interferon. The data on use of romiplostim in these clinical indications is also emerging. However, in the future, availability of interferon free regimens is likely to decrease the use of eltrombopag for enabling antiviral therapy. The review discusses the role of eltrombopag in management of liver disease related thrombocytopenia in wake of recent data as also the dosage, precautions and adverse effects associated with its use.

Platelet count/spleen diameter ratio to predict esophageal varices in Mexican patients with hepatic cirrhosis

AIM: To validate whether the platelet count/spleen size ratio can be used to predict the presence of esophageal varices in Mexican patients with hepatic cirrhosis.

METHODS: This was an analytical cross-sectional study to validate the diagnostic test for hepatic cirrhosis and was performed between February 2010 and December 2011. Patients with a diagnosis of hepatic cirrhosis were included and stratified using their Child-Pugh score. Biochemical parameters were evaluated, and ultrasound was used to measure the longest diameter of the spleen. The platelet count/spleen diameter ratio was calculated and analyzed to determine whether it can predict the presence of esophageal varices. Upper gastrointestinal endoscopy was used as the gold standard. Sensitivity and specificity, positive and negative predictive values, and positive and negative likelihood ratios were determined, with the cutoff points determined by receiver-operating characteristic curves.

RESULTS: A total of 91 patients were included. The mean age was 53.75 ± 12 years; 50 (54.9%) were men, and 41 (45.0%) women. The etiology of cirrhosis included alcohol in 48 (52.7%), virally induced in 24 (26.3%), alcoholism plus hepatitis C virus in three (3.2%), cryptogenic in nine (9.8%), and primary biliary cirrhosis in seven (7.6%). Esophageal varices were present in 73 (80.2%) patients. Child-Pugh classification, 17 (18.6%) patients were classified as class A, 37 (40.6%) as class B, and 37 (40.6%) as class C. The platelet count/spleen diameter ratio to detect esophageal varices independent of the grade showed using a cutoff value of ≤ 884.3, had 84% sensitivity, 70% specificity, and positive and negative predictive values of 94% and 40%, respectively.

CONCLUSION: Our results suggest that the platelet count/spleen diameter ratio may be a useful tool for detecting esophageal varices in patients with hepatic cirrhosis.

Assessment of risk of complications in cirrhosis using portal thallium scans

AIM: To investigate the usefulness of a novel thallium scan shunt index for assessing portosystemic shunt-related cirrhotic complications.

METHODS: We enrolled 209 chronic hepatitis B-related cirrhosis patients. After rectal thallium instillation, radioactive isotope activity in the heart and liver was measured. The ratio of radiation uptake between the heart and the liver was calculated (the shunt index). This value indicates the degree of portosystemic circulation shunting. Blood tests, serum biochemistry tests, abdominal ultrasonography, gastroscopy and examination of clinical features such as the occurrence of varices, bleeding and hepatic encephalopathy were performed. Multivariate analysis was used to identify independent risk factors for complications. We compared the cumulative incidence rates of complications during the follow-up period.

RESULTS: The thallium scan shunt index was significantly higher in the decompensated liver cirrhosis group than in the compensated liver cirrhosis group (0.91 ± 0.39 vs 0.39 ± 0.32, P < 0.001). It was also higher in the varices group, the hepatic encephalopathy group, and the variceal bleeding group than in the control group (P < 0.001). Multivariate analysis showed that the index was an independent risk factor for predicting decompensated liver cirrhosis. When the cut-off value was 0.75, the shunt index had a sensitivity of 82.6%, a specificity of 84%, a positive predictive value of 61.5%, and a negative predictive value of 94.4% in diagnosing decompensated cirrhosis. When the shunt index was greater than 0.75, there was a significant increase in the number of decompensated events.

CONCLUSION: The thallium shunt index is a good predictor of cirrhosis-related complications.

