Spleen Diameter Research Articles

Validation of PH and Varices Risk Scores for Prediction of High-Risk Esophageal Varix and Bleeding in Patients with B-Viral Cirrhosis.

Esophageal varices (EVs) can be accurately predicted using PH and varices risk scores. We aimed to validate their prognostic performances. Methods: We enrolled patients with B-viral cirrhosis as the training cohort (n = 503). Areas under receiver operating characteristic curves (AUROCs) for HEV were calculated for PH (=−5.953 + 0.188 × liver stiffness (LS) + 1.583 × sex (1:male/0:female) + 26.705 × spleen diameter/platelet count ratio) and varices (=−4.364 + 0.538 × spleen diameter −0.049 × platelet count −0.044 × LS + 0.001 × LS × platelet count) risk scores, and compared to LSPS (=LS × spleen diameter/platelet count). An independent cohort was recruited for further validation (n = 222). In the training cohort, the varices risk score showed the highest AUROC (0.926), followed by the PH risk score (0.924) and LSPS (0.924), but without any statistically significant differences. For varices risk scores ≤−1.70 and ≥1.48, a 95.0% negative predictive value (NPV) and 91.2% positive predictive value (PPV) were observed, respectively. At PH risk scores ≤2.25 and ≥7.71, 95.0% NPV and 90.0% PPV were observed, respectively. At LSPS ≤1.73 and ≥13.9, 95.3% NPV and 95.0% PPV were observed, respectively. The EV bleeding (EVB) risk during follow-up increased stepwise and significantly when stratified by PH, varices risk scores, and LSPS (all p < 0.001). In the validation cohort, NPVs were generally similar when stratified by PH (88.2%), varices risk scores (93.2%), and LSPS (88.9%); however, corresponding PPVs were suboptimal. PH and variceal risk scores are reliable for predicting HEV and future EVB. Patients with PH and varices risk scores ≤2.25 and ≤−1.70, respectively, may avoid endoscopy safely. For convenience, LSPS might be a good alternative, with comparable prognostic performance to these two models.

2D-Shear Wave Elastography in Predicting Esophageal Varices in Patients with Compensated Liver Cirrhosis

Background: Current guidelines require endoscopic screening for esophageal varices. It is a costly and invasive procedure. So, there has always been a search for non-invasive measures that can predict the varices obviating the use of endoscopy. We tried to see whether 2D-Shear wave elastography (2D-SWE) measurements could predict the presence of esophageal varices and high-risk esophageal varices in patients with compensated cirrhosis. Aim: To investigate the diagnostic performance of 2D-SWE in predicting the presence of esophageal varices and high-risk varices in patients with compensated cirrhosis and to compare the diagnostic capabilities of 2D-SWE with those of transient elastography(TE), and other non-invasive parameters. Methods: 108 patients with compensated cirrhosis undergoing B-mode, 2D-SWE, TE, and endoscopy were enrolled. Comparisons of the accuracy of prediction between groups were made by AUROCs. Regression analysis was performed for the multiple variables. Results: There were 64 males and 44 females, with a mean age of 51.73 ± 11.35 years. NASH(40%) and Alcohol(27%) were the main etiologies. Esophageal varices were found in 63 patients. 36 had high-risk varices. The AUROC value of 2D- SWE(0.967) was comparable to that of TE(0.961) but significantly higher than other non-invasive parameters(platelet count, spleen diameter, platelet count/spleen diameter ratio, FIB-4, APRI). 2D-SWE had 92.1% sensitivity, 88.7% specificity, 90.6% PPV, and 88.6% NPV for predicting the presence of varices at an optimal cut-off value > 21.1kPa, and 91.7% sensitivity, 88.6% specificity, 80.2 % PPV, and 95.1% NPV for predicting high-risk varices at an optimal cut-off value > 24.6 kPa. No patient with 2dSWE value <20.3 kPa had varices. Conclusion: In patients with compensated cirrhosis, liver stiffness measured by 2D- SWE is an effective non-invasive diagnostic tool for predicting the presence of esophageal varices and high-risk varices. The diagnostic performance of 2D-SWE is similar to that of TE, but better than other non-invasive parameters.

