Prediction of Esophageal Varices in Patients With Cirrhosis

Madhotra, Ravi; Mulcahy, Hugh; Willner, Ira; Reuben, Adrian

doi:10.1097/00004836-200201000-00016

Cited by 206 publications

(172 citation statements)

References 28 publications

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“…It may be explained according to the issue that palpable spleen as well as LEV may both be related to the presence of a higher portal pressure. Different factors found to be important for this purpose included splenomegaly [23][24][25][26][27][28] , thrombocytopenia [23][24][25][26][27][28][29][30] , ascites [25,27] , hepatic encephalopathy [25] , serum albumin concentration [30] , serum bilirubin levels [30] , and Child-Pugh score [27,28] . Thus, the results of our study are consistent with those of the previously published data.…”

Section: Resultsmentioning

confidence: 99%

Portal hemodynamics as predictors of high risk esophageal varices in cirrhotic patients

Tarzamni¹,

Somi²,

Farhang³

et al. 2008

WJG

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AIM:To evaluate portal hypertension parameters in liver cirrhosis patients with and without esophageal varices (EV). METHODS:A cohort of patients with biopsy confirmed liver cirrhosis was investigated endoscopically and with color Doppler ultrasonography as a possible noninvasive predictive tool. The relationship between portal hemodynamics and the presence and size of EV was evaluated using uni-and multivariate approaches. RESULTS:Eighty five consecutive cirrhotic patients (43 men and 42 women) were enrolled. Mean age (± SD) was 47.5 (± 15.9). Portal vein diameter (13.88 ± 2.42 vs 12.00 ± 1.69, P < 0.0005) and liver vascular index (8.31 ± 2.72 vs 17.8 ± 6.28, P < 0.0005) were found to be significantly higher in patients with EV irrespective of size and in patients with large varices (14.54 ± 1.48 vs 13.24 ± 2.55, P < 0.05 and 6.45 ± 2.78 vs 10.96 ± 5.05, P < 0.0005, respectively), while portal vein flow velocity (13.25 ± 3.66 vs 20.25 ± 5.05, P < 0.0005), congestion index (CI) (0.11 ± 0.03 vs 0.06 ± 0.03, P < 0.0005), portal hypertensive index (2.62 ± 0.79 vs 1.33 ± 0.53, P < 0.0005), and hepatic (0.73 ± 0.07 vs 0.66 ± 0.07, P < 0.001) and splenic artery resistance index (RI) (0.73 ± 0.06 vs 0.62 ± 0.08, P < 0.0005) were significantly lower. A logistic regression model confirmed spleen size (P = 0.002, AUC 0.72) and portal hypertensive index (P = 0.040, AUC 0.79) as independent predictors for the occurrence of large esophageal varices (LEV). CONCLUSION:Our data suggest two independent situations for beginning endoscopic evaluation of compensated cirrhotic patients: Portal hypertensive index > 2.08 and spleen size > 15.05 cm. These factors may help identifying patients with a low probability of LEV who may not need upper gastrointestinal endoscopy.

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Section: Resultsmentioning

confidence: 99%

Portal hemodynamics as predictors of high risk esophageal varices in cirrhotic patients

Tarzamni¹,

Somi²,

Farhang³

et al. 2008

WJG

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“…[14][15][16][17][18] Three of the four studies with higher sensitivities had poor specificity. In a study by Madhotra et al, 17 Fig. 4.…”

Section: Discussionmentioning

confidence: 98%

“…Platelet counts (PLT) from 68,000 to 160,000 have shown sensitivities ranging from 71% to 88% for small varices. [14][15][16][17][18] The sensitivities for large varices are better but with unsatisfactory specificities. However, many of these studies were crosssectional and were limited by the variability and severity of the liver disease.…”

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confidence: 99%

Platelet count is not a predictor of the presence or development of gastroesophageal varices in cirrhosis

et al. 2008

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Current guidelines recommend esophagogastroduodenoscopy (EGD) in patients with cirrhosis to screen for gastroesophageal varices (GEV). Thrombocytopenia has been proposed as a noninvasive test to predict the presence of GEV. There is no agreement regarding a specific platelet count (PLT) that can reliably predict GEV. The present longitudinal study aims to (1) further investigate the relationship between varices and PLT at the time of endoscopy, (2) investigate whether changes in PLT from the baseline over time can predict the development of GEV, and (3) investigate whether changes in PLT correlate with the hepatic venous pressure gradient (HVPG). A secondary analysis was conducted for 213 subjects with compensated cirrhosis with portal hypertension but without GEV enrolled in a randomized, placebo-controlled, double-blind trial of a nonselective beta-blocker used to prevent GEV. PLTs were obtained every 3 months, and HVPG measurements and EGD were done annually. The PLTs were compared between subjects who did and did not develop GEV. In a median follow-up of 54.9 months, 84 patients developed GEV. PLT was greater than 150,000 in 15% of patients at the development of GEV. A receiver operating curve did not show any PLT with high sensitivity or specificity for the presence of GEV. Subjects with clinically insignificant portal hypertension (HVPG < 10 mm Hg) whose PLT remained greater than 100,000 had a 2-fold reduction in the occurrence of GEV (P ‫؍‬ 0.0374). A significant correlation was found between HVPG and PLT at the baseline, year 1, and year 5 (P < V ariceal hemorrhage is a leading cause of morbidity and mortality in cirrhosis. 1-3 Primary prophylaxis with nonselective beta-blockers and endoscopic therapy with band ligation are effective in preventing variceal hemorrhage in patients with large varices. 1 Current guidelines recommend screening for gastroesophageal varices (GEV) with esophagogastroduodenoscopy (EGD) in all patients with cirrhosis and starting prophylactic therapy in those with medium to large varices. [4][5][6][7] In patients without varices, EGD is repeated in 2-3 years, whereas in patients with small varices, the recommendation is to repeat EGD in 1-2 years. 2 Because of the cost and invasive nature of endoscopic screening, there is interest in developing a noninvasive predictor of the presence and development of GEV that would decrease the number of EGDs performed. The ideal noninvasive marker should be widely available at a reasonable cost, require minimal expertise, be reproducible, and be relatively unaffected by any other factors. A number of clinical, laboratory, and ultrasonographic variables have been considered. 8 However, the accuracy of these variables in predicting varices is currently inadequate to be recommended for clinical practice. 2 As varices are a direct consequence of portal hypertension, it is not surprising that the degree of portal hypertension determined by the hepatic venous pressure gradient (HVPG) has been found to be predictive of the

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“…Several studies (13)(14)(15)(16)(17)(18)(19) have shown that platelet count and spleen diameter correlate well with the presence of EVs. However, in patients with chronic liver disease, the presence of a decreased platelet count may depend on several factors other than portal hypertension, such as shortened mean platelet lifetime, decreased thrombopoietin production or myelotoxic effects of alcohol or hepatitis viruses (20).…”

Section: Discussionmentioning

confidence: 99%

Platelet Count to Spleen Diameter Ratio for the Diagnosis of Esophageal Varices: Is It Feasible?

Baig

Nagaraja

Varma

et al. 2008

Canadian Journal of Gastroenterology

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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.

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Prediction of Esophageal Varices in Patients With Cirrhosis

Cited by 206 publications

References 28 publications

Portal hemodynamics as predictors of high risk esophageal varices in cirrhotic patients

Portal hemodynamics as predictors of high risk esophageal varices in cirrhotic patients

Platelet count is not a predictor of the presence or development of gastroesophageal varices in cirrhosis

Platelet Count to Spleen Diameter Ratio for the Diagnosis of Esophageal Varices: Is It Feasible?

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