Aspartate aminotransferase-to-platelet ratio index (APRI) for the non-invasive prediction of esophageal varices

BACKGROUND & AIMS

Variceal bleeding is a dramatic and common complication of cirrhosis, and, therefore, endoscopy is recommended for the screening of EV (esophageal varices) in every cirrhotic. This study evaluates the capacity of APRI (aspartate aminotransferase-to-platelet ratio index) in non-invasively predicting EV.

MATERIAL AND METHODS

This cross-sectional study evaluated cirrhotics for their APRI value and the presence of EV, with a cutoff point of 1, 3; platelet count, spleen diameter, PC/SD (platelet count/ spleen diameter ratio), aspartate aminotransferase/alanine aminotransferase ratio, Child-Pugh score and MELD (model for end-stage liver disease) score were also studied.

RESULTS

The study included 164 cirrhotics, 59.7% male, with a mean age of 56.7 years. APRI demonstrated a sensitivity of 64.7% (95% confidence interval-95%CI = 0.56-0.73), specificity of 72.7% (95%CI = 0.59-0.86), positive predictive value of 86.5% (95%CI = 0.79-0.94), negative predictive value of 43.2% (95%CI = 0.32-0.55). In the univariate analysis, platelet count, spleen diameter, Child and MELD scores, PC/SD and APRI were related to EV (p < 0.05). In the logistic regression, only platelet count and Child score were associated to EV (p < 0.05).

CONCLUSION

APRI is not an independent factor for the prediction of EV. Its sensitivity, specificity and predictive values are insufficient for the index to be used for the screening of EV in cirrhotics.

Noninvasive methods for prediction of esophageal varices in pediatric patients with portal hypertension

AIM: To evaluate clinical and laboratory parameters for prediction of bleeding from esophageal varices (EV) in children with portal hypertension.

METHODS: Retrospective study of 103 children (mean age: 10.1 ± 7.7 years), 95.1% with intrahepatic portal hypertension. All patients had no history of bleeding and underwent esophagogastroduodenoscopy for EV screening. We recorded variceal size (F1, F2 and F3), red-color signs and portal gastropathy, according to the Japanese Research Society for Portal Hypertension classification. Patients were classified into two groups: with and without EV. Seven noninvasive markers were evaluated as potential predictors of EV: (1) platelet count; (2) spleen size z score, expressed as a standard deviation score relative to normal values for age; (3) platelet count to spleen size z score ratio; (4) platelets count to spleen size (cm) ratio; (5) the clinical prediction rule (CPR); (6) the aspartate aminotransferase to platelet ratio index (APRI); and (7) the risk score.

RESULTS: Seventy-one children had EV on first endoscopy. On univariate analysis, spleen size, platelets, CPR, risk score, APRI, and platelet count to spleen size z score ratio showed significant associations. The best noninvasive predictors of EV were platelet count [area under the receiver operating characteristic curve (AUROC) 0.82; 95%CI: 0.73-0.91], platelet: spleen size z score (AUROC 0.78; 95%CI: 0.67-0.88), CPR (AUROC 0.77; 95%CI: 0.64-0.89), and risk score (AUROC 0.77; 95%CI: 0.66-0.88). A logistic regression model was applied with EV as the dependent variable and corrected by albumin, bilirubin and spleen size z score. Children with a CPR < 114 were 20.7-fold more likely to have EV compared to children with CPR > 114. A risk score > -1.2 increased the likelihood of EV (odds ratio 7.47; 95%CI: 2.06-26.99).

CONCLUSION: Children with portal hypertension with a CPR below 114 and a risk score greater than -1.2 are more likely to have present EV. Therefore, these two tests can be helpful in selecting children for endoscopy.

Formula to predict platelet count after partial splenic arterial embolization in patients with hypersplenism

PURPOSE

To establish a formula to guide appropriate embolization volume for postprocedural platelet gain following partial splenic arterial embolization (PSE) for hypersplenism.

MATERIALS AND METHODS

The hepatic volume (Vh) and splenic volume (Vsp) were measured by using 2-mm-thick computed tomography images before and after PSE in 20 patients with various chronic liver diseases. A formula was derived from the relationship between the platelet count increase ratio (dPlt%) and the organ volumes, which was then evaluated in another cohort.

