A Non-Invasive Simple And New Marker Predicting Esophageal Varices In Cirrhotic Patients: Platelet Count/ Spleen Size Ratio
Öz
Introduction and Aim: Esophageal varices are a serious consequence
of portal hypertension in patients with liver cirrhosis. Endoscopy is the most commonly
used method for the evaluation of esophageal varices. The aim of this study is
to evaluate non- invasive predictors of presence and size of esophageal varices
in chronic hepatitis B or C positive liver cirrhosis patients.
Material and Methods: 324 cirrhotic patients with hepatitis B
or C who applied to Gastroenterology clinic of Gaziantep University between the
years of 2009-2015 were included in the study. Demographic, clinical,
laboratory, radiological (spleen size, portal veindiameter, portal flow), and endoscopic
(presence and size of esophageal varices) findings were obtained from the patients
files as retrospectively. The relationship between presence of varices and laboratory/radiological
findings were assessed.
Results: A total of 324 patients were included.
The mean age was 57.4±11.2 years; 178 (54.9%) were men, and 146 (45.1%) women.
164 patients were chronic hepatitis B related cirrhosis and 160 were chronic hepatitis
C related cirrhosis. Esophageal varices were present in 255 (78,7%) patients and
in 69 patients (21.3%) had no esophageal varices. Out of 255 patients, 97
(29.9%) had grade 1, 129 (%39.8) grade 2, 29 (%9) grade 3 varices. Spleen size,
portal vein diameters, platelet count and platelet count/spleen size ratio had statistically
significant difference in varices group when compared with the non-varix group
(p=0001). In the estimation of varices; cut off value of platelet count/spleen size ratio was found as ≤846 with sensitivity of 90 %, and specificity
of 91 %, positive and negative predictive values of 97,4% and 71,5%,
respectively.
Conclusion:The ratio of platelet count / spleen
size as a parameter with high sensitivity and specificity which can predict the
presence of esophageal varices in patients with cirrhosis,
can be used as a new and non-invasive marker.
Anahtar Kelimeler
Kaynakça
- 1. Popper H. Pathologicaspects of cirrhosis. Am J Pathol. 1977;87(1):228-264.
- 2.Sherlock S, Dooley J. Hepaticcirrhosis. In: Disease of the liver disease and biliary system. 2th ed, London, Blackwell scientific pub. 2002;371.
- 3.Graham DY, Smith JL. The course of patients after variceal hemorrhage. Gastroenterology 1981;80:800-809.
- 4. De Franchis R, on behalf of the Baveno V Faculty. Revising consensus in portal hypertension: report of the Baveno V consensus workshop on methodology of diagnosis and therapy in portal hypertension. J Hepatol. 2010;53:762-768.
- 5. Wyllie R, Kay M. Esophagogastroduodenoscopy, colonoscopy and related techniques. In: Pediatric gastrointestinal disease. Wyllie R, Hyams JS (eds). Philadelphia, Saunderscompany. 1993;966-998.
- 6. Giannini E, Zaman A, Kreil A, Floreani A, Dulbecco P, Testa E, et al. Platelet count/ spleen diameter ratio for the non invasive diagnosis of esophageal varices: results of a multicenter, prospective, validation study. Am J Gastroenterol. 2006;101:2511-2519.
- 7. Kazemi F, Kettaneh A, N’kontchou G, Pinto E, Ganne-Carrie N, Trinchet JC, et al. Liver stiffness measurement selects patients with cirrhosis at risk of bearing large oesophageal varices. J Hepatol. 2006;45:230-235.
- 8. Perri RE, Chiorean MV, Fidler JL, Fletcher JG, Talwalkar JA, Stadheim L, et al. A prospective evaluation of computerized tomographic (CT) scanning as a screening modality for esophageal varices. Hepatology. 2008;47:1587-1594.
- 9. Schuppan D, Afdhal NH, Liver cirrhosis. Lancet. 2008;371:838-851.
- 10. Giannini E, Botta F, Borro P, Risso D, Romagnoli P, Fasoli A, et al. Platelet count/spleen diameter ratio: proposal and validation of a non-invasive parameter of oesophageal varices in patients with liver cirrhosis. Gut. 2003;52:1200-1205.
- 11. Garceau AJ, Chalmers TC. The Boston Inter-Hospital Liver Group. The natural history of cirrhosis: I. Survival with oesophageal varices. N Eng J Med. 1963;268:469-473.
- 12. Graham D, Smith JL. The course of patients after variceal hemorrhage. Gastroenterology. 1981;80;800-809.
- 13. Memik F,Dolar E. Karaciğer sirozu. Klinik gastroenteroloji Nobel &GuneşTıp Kitabevleri 2005; 626-33.
