Background: Esophageal varices (EVs) are serious consequences of liver cirrhosis. Several studies have evaluated the possible non-invasive markers for the diagnosis of EVs to reduce the number of endoscopic procedures in patients with cirrhosis but without varices. This study was performed to evaluate the diagnostic performance of two such parameters (platelet count to splenic diameter ratio and splenoportal index) for the detection of EVs. Materials and Methods: A total of 111 patients with liver cirrhosis were analyzed after performing upper gastrointestinal endoscopy and non-invasive tests including platelet count and ultrasound abdomen including Doppler study. Appropriate statistical tests were applied to compare the non-invasive tests with the gold standard of endoscopy. Results: Of 111 liver cirrhotics, 80 (72.1%) were male and 31 (27.9%) were female. EVs were present in 68 (61.3%) patients and absent in 43 (38.7%) patients. In platelet count to splenic diameter ratio, a cut-off value of 1014 was obtained, which gave a sensitivity of 75.0%, specificity of 65.1%, positive predictive value (PPV) of 77.3%, negative predictive value (NPV) of 62.2% and diagnostic accuracy of 71.2%. In the splenoportal index, a cut-off value of 3.5 cm/s was obtained, which gave a sensitivity of 79.4%, specificity of 72.0%, PPV of 81.8%, NPV of 68.8% and diagnostic accuracy of 76.5% for the diagnosis of EVs. Conclusions: The platelet count to spleen diameter ratio and splenoportal index are non-invasive and fairly accurate alternatives in identifying the presence or absence of EVs in patients with compensated cirrhosis.
1. Schepis F, Camma C, Niceforo D, Magnano A, Pallio S, Cinquegrani M, et al. Which patients with cirrhosis should undergo endoscopic screening for esophageal varices detection? Hepatology 2001;33:333-8.
2. D’Amico G, Luca A. Natural history. Clinical-hemodynamic correlations. Prediction of the risk of bleeding. Bailliere’s Clin Gastroenterol 1997;11:243-56.
3. Giannini E, Botta F, Borro P, Risso D, Romagnoli P, Fasoli A, et al. Platelet count/spleen diameter ratio: Proposal and validation of noninvasive parameter to predict the presence of oesophageal varices in patients with liver cirrhosis. Gut 2003;52:1200-5.
4. The Northern Italian Endoscopic Club for the Study and Treatment of Esophageal Varices. Prediction of the first variceal hemorrhage in patients with cirrhosis of the liver and esophageal varices: A prospective multicenter study. N Engl J Med 1988;319:983-9.
5. Chalasani N, Imperiale TF, Ismail A, Sood G, Carey M, Wilcox CM, et al. Predictors of large esophageal varices in patients with cirrhosis. Am J Gastroenterol 1999;94:3285-91.
6. Grace ND, Groszman RJ, Tsao GG, Burroughs AK, Pagliaro L, Makuch RW, et al. Portal hypertension and variceal bleeding: An AASLD single topic symposium. Hepatology 1998;28:868-80.
7. de Franchis R. Evolving consensus in portal hypertension report of the Baveno IV consensus workshop on methodology of diagnosis and therapy in portal hypertension. J Hepatol 2005;43:167-76.
8. Spiegel BM, Targownik L, Dulai GS, Karsan HA, Gralnek IM. Endoscopic screening for esophageal varices in cirrhosis. Is it ever cost effective? Hepatology 2003;37:366-77.
9. Arguedas MR, Heudebert GR, Eloubeidi MA, Abrams GA, Fallon MB. Cost-effectiveness of screening, surveillance and primary prophylaxis strategies for esophageal varices. Am J Gastroenterol 2002;97:2441-52.
10. Amico GD, Morabito A. Noninvasive markers of esophageal varices: Another round, not the last. Hepatology 2004;39:30-4.
11. Pilette C, Oberti F, Aube C, Rousselet MC, Bedossa P, Gallois Y, et al. Non-invasive diagnosis of esophageal varices in chronic liver diseases. J Hepatol 1999;31:867-73.
12. Madhotra R, Mulcahy HE, Willner I, Reuben A. Prediction of esophageal varices in patients with cirrhosis. J Clin Gastroenterol 2002;34:81-5.
13. Thomopoulos KC, Labropoulou-Karatza C, Mimidis KP, Katsakoulis EC, Iconomou G, Nikolopoulou VN. Non-invasive predictors of the presence of large esophageal varices in patients with cirrhosis. Dig Liver Dis 2003;35:473-8.
14. Amarapurkar DN, Parikh SS, Shankaran K, Chopra K, Dhawan P, Kalro RH, et al. Correlation between splenomegaly and oesophageal varices in patients with liver cirrhosis. Endoscopy 1994;26:563.
15. Chalasani N, Imperiale TF, Ismail A, Sood G, Carey M, Wilcox CM, et al. Predictors of large esophageal varices in patients with cirrhosis. Am J Gastroenterol 1999;94:3285-91.
16. Zaman A, Becker T, Lapidus J, Benner K. Risk factors for the presence of varices in cirrhotic patients without a history of variceal hemorrhage. Arch Intern Med 2001;161:2564-7.
17. Sharma SK, Aggarwal R. Prediction of large esophageal varices in patients with cirrhosis of the liver using clinical, laboratory and imaging parameters. J Gastroenterol Hepatol 2007;22:1909-15.
18. Giannini EG, Zaman A, Kreil A, Floreani A, Dulbecco P, Testa E, et al. Platelet count/spleen diameter ratio for the noninvasive diagnosis of esophageal varices: Results of a multicenter, prospective, validation study. Am J Gastroenterol 2006;101:2511-9.