RESULTS

After an embolization of a median of 72.1% of the spleen (interquartile range, 38.2%-93.8%), the dPlt% was 67.7% ± 40.0 and significantly correlated with the increasing ratio of Vh to Vsp (P = .019, ρ = 0.52). Because the difference in Vh/Vsp ratio after PSE was significantly correlated with the spleen embolization ratio (eVsp%; P = .0003, ρ = 0.72), the estimated dPlt% could be derived from the Vh/Vsp ratio before PSE and the eVsp%. The estimated dPlt% was significantly correlated with the actual dPlt% (P = .0003, ρ = 0.72). When the formula was evaluated in another cohort of 14 cases, another strict correlation was observed (P < .0001, ρ = 0.92).

CONCLUSIONS

These data suggest that platelet count after PSE can be predicted before the procedure by using the Vh/Vsp ratio and the anticipated spleen embolization volume. The use of such a prediction can prevent too much or too little embolization, thereby leading to an improvement in the risk/return trade-off in PSE.

Platelet count/spleen diameter ratio for non-invasive diagnosis of oesophageal varices: is it useful in compensated cirrhosis?

AIM

To assess the diagnostic accuracy of the platelet count/spleen diameter ratio for identification of oesophageal varices and/or hypertensive gastropathy in patients with compensated cirrhosis.

METHODS

Platelet count/spleen diameter ratio was calculated in 87 consecutive patients with compensated cirrhosis. A new cut-off with the highest sensitivity and specificity for the presence/absence of oesophageal varices and/or hypertensive gastropathy was identified. Performance of the platelet count/spleen diameter ratio considering previously reported cut-off values were then tested in our population.

RESULTS

A platelet count/spleen diameter ratio <936.4 had the best sensitivity and specificity for the diagnosis of oesophageal varices and for all endoscopic findings of portal hypertension. A value lower than 936.4 allowed identification of 64.5% of patients with oesophageal varices and 66.7% of patients with any sign of portal hypertension; a value higher than 936.4 excluded oesophageal varices in 64.3% of patients and any sign of portal hypertension in 68.6% of patients.

CONCLUSIONS

In patients with compensated cirrhosis, the platelet count/spleen diameter ratio is not a useful parameter to avoid unnecessary upper endoscopy, independently of the cut-off.

Can we consider the right hepatic lobe size/albumin ratio a noninvasive predictor of oesophageal varices in hepatitis C virus-related liver cirrhotic Egyptian patients?

BACKGROUND

The current guidelines recommend the screening of all cirrhotic patients by endoscopy, but repeated endoscopic examinations are unpleasant for patients and have a high cost impact and burden on endoscopic units. The aim of this study is to evaluate the optimal liver lobe size/albumin ratio and to compare this ratio with spleen size, platelet count and platelet count/spleen diameter ratio as potential noninvasive predictors of oesophageal varices in hepatitis C virus (HCV)-related liver cirrhosis in Egyptian patients.

METHODS

This prospective study included one hundred patients with HCV-related liver cirrhosis. All studied subjects underwent a detailed clinical examination, biochemical workup, upper gastrointestinal endoscopy and abdominal ultrasound. The platelet count/spleen diameter ratio and the right liver lobe/albumin concentration ratio for all patients were calculated.

RESULTS

The 4 predictors demonstrated a high statistically significant correlation with the presence and grade of oesophageal varices (P values<0.001). The platelet count/spleen diameter ratio had the highest accuracy, followed by the right liver lobe/albumin concentration ratio, spleen size and then platelet count.

CONCLUSION

The use of the studied noninvasive predictors, especially the platelet count/spleen diameter ratio and the right liver lobe/albumin concentration ratio, can help physicians by restricting the use of endoscopic screening only to patients presenting a high probability of oesophageal varices. This is especially useful in clinical settings where resources are limited and endoscopic facilities are not present in all areas. Such is the case in Egypt, where there is a large number of patients who require oesophageal screening for oesophageal varices.