Spleen stiffness measurement based on shear-wave elastography for noninvasive assessment of esophageal varices in liver cirrhosis cases

Background and aim Several laboratory tests and procedures have been considered as noninvasive prediction of esophageal varices (OV). This study assessed the usefulness of shear-wave elastography in splenic stiffness measurement (SSM) as a noninvasive assessment for OV prediction. Patients and methods This study was performed on 100 cases in Sohag Cardiology and Gastroenterology 1Center who were categorized into three groups: group A: (n=40) included liver cirrhosis of any cause proved clinically, laboratory, and by ultrasound; group B: (n=30) included chronic hepatitis of any cause; and group C: (n=30) included nonhepatic cases attending the hospital with gastrointestinal tract complaints. All cases have been subjected to full history taking and clinical examination before classification, complete blood count, alanine aminotransferase, aspartate transaminase, serum albumin, coagulation profile and serum bilirubin, hepatitis C virus antibody (HCV Ab) and hepatitis B surface antigen (HB Ag), abdominal ultrasonography, SSM by shear-wave elastography, and upper endoscopy for diagnosing of OV. Results As regards to abdominal ultrasound and upper endoscopy, significant differences were noted between three groups regarding spleen, spleen diameter, SSM, ascites, and OV (as 27.5 and 65% cases in group I had ascites and OV versus no cases in groups II and III as P&lt;0.001). As regards to spleen diameter and SSM, significant increase was noted in group A than B and C, but insignificant differences were noted among groups B and C. As regards to OV grades in group A, there were five cases with grade I, nine cases with grade II, five cases with grade III, and seven cases with grade IV. Considerable positive correlations were noted among OV grades and acoustic radiation force impulse elastography (r=0.904, P &lt;0.001). Conclusion SSM by shear-wave elastography is a useful noninvasive parameter for detection of OV presence and grading in cases of liver cirrhosis.

Noninvasive predictors of esophageal varices in patients with hepatosplenic schistosomiasis mansoni

Background: No previous study have evaluated transient elastography for predicting esophageal varices in hepatosplenic schistosomiasis.Aim: To investigate noninvasive methods of predicting esophageal varices in patients with hepatosplenic schistosomiasis mansoni.Methods: Cross-sectional multicentric study included 51 patients with hepatosplenic schistosomiasis. Patients underwent ultrasonography-dopplerfluxometry, upper endoscopy, complete blood cell count and transient elastography (Fibroscan®) for liver and spleen stiffness measurement (LSM and SSM). Noninvasive scores previously established for cirrhotic population were studied: platelet count to spleen diameter ratio (PSR), LSM-spleen diameter to platelet ratio score (LSPS) and varices risk score (VRS). We proposed a version of LSPS and VRS by replacing LSM with SSM and named them SSPS and modified-VRS, respectively.Results: Esophageal varices were detected in 42 (82.4%) subjects. Individuals with varices presented higher SSM (73.5 vs 36.3 Kpa, p = 0.001), splenic vein diameter (10.8 vs 8.0 mm, p = 0.017), SSPS (18.7 vs 6.7, p = 0.003) and modified-VRS (4.0 vs 1.4, p = 0.013), besides lower PSR (332 vs 542, p = 0.038), than those without varices. SSPS was independently associated with varices presence (OR=1.19, 95%CI 1.03–1.37, p = 0.020) after multivariate analysis. In a model excluding noninvasive scores, SSM was independently associated with varices diagnosis (OR=1.09, 95%CI 1.03–1.16, p = 0.004). AUROC was 0.856 (95%CI 0.752–0.961, p = 0.001) for SSM and 0.816 (95%CI 0.699–0.932, p = 0.003) for SSPS (p = 0.551).Conclusions: Spleen-related variables were predictors of esophageal varices: SSM, splenic vein diameter, SSPS, modified-VRS and PSR. Multivariate models indicated that SSM and SSPS are useful tools for predicting varices in non-cirrhotic portal hypertension by hepatosplenic schistosomiasis and may be used in clinical practice.

