AIM: To study the value of platelet count to spleen diameter ratio as a noninvasive parameter for diagnosing esophageal varices (EVs) in liver cirrhosis.METHODS: The laboratory and ultrasonographic variables were prospectively evaluated in 150 patients with liver cirrhosis. Only stable patients were included in the study. Patients with active gastrointestinal bleeding at the time of admission were excluded. All patients underwent screening upper gastrointestinal endoscopy.RESULTS: The platelet count, spleen diameter and platelet count to spleen diameter ratio in patients with EVs were significantly different from patients without EVs. The platelet count to spleen diameter ratio had the highest accuracy among the three parameters. By applying receiver operating characteristic curves, a platelet count to spleen diameter ratio cut-off value of 1014 was obtained, which gave positive and negative predictive values of 95.4% and 95.1%, respectively. The accuracy of this cut-off value as evaluated by applying receiver operating characteristic curves was 0.942 (95% CI 0.890 to 0.995).CONCLUSION: Among the noninvasive parameters studied, platelet count to spleen diameter ratio had the highest accuracy for diagnosing EVs. However, the evidence for the noninvasive diagnosis is not yet sufficient to replace endoscopy as a diagnostic screening tool for EVs in all cirrhotic patients. The platelet count to spleen diameter ratio may be a useful tool for diagnosing EVs in liver cirrhosis noninvasively when endoscopy facilities are not available.

We report two cases of Pure Red Cell Aplasia (PRCA) associated with plasma cell dyscrasia. The first case is of an elderly woman with PRCA and light chain disease (LCD)/multiple myeloma (MM). She received multiple blood transfusions and was refractory to conventional therapies. Subsequent bortezomib therapy resulted in symptomatic improvement and normalization of her bone marrow and transfusion independence. This unique case of LCD/MM and PRCA treated with bortezomib induced long lasting remission of myeloma and resulted in reversal of PRCA and hence transfusion independence. This novel therapy is useful in elderly patients even with a high tumour burden of multiple myeloma. PRCA can also be associated in patients with low tumour bulk plasma cell disorders such as Monoclonal Gammopathy of Uncertain Significance (MGUS) as evidenced by the second case. Combination of prednisolone and oral cyclophosphamide therapies controlled her anemia. Hence, a tailored therapy approach is recommended. Furthermore, patients with PRCA would benefit from thorough investigation to exclude plasma cell disorders.

In this study there were 68 males and 32 females. Peak incidence by age was in the fifth decade. There was no increased mortality in any age group (p = 0.278). A total of 19 patients had pre-renal ARF, 74 patients had intrinsic ARF, of which 46 were acute tubular necrosis (ATN); 7 patients had obstructive ARF. A total of 21 patients had Liano score greater than 0.9, of which 18 patients died and 3 were discharged against medical advice in a critical condition (and died later at home). Calculated sensitivity was 62.1%, specificity was 100% and positive predictive value was 100%. Sensitivity and specificity when calculated separately for intrinsic renal ARF (after excluding post renal ARF) were 60.7% and 100%, respectively. There was statistically significant correlation between Liano score and mortality (p < 0.001).

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