Platelet count/spleen diameter ratio to predict the presence of esophageal varices in patients with cirrhosis: a systematic review

BACKGROUND

Esophageal variceal bleeding remains the leading cause of acute mortality in patients with cirrhosis. Platelet count to spleen diameter (PC/SD) ratio less than 909 is one of several parameters proposed for the noninvasive prediction of esophageal varices. The aim of this study is to systematically review the evidence on the diagnostic accuracy of the 909 ratio.

METHODS

We identified relevant studies from a MEDLINE search and performed a meta-analysis to estimate the pooled sensitivity, specificity, and positive and negative likelihood ratios (LRs) using Meta-Disc software.

RESULTS

Eight studies met the inclusion criteria and included a total of 1275 patients. Meta-analysis yielded a pooled sensitivity of 89% [95% confidence interval (CI) 87-92%; I2 statistic 92.9%] and a pooled specificity of 74% (95% CI 70-78%; I2 statistic 94.5%). The pooled positive LR was 3.5 (95% CI 1.92-6.25; I2 statistic 94.0%) and the pooled negative LR was 0.12 (95% CI 0.05-0.32; I2 statistic 90.8%). The quality of the evidence as assessed by the GRADE methodology was low.

CONCLUSION

In its present form, the test characteristics of PC/SD ratio of 909 may not be adequate to completely replace esophagogastroduodenoscopy as a noninvasive screening tool for esophageal varices, given the low grade of evidence. However, it may be potentially useful as part of a prediction rule incorporating other clinical characteristics or varying PC/SD cutoffs. When compared with other noninvasive predictor tools, the PC/SD ratio is elegant, simple, and inexpensive. With some minor modifications, it may become a helpful tool to limit the number of endoscopies in primary prophylaxis to be performed in patients with portal hypertension.

Less-invasive MR indices of clinically evident esophageal variceal bleeding in biliary atresia patients

BACKGROUND/PURPOSE

Esophageal variceal hemorrhaging is potentially life threatening for long-term survivors of biliary atresia. We evaluated the feasibility of less-invasive parameters for predicting the presence of clinically significant esophageal variceal bleeding in biliary atresia patients.

METHODS

A total of 30 patients aged 108-5314 days (median = 285 days) with biliary atresia underwent a magnetic resonance examination with fast spin-echo T2-weighted imaging and spin-echo, T1-weighted images with fat saturation after use of a contrast medium on a 1.5-tesla scanner. The splenic length-platelet ratio was divided by the each patient's body height (m) to produce the corrected splenic length-platelet ratios. In addition, the splenic volume index-to-platelet count ratio was divided by the patient's body weight (kg) to produce a corrected ratio.

RESULTS

The corrected splenic length-platelet ratio was more significantly increased in 21 patients with esophageal variceal bleeding (Group A) than in nine patients without variceal bleeding [(Group B) 0.98 ± 0.64 vs. 0.44 ± 0.18, p < 0.01]. The splenic volume index-to-platelet count ratio corrected by body weight was significantly larger in Group A (510.7 ± 536.2) than in Group B (148.1 ± 88.9, p < 0.01).

CONCLUSION

Less-invasive indices, including the corrected splenic length platelet ratio and the splenic volume index-to-platelet count ratio, may be valuable predictors of esophageal variceal bleeding in patients with biliary atresia.

A clinical prediction rule and platelet count predict esophageal varices in children

BACKGROUND & AIMS

The validation of noninvasive tests to diagnose esophageal varices is a priority in children because repeated endoscopic evaluations are too invasive. We measured the ability of a previously developed noninvasive clinical prediction rule (CPR) to predict the presence of esophageal varices in children.