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

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. 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). 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.

A Study on Platelet Count/ Spleen Diameter Ratio and AST/ALT Ratio as a Marker for Detection of Esophageal Varices in Cirrhosis

A Study on Platelet Count/ Spleen Diameter Ratio and AST/ALT Ratio as a Marker for Detection of Esophageal Varices in Cirrhosis

Validation of a standardized CT protocol for the evaluation of varices and porto-systemic shunts in cirrhotic patients

PurposeThe aim of the present study was to propose and validate a standardized CT protocol for evaluating all the types of portosystemic collaterals (P-SC), including gastroesophageal varices and spontaneous portosystemic shunts (SPSS), and to evaluate the prognostic role of portal hypertension CT features for the prediction of the hepatic decompensation risk in cirrhotic patients. MethodsA retrospective cohort study of 184 advanced chronic liver disease who underwent CT scan between January 2014 and December 2017. Patients with an interval > 6 months between the imaging, elastometric, endoscopic and biochemical evaluation were excluded, as well as patients with previous transjugular intrahepatic portosystemic shunt (TIPS), liver transplantation (LT) or terminal medical conditions. Data on liver disease history, co-morbidities, endoscopic and radiologic findings were collected. The incidence of hepatic decompensation and other events, such as portal vein thrombosis, HCC, TIPS placement, LT, death, and its cause, were also recorded.The procedure was performed at baseline and after the administration of contrast agent using a multiphasic technique and bolus tracking. Two senior radiologists working in different centres and a non-expert radiologist reviewed all CT examinations, to evaluate both intra-observer and inter-observer variability of the CT protocol and to obtain an external validation. The radiological variables were evaluated using both univariate and adjusted multivariate competing risk regression models. ResultsBoth intra-observer and inter-observer agreement were excellent in detection and measurement of almost all types of P-SC. The presence of SPSS, a spleen diameter > 16 cm, a portal vein diameter > 17 mm and the presence of ascites resulted independent predictors of decompensation-free survival for cirrhotic patients and were incorporated in an easy-to-use score (AUROC = 0.799, p-value = 0.732) which can the risk of decompensation at 5 years, ranking it as low (11.3%), moderate (35.6%) or high (70.8%). ConclusionsThe CT protocol commonly performed during the HCC surveillance program for cirrhotic patients is valid for detecting all types of P-SC. The radiological score identified to predict the decompensation-free survival for cirrhotic patients could be an easy-to-use clinical tool.

Identification of potential metabolic biomarkers in predicting esophageal varices needing treatment in patients with liver cirrhosis

The goal of this study was to determine the diagnostic performance of in vivo quantitative proton magnetic resonance spectroscopy (1H-MRS) to identify the presence of esophageal varices needing treatment (VNT), as well as investigate its correlation with clinical characteristics in patients with liver cirrhosis. Forty cirrhotic patients without VNT showing the negative red color sign, and 40 cirrhotic patients with VNT showing positive red color sign underwent laboratory tests, esophago-gastro-duodenoscopy, and 1H-MRS with single-voxel localization in the cirrhotic liver parenchyma. The levels of lactate + triglyceride (TG) and choline in cirrhotic patients with VNT were significantly higher than those in cirrhotic patients without VNT. In multivariate analysis, spleen diameter, platelet count, and platelet count/spleen diameter ratio, as well as lactate + TG, and choline were associated with the presence of VNT. Moreover, lactate + TG and choline levels were positively correlated with spleen diameter and negatively correlated with platelet count in the combined group of cirrhotic patients with and without VNT. Our study demonstrated that higher hepatic lactate + TG and choline levels in cirrhotic patients in conjunction with longer spleen diameter, lower platelet counts, and lower ratios of platelet count to spleen diameter were associated with the presence of esophageal VNT and the risk of developing variceal bleeding. Therefore, in vivo 1H-MRS might be an effective tool for diagnosing and predicting esophageal VNT in patients with liver cirrhosis.

