Platelet Count/spleen Diameter Ratio: a Noninvasive Parameter to Predict the Presence of Esophageal Varices

Abstract

Introduction: Variceal bleeding is one of the most dreaded complications of cirrhosis because of its attendant high mortality. The prevalence of varices in patients with cirrhosis is approximately 6080% and the risk of bleeding is 25-35%. Incidence of first variceal hemorrhage ranges from 20 to 40% within 2 years. Recurrent bleeding occurs in 30% to 40% of patients within the next 2 to 3 days and in up to 60 % within 1 week. Thus, prevention of esophageal variceal bleeding remains at the forefront of long-term management of cirrhotic patients. However, subjecting all patients with cirrhosis to screening endoscopy may not be cost effective. If patients at low or high risk of having esophageal varices (EV) could be identified from easily obtainable clinical variables, a more affordable approach for screening would be possible. The study was conducted to identify clinical, biochemical and ultrasonographic parameters associated with the presence of esophageal varices in patients with compensated cirrhosis. Methodology: This is a cross-sectional study of patients aged 20-84 y/o admitted at the FEU-NRMF Medical Center and the Chinese General Hospital between January 2002 to July 2004 with a diagnosis of cirrhosis based on clinical, biochemical, and/or histopathological data. All patients underwent a complete biochemical work-up, gastroscopy and ultrasonographic measurement of spleen bipolar diameter. Platelet count/spleen diameter ratio was calculated for all patients, tabulated and analyzed. Results: 150 patients underwent blood extractions, ultrasound and upper endoscopy. The prevalence rate of EV was 46%. In the study, the authors found out that age, sex, protime, platelet/spleen diameter ratio, platelet count and spleen diameter were significantly different among patients with or without esophageal varices (NEV), although the platelet count/spleen diameter ratio was the only parameter which was independently associated with the presence of EV in a univariate analysis. A platelet count/spleen diameter ratio cut off value of <160 was highly predictive in the diagnosis EV with a sensitivity of 88.4% (95% CI, 77.9, 94.5) and specificity of 80.2% (95% CI 69.6, 88). Positive and negative predictive values were 79.2% (95% CI 68.2, 87.3) and 89% (95% CI 79, 94.8), respectively. INTRODUCTION Chronic liver disease generally progresses slowly from hepatitis to cirrhosis, often over 20 to 40 years. Some forms of liver disease are nonprogressive or only slowly progressive. Other, more severe forms are associated with scarring and architectural disorganization, which, if advanced, lead to cirrhosis. The scarring causes increased resistance to blood flow through the portal vein leading to ascites, esophageal varices, and increased risk of infection. Portal hypertension, a common complication of cirrhosis, results in the development of collaterals to bypass the increased resistance to flow within the portal bed to return blood to the systemic circulation. Gastrointestinal bleeding is the most severe complication of portal hypertension, and esophageal and gastric varices are by far the most common sources of bleeding in these patients. Thirty percent of patients with compensated cirrhosis and 60% of patients with decompensated cirrhosis have gastroesophageal varices at the time of presentation. Mortality is highest in the first 5 days after the index episode of variceal bleeding and returns to baseline levels by 3 to 4 months. This is the critical window for optimal treatment to improve the survival of variceal bleeders. The rate of early rebleeding translates into an increased risk of mortality. It appears that the rate of growth of varices from small to large in compensated cirrhotic patients is faster than the rate of de novo appearance of varices. Therefore, the presence of esophageal varices (EV) is considered a prognostic indicator and a factor affecting the morbidity and mortality of surgical procedures. The American College of Gastroenterology (ACG) recommends endoscopic screening to detect varices in patients with cirrhosis with no previous variceal hemorrhage. If initial endoscopy shows no varices, the examination should be repeated at 2-3 year intervals and at 12 year intervals in patients with small varices so as to evaluate its development or progression. In order to reduce the increasing burden of invasive procedures, some studies have attempted to identify noninvasive parameters to predict the presence of esophageal varices. Overall, the most common finding of these studies was that parameters directly linked to portal hypertension such as splenomegaly and decreased platelet count were predictors of the presence of esophageal varices. In patients with chronic liver disease, several factors other than portal hypertension such as myelotoxic effects of alcohol or hepatitis, shortened platelet mean lifespan and decreased thrombopoietin production may decrease platelet count. On the other hand, the presence of splenomegaly in cirrhotic patients is likely the result of vascular disturbance. The study was conducted to determine the association of esophageal varices and platelet count/spleen diameter ratio in patients with compensated cirrhosis. METHODOLOGY This is a cross-sectional study of patients with a diagnosis of cirrhosis based on clinical, biochemical, and/or histopathological data to determine the association of esophageal varices and platelet count/spleen diameter ratio. The study group consisted of patients aged 20-84 years old diagnosed to have cirrhosis who were admitted at the FEU Medical Center or the Chinese General Hospital from January 2002 to July 2004. Patients were asked to sign an informed consent prior to enrollment in the study. Patients were excluded if they had any of the following; 1. hepatocellular carcinoma detected by ultrasonography and/or elevated alpha-feto protein (more than 10 times the upper normal limit of normal) 2. primary hematologic disorders 3. active gastrointestinal bleeding on admission 4. previously known gastrointestinal bleeding 5. taking drugs for primary prophylaxis of variceal bleeding 6. taking alcohol less than 6 months before enrollment 7. history of parenteral drug addiction 8. history of sclerosis or band ligation, transPlatelet Count/Spleen Diameter Ratio 34

Cite this paper

@inproceedings{Legasto2006PlateletCD, title={Platelet Count/spleen Diameter Ratio: a Noninvasive Parameter to Predict the Presence of Esophageal Varices}, author={Grace Marie A Legasto and Judy Sevilla and Angelito Balay and Jose Antonio R. Tan and Lirio V Cham and Arnold Vitug}, year={2006} }