METHODS

We analyzed data from 108 children, younger than age 18, who received endoscopies at 8 centers, to assess portal hypertension from chronic liver disease or portal vein obstruction. Blood test and abdominal ultrasound scan results were obtained within 4 months of endoscopy. Grading of varices identified by endoscopy was confirmed by independent blinded review. Spleen size, based on data from the ultrasound scan, was expressed as a standard deviation score relative to normal values for age.

RESULTS

Of the children studied, 74 had esophageal varices (69%), including 35 with large varices (32%). The best noninvasive predictors of esophageal varices of any size were as follows: platelet:spleen size z-score ratio (area under the receiver operating characteristic curve [AUROC], 0.84; 95% confidence interval [CI] 0.75-0.93), CPR (AUROC, 0.80; 95% CI, 0.70-0.91), and platelet count (AUROC, 0.79; 95% CI, 0.69-0.90). The positive predictive values for the CPR and platelet count were 0.87 and 0.86, the negative predictive values were 0.64 and 0.63, the positive likelihood ratios were 3.06 and 2.76, and the negative likelihood ratios were 0.64 and 0.63, respectively. Based on positive and negative predictive values, the most accurate noninvasive tests were the CPR and platelet counts.

CONCLUSIONS

Noninvasive tests such as CPR and platelet count can assist in triaging children for endoscopy to identify esophageal varices.

Platelet count/spleen diameter ratio: analysis of its capacity as a predictor of the existence of esophageal varices

CONTEXT

Upper gastrointestinal bleeding associated to esophageal varices is the most dramatic complication of cirrhosis. It is recommended screening every cirrhotic for esophageal varices with endoscopy.

OBJECTIVES

To evaluate the capacity of the platelet count/spleen diameter ratio in non-invasively predicting esophageal varices in a population of cirrhotics originated in an independent center from the one in which it was developed.

METHODS

The study included patients from the ambulatory care clinic of cirrhosis of a Brazilian hospital and studied platelet count, spleen diameter and presence of esophageal varices, as well as Child and MELD scores. It used a cutoff value of 909 for the platelet count/spleen diameter ratio, as previously published. A sample of 139 patients was needed to grant results a 95% confidence level.

RESULTS

The study included 164 cirrhotics, 56.7% male, with a mean age of 56.6 ± 11.6 years. In the univariate analysis, platelet count, spleen diameter, presence of ascites, Child and MELD scores and the platelet count/spleen diameter ratio were related to esophageal varices (P<0.05). The platelet count/spleen diameter ratio had sensitivity of 77.5% (95% CI = 0.700-0.850), specificity of 45.5% (95% CI = 0.307-0.602), positive predictive value of 79.5% (95% CI = 0.722-0.868), negative predictive value of 42.6% (95% CI = 0.284-0.567) and accuracy of 68.9% (95% CI = 0.618-0.760). In the multivariate analysis, platelet count was the only variable which related to esophageal varices (P<0.05).

CONCLUSION

Platelet count/ spleen diameter ratio is not adequate to predict esophageal varices in cirrhotics.

Use of the platelet count/spleen diameter ratio for the noninvasive diagnosis of esophageal varices in patients with schistosomiasis

BACKGROUND/AIM

In patients with liver cirrhosis, the platelet count/spleen diameter ratio has been validated as a parameter for the noninvasive diagnosis of esophageal varices. Schistosoma infection is a frequent cause of portal hypertension in Middle Eastern countries, and is associated with the development of esophageal varices. In this study we aimed to evaluate the platelet count/spleen diameter ratio as a noninvasive tool for the prediction of the presence of esophageal varices in patients with schistosoma-related chronic liver disease.

PATIENTS AND METHODS

Forty-three patients with hepatosplenic schistosomiasis underwent upper digestive endoscopy to check for the presence of esophageal varices. Furthermore, all patients underwent abdominal ultrasonography, and maximum spleen diameter (in mm) was measured. The platelet count/spleen diameter ratio was calculated in all patients.