Role of Transient Elastography to Stage Fontan-Associated Liver Disease (FALD) in Adults with Single Ventricle Congenital Heart Disease Correction.

Fontan-associated liver disease (FALD) is an arising clinical entity that can occur long after a successful Fontan operation for correction of single ventricle (SV) congenital heart disease (CHD). Occurrence of FALD is characterized by liver cirrhosis and other hepatic complications, and determinates an increased morbidity and mortality. Currently, there is no consensus on how to stage FALD. We report here our experience by an observational study in 52 patients with SV-CHD after Fontan operation that were recruited through a period of 36 ± 9.3 months. All cases underwent lab tests and liver and cardiac imaging evaluation, including liver stiffness (LS) measurement by transient elastography (TE) (FibroScan®). According to selective criteria for liver disease, we identified 23/43 (53.5%) cases with advanced FALD that showed: older age (p < 0.05), larger hepatic and cava veins diameter (p < 0.05), worsened NYHA class (p < 0.05), abnormal lymphocytes (p < 0.01), platelet count (p < 0.05), and GGT, prothrombin time (INR), albumin and cystatin C levels (p < 0.05), with respect to cases without advanced FALD. LS values were significantly increased in cases with advanced FALD, at cut-off values higher than 22 kPa (p < 0.001). LS, and its combined score with spleen diameter and platelet count (LSPS) successfully helped to detect 100% of cases with portal hypertension (p < 0.001). In conclusion, LS can be effective to stage FALD and to uncover cases with severe risk of complications, avoiding higher morbidity and mortality related to advanced FALD.

P-35 NONINVASIVE PREDICTORS OF ESOPHAGEAL VARICES IN PATIENTS WITH HEPATOSPLENIC SCHISTOSOMIASIS MANSONI: MULTICENTER STUDY

No previous study have evaluated transient elastography (TE) for predicting esophageal varices (EV) in hepatosplenic schistosomiasis (HSS). To investigate noninvasive methods of predicting EV in patients with HSS mansoni. Cross-sectional multicentric study included 51 patients with HSS. Patients underwent ultrasonography-dopplerfluxometry, upper endoscopy, complete blood cell count and TE (Fibroscan®) for liver and spleen stiffness measurement (LSM and SSM). Noninvasive scores previously established for cirrhotic population were studied: platelet count to spleen diameter ratio (PSR), LSM-spleen diameter to platelet ratio score (LSPS) and varices risk score (VRS). We proposed a version of LSPS and VRS by replacing LSM with SSM and named them SSPS and modified-VRS, respectively. EV was detected in 42 (82.4%) subjects. Individuals with EV presented higher SSM (73.5 vs 36.3 Kpa, p=0.001), splenic vein diameter (10.8 vs 8.0 mm, p=0.017), SSPS (18.7 vs 6.7, p=0.003) and modified-VRS (4.0 vs 1.4, p=0.013), besides lower PSR (332 vs 542, p=0.038), than those without EV. SSPS was independently associated with EV presence (OR=1.19, 95%CI 1.03-1.37, p=0.020) after multivariate analysis. In a model excluding noninvasive scores, SSM was independently associated with EV diagnosis (OR=1.09, 95%CI 1.03-1.16, p=0.004). AUROC was 0.856 (95%CI 0.752-0.961, p=0.001) for SSM and 0.816 (95%CI 0.699-0.932, p=0.003) for SSPS (p=0.551). Spleen-related variables were predictors of EV: SSM, splenic vein diameter, SSPS, modified-VRS and PSR. Multivariate models indicated that SSM and SSPS are useful tools for predicting EV in non-cirrhotic portal hypertension by HSS and may be used in clinical practice.

