Noninvasive Prediction Of Esophageal Varices Research Articles

A Clinical Prediction Rule and Platelet Count Predict Esophageal Varices in Children

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

HEPATIC CIRRHOSIS

Objective: To see the association of platelet count, splenomegaly and development of oesophageal varices. Study Design: Observational study. Duration of study: One year from January 2010 to December 2010. Setting: Gastroenterology Department, Medical Unit III, Nishtar Hospital Multan. Methodology: One hundred ten cirrhotic patients were included. The record of these patients was scrutinized and data collected was entered and analyzed through SPSS 11. The patients were divided into three groups according to platelet count. Group I with platelet count less than 50000/mm3, group II with platelet count of 50000 to 100000/mm3 and group III with platelet count of 100000 to 150000/mm3. Similarly patients were also divided into three groups according to splenic size. Group I with splenic size 11 – 13 cm, group II with splenic size 13–16 cm and group III splenic size more than 16 cm. In each group presence of esophageal varices along with grading was noted. Results: The age of the patients varied from 15 to 80 years and mean age was 48.55 ± 13.88 years. Sixty five (59.1 %) were male and 45 (40.9%) were female. The hemoglobin level of these patients varied from 6.0 to 14.3 gm/100 ml with mean level of 9.23 ± 2.11gm/100ml. The platelet count varied from 22000 to 385000/mm3. The splenic size varied from 9 to 18 cm with mean of 12.53 ± 2.14 cm. Esophageal varices were detected in 102 cases. Seventeen cases were of grade I varices, 25 cases were of grade II varices, 40 cases were in grade III varices and 4 cases were in grade IV varices. Maximum number of grade-III (22 patients) and grade IV (3patients) esophageal varices occurred in patients having platelet count less than 50000/mm3. As the splenic size increases the grade of esophageal varices also increases. Maximum number of esophageal varices occur in grade II (25) followed by grade-III (37) in patients with splenic size in the range of 13 to 16 cm. Conclusions: A low platelet count and large splenic size are good non-invasive predictors of esophageal varices. These parameters can also accurately assess the presence of large varices. So a patient of cirrhosis with low platelet count and large spleen has an increased diagnostic yield of esophageal varices on upper GI endoscopy.

Receiver Operating Characteristic Curve and Odds Ratio Should Be Used with Caution

Dear Editor, We read with interest the article by Abu El Makarem MA et al. [1] entitled, “Platelet count/bipolar spleen diameter ratio for the prediction of esophageal varices: The special Egyptian situation.” This study evaluated noninvasive predictors of esophageal varices in cirrhotic patients by multivariate logistic regression and receiver operating characteristic (ROC) curve analysis. However, in our opinion, some aspects of the statistical analysis could be clarified. The first issue concerns the ROC analysis. The full area under the ROC curve (AUC) is a measure of the performance of the diagnostic test because it reflects the test performance at all possible cutoff levels. The AUC lies in the interval [0.5,1], and the larger area, the better performance. A perfect test has an AUC of 1.0, whereas random chance gives an AUC of 0.5 [2],[3]). In Abu El Makarem MA et al.’s [1] paper, the AUC for age is 0.33, which is less than 0.5. Therefore, we think that something might have gone wrong when the authors performed the ROC analysis with the SPSS software. Because both the univariate analysis and multivariate logistic regression identified age as a valuable predictor of varices, older patients experienced a higher risk having varices. We presume that the AUC for age may be 0.67 (1-0.33) rather than 0.33. The second issue has to do with the odds ratio. The odds ratio refers to a ratio of the odds of the outcome occurring in one group divided by the odds of the outcome occurring in the other group with a 1-unit increase in x [4]. The odds ratio for age was 1.205 in Abu El Makarem MA et al.’s [1] paper, but no statement such as “for a one year increase in age” was mentioned.