19. Khan H, Iman NU. Hypoalbuminemia: A marker of oesophageal varices in chronic liver disease due to hepatitis B and C. Rawal Med J 2009;34:98-101.
20. Javed IF, Hameed A, Qazi I, Farooq A, Masoodur R. Predictors of esophageal varices in patients of liver cirrhosis. J Postgrad Med Inst 2007;21:60-4.
21. Gill ML, Atiq M, Sattar S, Khokhar N. Non-endoscopic parameters for the identification of Esophageal Varices in patients with chronic hepatitis. J Pak Med Assoc 2004;54:575-7.
22. Muhammad K, Naveed YK, Muhammad A, Mian MA, Hamamatul BK, Zubai H, et al. Association of platelet count to splenic index ratio with presence of esophageal varices in patients with hepatitis C virus related compensated cirrhosis. Pak J Gastroenterol 2006;20:37-42.
23. Shahid S, Altaf A, Anwaar AK, Arshad KB, Farzana S, Waqar Hassan S, et al. Platelet count / spleen diameter ratio: Can it predict the presence of varices in patients with cirrhosis of liver? Proc Shaikh Zayed Postgrad Med Inst 2004;18:21-6.
24. Sethar GH1, Ahmed R, Rathi SK, Shaikh NA. Platelet count/splenic size ratio. A parameter to predict the presence of esophageal varices in cirrhotics. J Coll Physicians Surg Pak 2006;16:183-6.
25. Liu CH, Hsu SJ, Liang CC, Tsai FC, Lin JW, Liu CJ, et al. Esophageal varices: noninvasive diagnosis with duplex US in patients with compensated cirrhosis. Radiology 2008;248:132-9.
26. Zimbwa TA, Blanshard C, Subramaniam A. Platelet count/spleen diameter ratio as a predictor of oesophageal varices in alcoholic cirrhosis. Gut 2004;53:1055.
27. Baig WW, Nagaraja MV, Varma M, Prabhu R. Platelet count to spleen diameter ratio for the diagnosis of esophageal varices: Is it feasible? Can J Gastroenterol 2008;22:825-8.
28. Agha A, Anwar A, Bashir K, Savarino E, Giannini EG. External validation of the platelet count/spleen diameter ratio for the diagnosis of esophageal varices in hepatitis C virus-related cirrhosis. Dig Dis Sci 2009;54:654-60.
29. Sarangapani A, Shanmugam C, Kayanasundaram M, Rangachari B, Thangavelu P, Subbarayan JK. Noninvasive prediction of large esophageal varices in chronic liver disease patients. Saudi J Gastroenterol 2010;16:38-42.
30. Zaman A, Hapke R, Flora K, Rosen HR, Benner K. Factors predicting the presence of esophageal or gastric varices in patients with advanced liver disease. Am J Gastroenterol 1999;94:3292-6.
31. Finn JP, Kane RA, Edelman RR, Jenkins RL, Lewis WD, Muller M, et al. Imaging of the portal venous system in patients with cirrhosis: MR angiography vs duplex Doppler sonography. AJR Am J Roentgenol 1993;161:989-94.
32. Gines P, Quintero E, Arroyo V, Terés J, Bruguera M, Rimola A, et al. Compensated cirrhosis: Natural history and prognostic factors. Hepatology 1987;7:122-8.
33. D’Amico G, Morabito A, Pagliaro L, Marubini E. Survival and prognostic indicators in compensated and decompensated cirrhosis. Dig Dis Sci 1986;31:468-75.
34. Grace ND. Prevention of initial variceal hemorrhage. Gastroenterol Clin North Am 1992;21:149-61.
35. Smith JL, Graham DY. Variceal hemorrhage: A critical evaluation of survival analysis. Gastroenterology 1982;82:968-73.
36. Graham DY, Smith JL. The course of patients after variceal hemorrhage. Gastroenterology 1981;80:800-9.
37. Ripoll C, Groszmann R, Garcia-Tsao G, Grace N, Burroughs A, Planas R, et al. Hepatic venous pressure gradient predicts clinical decompensation in patients with compensated cirrhosis. Gastroenterology 2007;133:481-8.
38. Garcia-Tsao G, Bosch J, Groszmann RJ. Portal hypertension and variceal bleeding - unresolved issues. Summary of an American Association for the Study of Liver Diseases and European Association for the Study of the Liver single-topic conference. Hepatology 2008;47:1764-72.
39. Sarin SK, Selhi KK, Nanda R. Measurement and condition of wedged hepatic, intrahepatic, intrasplenic and intravariceal pressures in patients with cirrhosis of the liver and non-cirrhotic portal fibrosis. Gut 1987;28:260-6.
40. de Franchis R. Evolving consensus in portal hypertension. Report of the Baveno IV consensus workshop on methodology of diagnosis and therapy in portal hypertension. J Hepatol 2005;43:167-76.
41. Madhotra R, Mulcahy HE, Willner I, Reuben A. Prediction of esophageal varices in patients with cirrhosis. J Clin Gastroenterol 2002;34:81-5.
42. Watanabe S, Hosomi N, Kitade Y, Kurokohchi K, Arima K, Kawabata H, et al. Assessment of the presence and severity of esophagogastric varices by splenic index in patients with liver cirrhosis. J Comput Assist Tomogr 2000;24:788-94.
43. Iwao T, Toyonaga A, Oho K, Tayama C, Masumoto H, Sakai T, et al. Value of Doppler ultrasound parameters of portal vein and hepatic artery in the diagnosis of cirrhosis and portal hypertension. Am J Gastroenterol.1997;92:1012-17.