Study of the correlation of oesophageal varices with portal vein diameter and ratio of platelet count to splenic diameter and their comparative evaluation in liver cirrhosis

Background: The aim of the study was to determine the correlation of oesophageal varices (OV) with portal vein diameter and the platelet count to splenic diameter ratio and their comparative evaluation in patients of liver cirrhosis.Methods:The present study consisted of 50 patients diagnosed with liver cirrhosis. Necessary investigations were performed in all the patients including Upper gastrointestinal (GI) endoscopy. Platelet count/spleen diameter ratio, spleen diameter and portal vein diameter were calculated for all patients and the presence and grading of OV was then comparatively evaluated. The results were systematically recorded and statistically analysed.Results: The mean age of patients was 49.82±10.23 years. 78% of patients presented with OV. The portal vein diameter, platelet count, spleen diameter and platelet count/spleen diameter ratio were significantly increased in patients with OV than those without OV (p&lt;0.0001). Highly significant positive correlation between portal vein diameter, spleen diameter and grading of OV was seen. Platelet count/spleen diameter ratio and platelet count was significantly decreased as the grade of OV increased in the patients. There was statistically, a highly significant negative correlation between them.Conclusions: The non-invasive parameters used to detect presence of OV in liver cirrhosis were portal vein diameter and platelet count/spleen diameter ratio. Though, both seemed to be effective in predicting OV, platelet count/spleen diameter ratio proved to be slightly more significant when compared to the other.

Value of spleen stiffness measured by two-dimensional shear wave elastography combined with platelet count/spleen diameter ratio in evaluating moderate-to-severe gastroesophageal varices in patients with hepatitis B cirrhosis

Objective To establish a noninvasive diagnostic model for moderate-to-severe gastroesophageal varices (GEV) in patients with hepatitis B cirrhosis. Methods The patients with hepatitis B cirrhosis who attended The First Affiliated Hospital of China Medical University from October 2017 to December 2019 were enrolled, and with the results of gastroscopy as the gold standard, the patients were divided into none-to-mild GEV group and moderate-to-severe GEV group. The Mann-Whitney U test was used for comparison of non-normally distributed continuous data between groups, and the chi-square test was used for comparison of categorical data. A logistic regression analysis was used to investigate the association of moderate-to-severe GEV with spleen stiffness measured by two-dimensional shear wave elastography (2D-SWE) and platelet count (PLT)/spleen diameter ratio in patients with hepatitis B cirrhosis, and with the backward method for independent variable screening, a regression equation, i.e., a diagnostic model, was established and validated. The receiver operating characteristic (ROC) curve was plotted to investigate the diagnostic value of noninvasive examination indices including liver and spleen stiffness, PLT/spleen diameter ratio, and the above diagnostic model and obtain their cut-off values, the DeLong test was used to compare whether there is a statistical significance between the ROC curves of the above noninvasive indices. Results A total of 168 patients with hepatitis B cirrhosis were enrolled, among whom 67 were diagnosed with moderate-to-severe GEV. There were significant differences in PLT, alanine aminotransferase, albumin, white blood cell count, and international normalized ratio between the none-to-mild GEV group and the moderate-to-severe GEV group (Z=-6.508, -2.132, -2.470, -4.510, and -5.298, all P Conclusion The noninvasive diagnostic model based on spleen stiffness measured by 2D-SWE and PLT/spleen diameter ratio can be used to assist the judgment of moderate-to-severe GEV in patients with hepatitis B cirrhosis, with a higher accuracy than liver stiffness or spleen stiffness alone.

Predictors of early rebleeding after endoscopic therapy of first variceal bleeding in liver cirrhosis