RESULTS

Esophageal varices were found in 31 patients (72%). Age and gender were not significantly different between patients with and without varices. In patients with varices, median platelet count (82,000/μL versus 172,000/μL, P < 0.0001) and platelet count/spleen diameter ratio (571 versus 1651, P < 0.0001) were significantly lower, while spleen diameter (147 mm versus 109 mm, P = 0.0006) was significantly larger. In multivariate analysis, the platelet count/spleen diameter ratio was the only parameter independently associated with the presence of varices (P < 0.0001).

CONCLUSIONS

In this study we have validated the use of the platelet count/spleen diameter ratio for the noninvasive diagnosis of esophageal varices in patients with portal hypertension caused by schistosoma infection. In these patients, the platelet count/spleen diameter ratio might be used to allow better rationalization of medical resources and use of endoscopy.

Utilization of platelet count spleen diameter ratio in predicting the presence of esophageal varices in patients with cirrhosis

GOALS

To assess whether the platelet count/spleen diameter ratio is a useful noninvasive predictor of esophageal varices.

BACKGROUND

Current guidelines recommend that all patients with cirrhosis undergo screening endoscopy for the presence of varices. Recent studies have focused on using noninvasive techniques to stratify cirrhotic patients according to their risk of having varices. One study examining the platelet count/spleen diameter ratio using a cut-off value of 909, yielded a negative predictive value of 100% for the presence of varices.

STUDY

A retrospective analysis of 137 patients with cirrhosis over the age of 18 that underwent screening endoscopy for varices between January 2003 and October 2005. The data collected were age, sex, etiology of cirrhosis, spleen diameter, prothrombin time/international normalized ratio, total bilirubin, platelet count, albumin, Child-Pugh score, and endoscopic findings.

RESULTS

There were 137 patients with 87 (63.5%) men and a mean age of 56 years. Seventy-six (55%) patients had esophageal varices. The mean age, sex, and etiology of cirrhosis were similar between those with and without varices. Using a platelet count/spleen diameter ratio with a cut-off value of 909, yielded a negative predictive value of only 73% and a positive predictive value of 74%.

CONCLUSIONS

The platelet count/spleen diameter ratio with a cut-off value of 909 may not be sufficiently accurate in predicting the presence of esophageal varices. Upper endoscopy remains the method of choice to screen for the presence of varices.

Derivation of a clinical prediction rule for the noninvasive diagnosis of varices in children

BACKGROUND AND OBJECTIVES

Identification of children who are at high risk for having varices using noninvasive tests would enable the selection of children for future studies of primary prophylaxis of variceal hemorrhage, but this has been inadequately studied. The objective of the study was to derive a noninvasive clinical prediction rule that is able to identify children with esophageal varices.

METHODS

Fifty-one consecutive children with liver disease or portal hypertension who underwent endoscopy were included in the present retrospective study. At endoscopy, variceal size was graded on a 4-point Likert scale. Results of physical examination, blood tests, and abdominal ultrasound scan (USS) were recorded. Spleen length on USS was expressed as a standard deviation score (z score). A descriptive univariate analysis was performed on variables that were potentially associated with esophageal varices and multivariate logistic regression was then modeled to derive a clinical prediction rule.

RESULTS

Esophageal varices were found in 17 of the 51 children (33%). Variables found to differ significantly between children with and without varices included platelet/spleen-length z score ratio (P < 0.001), platelet count (P < 0.001), international normalized ratio (P = 0.001), aspartate aminotransferase/alanine aminotransferase ratio (P = 0.002), and albumin (P = 0.003). Using multivariate logistic regression, a model with platelet count, spleen length z score, and albumin as the independent variables had the best fit. Area under the receiver operating characteristic curve for this clinical prediction rule was 0.93 (95% confidence interval 0.85-0.99), sensitivity 94%, specificity 81%, positive predictive value 0.83, negative predictive value 0.94, positive likelihood ratio 5, and negative likelihood ratio 0.06.

CONCLUSIONS

This clinical prediction rule is a simple noninvasive measure that may identify children at high risk for esophageal varices. A prospective validation study is in progress.