F-22 Spleen stiffness measurement as a non-invasive predictor of esophageal varices in cirrhotic patients

F-22 Spleen stiffness measurement as a non-invasive predictor of esophageal varices in cirrhotic patients

Non-invasive predictors of esophageal varices

Background/Aim:Current guidelines recommend screening cirrhotic patients with an endoscopy to detect esophageal varices and to institute prophylactic measures in patients with large esophageal varices. In this study, we aimed at identifying non-endoscopic parameters that could predict the presence and grades of esophageal varices.Patients and Methods:In a prospective study, 229 newly diagnosed patients with liver cirrhosis, without a history of variceal bleeding, were included. Demographic, clinical, biochemical and ultrasonographic parameters were recorded. Esophageal varices were classified as small and large, at endoscopy. Univariate analysis and multivariate logistic regression analysis were done to identify independent predictors for the presence and grades of varices.Results:Of the 229 patients (141 males; median age 42 years; range 17-73 years) with liver cirrhosis, 97 (42.3%) had small and 81 (35.4%) had large varices. On multivariate analysis, low platelet count (Odd’s Ratio [OR], 4.3; 95% confidence interval [CI], 1.2-14.9), Child Pugh class B/C (OR, 3.3; 95% CI, 1.8-6.3), spleen diameter (OR, 4.3; 95% CI, 1.6-11.9) and portal vein diameter (OR, 2.4; 95% CI, 1.1-5.3) were independent predictors for the presence of varices. Likewise, for the presence of large esophageal varices, low platelet count (OR, 2.7; 95% CI, 1.4-5.2), Child Pugh class B/C (OR, 3.8; 95% CI, 2.3-6.5) and spleen diameter (OR, 3.1; 95% CI, 1.6-6.0) were the independent risk factors.Conclusion:The presence and higher grades of varices can be predicted by a low platelet count, Child-Pugh class B/C and spleen diameter. These may be considered as non-endoscopic predictors for the diagnosis and management of large grade varices.

Non-invasive prediction of esophageal varices: Is it possible?

Non-invasive prediction of esophageal varices: Is it possible?

American association for the study of liver diseases endpoints conference: Design and endpoints for clinical trials in primary biliary cirrhosis

American association for the study of liver diseases endpoints conference: Design and endpoints for clinical trials in primary biliary cirrhosis

Prevalence and Predictors of Esophageal Varices in Patients With Primary Biliary Cirrhosis

Esophageal varices and bleeding are among the most feared complications of primary biliary cirrhosis (PBC). We aimed to determine the prevalence of esophageal varices in patients with PBC, to evaluate noninvasive markers of esophageal varices in this population, and to validate the results in an independent set of patients. Data were collected on all patients with PBC seen for the first time at the University of Florida (study group) and at Case Western Reserve University hospitals (cross-validation group) during 7 consecutive years. Logistic regression analysis was used to identify independent predictors of esophageal varices. The best cut-off values were calculated based on receiver operating characteristic curves. The diagnostic accuracy of the independent predictors of esophageal varices identified in the study group were retested in the cross-validation group. Of 210 patients with PBC seen at the University of Florida, 113 had an endoscopy and 49.6% (56 of 113) were found to have esophageal varices. After excluding 22 patients with a history of variceal bleeding, data on 91 patients were analyzed. Thirty-four patients had esophageal varices (37%). Multivariate analysis revealed that a platelet count of less than 140,000 (odds ratio, 7.6; 95% confidence interval, 1.6-37) and a Mayo risk score of 4.5 or greater (odds ratio, 10.6; 95% confidence interval, 1.8-62) were independent predictors of esophageal varices. The diagnostic accuracy of these predictors was confirmed in an independent set of patients. Among patients with PBC, a platelet count of less than 140,000 and/or a Mayo risk score of 4.5 or greater appears to identify those patients more likely to benefit from a screening endoscopy.

Noninvasive Diagnosis of Esophageal Varices: Is It Feasible?

The possibility of identifying cirrhotic patients with esophageal varices by noninvasive means is attractive, because it would allow for the restriction of the performance of screening endoscopy to patients at high risk of having varices. Over the years, several studies addressing this issue have been performed with little success. The recently proposed platelet count/spleen diameter ratio appears to be the best noninvasive predictor of esophageal varices developed so far. However, the available evidence is not yet sufficient to allow for the modification of the current policy of screening cirrhotic patients by endoscopy at the time of diagnosis to detect varices.