BackgroundDespite the great advancement in therapeutic modalities for esophageal varices, early variceal rebleeding still occurs at high rates leading to an exaggeration of the morbidity and mortality for cirrhotic patients, so meticulous follow-up with optimum prediction and proper preventive measures for early variceal rebleeding are mandatory for increasing survival of those patients. In this respect, we evaluated the clinical, laboratory, abdominal ultrasound, and endoscopic criteria of variceal cirrhotic patients as possible risk predictors of early variceal rebleeding after endoscopic control of first variceal bleeding. All included patients were followed up blindly for 12 weeks after endoscopic control of bleeding for ascertainment of first variceal rebleeding. The demographic, clinical, laboratory, abdominal ultrasound, and upper gastrointestinal endoscopic criteria were evaluated for all patients at first admission.ResultsBy univariate regression analysis, the statistically significant predictors for early variceal rebleeding were serum albumin, serum bilirubin, prothrombin concentration, Child-Pugh score, platelet count, spleen diameter, ascites, portal vein diameter and velocity, variceal size, variceal location, and red color sign. By using multivariate regression analysis, the most independent significant predictors were Child-Pugh score (sig: 0.001 and OR: 1.661), platelets count (sig: 0.000 and OR: 0.956), portal vein velocity (sig: 0.000 and OR: 0.664), variceal grading (sig: 0.000 and OR: 3.964), and variceal red color sign (sig: 0.000 and OR: 4.964). We used the multivariate regression coefficients for the significant predictors to build up early variceal rebleeding risk (EVRR) score with a significant discriminatory performance (AUC: 0.965 and sig: 0.000).ConclusionChild-Pugh score, platelet count, portal vein velocity, variceal grading, and variceal red color sign are independent risk predictors for early variceal rebleeding after successful control of first variceal bleeding in cirrhotic patients. Our proposed EVRR score could be helpful for the prediction of early variceal rebleeding in cirrhotic patients after endoscopic control of acute variceal bleeding; however, it should be externally validated in large prospective studies.

Effect of band ligation or combined with tissue adhesive in the treatment of gastroesophageal varices and portal vein blood flow situational changes

42 cases with gastroesophageal varices were prospectively included. The groups were treated with endoscopic band ligation or combined with tissue adhesive. The results showed that the left gastric vein internal diameter, average blood flow velocity and blood flow volume after the treatment of band ligation combined with tissue adhesive were significantly lower than that of the treatment of band ligation alone, and the differences were statistically significant (P < 0.05). Spleen and portal vein internal diameter, blood flow and average velocity, the liver and spleen size, shear wave velocity and liver function grade of the two groups after treatment did not change significantly (P > 0.05). The effective rate of band ligation combined with tissue adhesive in the treatment of esophageal and gastric varices (66.67%, 52.38%) were higher than that of band ligation alone (42.85%, 23.81%) (P > 0.05), and the re-bleeding rate of the latter was higher (9.52% and 19.05%, P > 0.05). Hence, it is suggested that the combined therapy is safe and more effective, and has no apparent effect on liver function and portal hypertension.

Non-invasive laboratory, imaging and elastography markers in predicting varices with high risk of bleeding in cirrhotic patients.

Introduction. Upper digestive tract endoscopy remains the gold-standard for detecting esophageal or gastric varices and assessment of bleeding risk, but this method is invasive. The aim of the study was to identify non-invasive factors that could be incorporated into an algorithm for estimating the risk of variceal bleeding.Methods. A prospective study was performed on 130 cirrhotic patients. Tests were performed on all patients which included liver enzymes, complete blood count and coagulation parameters, abdominal ultrasound, elastography of both the liver and the spleen. Upper gastrointestinal endoscopy was performed in all patients included in the study and the results were classified, in accordance with Baveno VI into 2 outcome groups: Group 1 - patients with low bleeding risk and Group 2 - patients with varices needing treatment.Results. The study lot (130 patients) was divided into: Group I (low bleeding risk - 102 patients), and Group II (high bleeding risk - 28 patients). Parameters found to have significant differences in univariate analysis were transaminases, platelet count, spleen size, INR, portal vein diameter and both liver and spleen elastography. Calculating AUROC for each parameter identifies spleen elastography as having the best result, followed by INR, AST and platelet count. Liver elastography had the worst AUROC. Independent variables identified by logistic regression included spleen elastography, INR, platelet count, spleen diameter, ALT, age, and gender.Conclusions. Spleen stiffness is the best single parameter predicting the presence of high-risk esophageal varices.

Neinvazivní metody v posuzování závažnosti portální hypertenze

Portal hypertension represents a wide spectrum of complications of chronic liver diseases and may present by ascites, oesophageal varices, splenomegaly, hypersplenism, hepatorenal and hepatopulmonary syndrome or portopulmonary hypertension. Portal hypertension and its severity predicts the patient‘s prognosis: as an invasive technique, the portosystemic gradient (HPVG – hepatic venous pressure gradient) measurement by hepatic veins catheterisation has remained the gold standard of its assessment. A reliable, non-invasive method to assess the severity of portal hypertension is of paramount importance; the patients with clinically significant portal hypertension have a high risk of variceal bleeding and higher mortality. Recently, non-invasive methods enabling the assessment of liver stiffness have been introduced into clinical practice in hepatology. Not only may these methods substitute for liver biopsy, but they may also be used to assess the degree of liver fibrosis and predict the severity of portal hypertension. Nowadays, we can use the quantitative elastography (transient elastography, point shear-wave elastrography, 2D-shear-wave elastography) or magnetic resonance imaging. We may also assess the severity of portal hypertension based on the non-invasive markers of liver fibrosis (i.e. ELF test) or estimate clinically signifi cant portal hypertension using composite scores (LSPS – liver spleen stiff ness score), based on liver stiffness value, spleen diameter and platelet count. Spleen stiffness measurement is a new method that needs further prospective studies. The review describes current possibilities of the non-invasive assessment of portal hypertension and its severity.

PLATELET COUNT AND SPLEEN DIAMETER RATIO FOR NON INVASIVE DIAGNOSIS OF ESOPHAGEAL VARICES

BACKGROUND: Portal Hypertension and its consequences mainly, Esophageal Varies (EVs) is one of the most important causes of morbidity and mortality in patients with cirrhosis of liver. Upper GI endoscopy is the investigation of choice for diagnosis of EVs and periodic endoscopies have been recommended for monitoring of varices. There is a need for non-invasive parameters to detect the presence of EVs. Identication of noninvasive predictors of EVs will help us to carry out EGD in selected groups of patients. Unnecessary endoscopies can be avoided and at the same time, patients who require endoscopy can be referred to a higher center, where facilities for endoscopy are available. Among the non-invasive modalities, the platelet count and bipolar spleen diameter ratio has shown promising results in terms of its accuracy in predicting the presence of Esophageal Varices in many studies MATERIALS AND METHODS: Patients with chronic liver disease diagnosed using clinical, Laboratory and ultrasound parameters were assessed using esophagogastroduodenoscopy for the presence or absence of esophageal varices. USG abdomen was done to assess for bipolar splenic diameter and the presence or absence of EV's was correlated with the platelet count/ splenic diameter ratio, CHILD SCORE, MELD score, Platelet count alone and splenic diameter alone. Platelet count/SD ratio of 909 based on previous studies was correlated with the presence or absence of varices. Statistical analysis was done using IBM SPSS software version 20.0 and variables showing statistically signicant correlations with presence of arices were used for plotting ROC curves to assess the cut of points which could be used for non invasive prediction of varices. RESULTS: The PC/SD ratio cut off (909), based on previous studies for non invasive diagnosis of Esophageal Varices gave sensitivity and specicity of 97.9% and 91.7% respectively, in our study, which was statistically signicant (P value &lt;0.001). The positive predicitive value and negative predictive value of the PC/SD ratio (909) was 96.5% and 94.8% respectively and the accuracy of the test was 96%. ROC curve for Platelet count and Splenic diameter ratio area under the curve is 97.8% with P value &lt; 0.001 and cutoff value 895.02 with sensitivity 96.6% and specicity 96.5%. The Positive predictive value and negative predictive value of PC/SD ratio of 895 was found to be 98.6% and 91.8% respectively and the accuracy of the test 96.5%. ROC curve for Child score in our study, area under the curve 71% with a signicant P value &lt; 0.001, and cut-off value obtained for Child score was 8.50 with sensitivity 64.8% and specicity 63.8 %. ROC curve for MELD score revealed area under the curve was 74.3% with P value as &lt; 0.001, and the cut-off value was 15.5 with sensitivity 67.6 % and specicity 67.2%. ROC curve for Platelet count in our study, the area under the curve was 94.5% with P value as &lt; 0.001, and the cut-off value was 108500 with sensitivity and specicity of 89.7% and 89.4% respectively. The ROC curve for Spleen diameter in our study revealed that the area under the curve was 86.8%% with P value as &lt; 0.001, and the cutoff value was 121 with sensitivity and specicity of 78.9% and 81.0% respectively. CONCLUSION: Among the variables studied for non-invasive diagnosis of Esophageal varices, the Platelet count / Spleen diameter ratio had the best sensitivity and specicity for diagnosing EVs. In view of low sensitivities and specicities for the cut off values obtained for Child score, MELD score, platelet count and spleen diameter, these indices may not be useful as PC/SD ratio in the non-invasive prediction of EV's. The Platelet count / Splenic diameter ratio may be proposed as a safe parameter for diagnosing Esophageal Varices in Chronic Liver disease noninvasively, where resources are limited and endoscopy facilities are not available, to select the patients with probable Esophageal Varices who can be referred to higher centres

Validation and comparison of non-invasive prediction models based on liver stiffness measurement to identify patients who could avoid gastroscopy

Several non‐invasive tests (NITs) based on liver stiffness measurement (LSM) have been developed to rule out varices needing treatment (VNT), including the Baveno VI criteria (B6C), the expanded Baveno VI criteria (EB6C), the LSM-spleen diameter to platelet ratio score (LSPS), and the VariScreen algorithm. We aimed to validate and compare those NITs in patients with compensated advanced chronic liver disease (cACLD). This retrospective study enrolled 354 patients with cACLD; LSM, platelet count (PLT), international normalized ratio (INR), gastroscopy and spleen diameter (SD) were collected. VNT prevalence was 28.5%. In comparison, patients with VNT included higher LSM, INR, and SD and lower PLT. Gastroscopies were spared for 27.7% of patients using the B6C with 1.0% VNT missed rate, 47.2% of patients using the EB6C with 5.9% VNT missed rate, 57.6% of patients using the LSPS with 9.9% VNT missed rate, and 45.5% of patients using the VariScreen algorithm with 3.0% VNT missed rate. Only the B6C and the VariScreen algorithm could safely avoid gastroscopies, and the VariScreen algorithm spared more gastroscopies than the B6C. The results were consistent with the previous when performed subgroup analysis. In conclusion, the VariScreen algorithm performed the best and can be used in clinical.

Development and validation of a nomogram for predicting varices needing treatment in compensated advanced chronic liver disease: A multicenter study.

Background:Only a small proportion of patients with compensated advanced chronic liver disease (cACLD) had varices needing treatment (VNT) after recommended esophagogastroduodenoscopy (EGD) screening. We aimed to create a non-invasive nomogram based on routine tests to detect VNT in cACLD patients.Methods:The training cohort included 162 cACLD patients undergoing EGD in a university hospital, between January 2014 and September 2019. A nomogram was developed based on the independent predictors of VNT, selected using a multivariate logistic regression analysis. Thirty-three patients from eight university hospitals were prospectively enrolled as validation cohort between December 2018 and December 2019.Results:The prevalence of VNT was 32.7% (53/162) and 39.4% (13/33) in training and validation cohorts, respectively. The univariate analysis identified six risk factors for VNT. On the multivariate analysis, four of them, i.e., gallbladder wall thickness (odds ratio [OR]: 1.23; 95% confidence interval [CI]: 0.98-1.56), spleen diameter (OR: 1.02; 95% CI: 1.00-1.04), platelet count (OR: 0.98; 95% CI: 0.97-0.99), and international normalized ratio (OR: 0.58; 95% CI: 0.06-5.84) were independently associated with VNT. Thus, a nomogram based on the four above - mentioned variables was developed, and showed a favorable performance for detecting VNT, with an area under receiver operating characteristic curve of 0.848 (95% CI: 0.769-0.927) in training cohort. By applying a cut-off value of 105 in validation cohort, 31.0% of EGD were safely spared with 3.4% of missed VNT.Conclusion:A nomogram based on routine clinical parameters was developed for detecting VNT and avoiding unnecessary EGD in cACLD patients.

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