- 14. Schepis F, Cammà C, Niceforo D, Magnano A, Pallio S, Cinquegrani M, et al. Which patients should undergo endoscopic screening for oesophageal varices detection? Hepatology. 2001;33:333-338.
- 15. Mifune H, Akaki S, Ida K, Sei T, Kanazawa S, Okada H. Evaluation of esophageal varices by multidetector-row CT: correlation with endoscopic 'red color sign'. Acta Med Okayama. 2007;61(5):247-254.
- 16. Carbonell N, Pauwels A, Serfaty L, Fourdan O, Lévy VG, Poupon R. Improved survival after variceal bleeding in patients with cirrhosis over the past two decades. Hepatology. 2004;40(3):652-659.
- 17. Patriquin H, Lafortune M, Burns P, Dauzat M. Duplex doppler examination in portal hypertension: technique and anatomy. AJR 1987;149:71-77.
- 18. D’Amico G, Garcia-Tsao G, Cale`s P, Escorsell A, Nevens F, Cestari R, et al. Diagnosis of portal hypertension: How and when. In: De Franchis R, ed. Proceedings of the Third Baveno International Consensus Workshop on Definitions, Methodology and Therapeutic Strategies. Oxford: Blackwell-Science, 2001:36-63.
- 19. Berzigotto A, Gilabert R, Abraldes JG, Nicolau C, Bru C, Bosch J, et al. Noninvasive prediction of clinically significant portal hypertension and esophageal varices in patients with compensated liver cirrhosis. Am J Gastroenterol. 2008;103:1159-1167.
- 20. Garcia-Tsao G, Sanyal AJ, Grace ND, Carey W. The Practice Guidelines Committee of the American Association for the Study of Liver Diseases, the Practice Parameters Committee of the American College of Gastroenterology. Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis. Hepatology. 2007;46:922-938.
- 21. D’Amico G, de Franchis R and a cooperative study group: Upper digestive bleeding in cirrhosis: post-therapeutic outcomes and prognostic indicators. Hepatology. 2003;38:599–612.
- 22. Tarzamni MK, Somi MH, Farhang S, Jalilvand M. Portal hemodynamics as predictors of high risk esophageal varices in cirrhotic patients. World J Gastroenterol. 2008;14(12):1898-1902.
- 23. Mangone M, Moretti A, Alivernini F, Papi C, Orefice R, Dezi A, et al. Platelet count/ spleen diameter ratio for non-invasive diagnosis of oesophageal varices: is it useful in compensated cirrhosis? Dig Liver Dis. 2012;44(6):504-507.
- 24. Shastri M, Kulkarni S, Patell R, Jasdanwala S. Portal veinDoppler: a tool for non-invasive prediction of esophageal varices in cirrhosis. J Clin Diagn Res. 2014;8(7):12-25.
- 25. Sheth S, Flamm SL, Gordon FD. AST/ALT ratio predicts cirrhosis in patients with chronic hepatitis C virus infection. Am J Gastroenterol. 1998;93:44-48.
- 26. Dib N, Konate A, Oberti F, Cales P. Non-invasivediagnosis of portal hypertension in cirrhosis. Application to the primary prevention of varices. Gastroenterol Clin Biol. 2005;29:975-987.
- 27. Sarwar S, Khan AA, Alam A, Butt AK, Shafqat F, Malik K, et al. Non-endoscopic prediction of presence of esophageal varices in cirrhosis. J Coll Physicians Surg Pak. 2005;15:528-531.
- 28. Prihatini J, Lesmana LA, Manan C, Gani RA. Detection of esophageal varices in liver cirrhosis using non-invasive parameters. Acta Med Indones. 2005;37:126-131.
- 29. Mangone M, Moretti A, Alivernini F, Papi C, Orefice R, Dezi A, et al. Platelet count/spleen diameter ratio for non-invasive diagnosis of oesophageal varices: is it useful in compensated cirrhosis? Dig Liver Dis. 2012;44(6):504-507.
Sirozlu Hastalarda Özofagus Varisini Predikte Eden Non-İnvazif, Basit ve Yeni Bir Belirteç; Trombosit Sayısı/Dalak Volümü Oranı
Öz
Sirozlu Hastalarda Özofagus Varisini
Predikte Eden Non-İnvazif, Basit ve Yeni Bir Belirteç: Trombosit Sayısı/Dalak
Boyutu Oranı
Giriş ve Amaç:Özofagus varisleri siroz hastalarında
portal hipertansiyonun ciddi bir sonucudur. Varisleri değerlendirmede endoskopi
en sık kullanılan yöntemdir. Çalışmamızda kronik hepatit B ve/veya hepatit C’
ye bağlı karaciğer sirozu olan hastalarda özofagus varislerinin varlığı ve
derecesinin öngörülmesinde noninvaziv parametreler değerlendirildi.
Gereç ve Yöntemler: Çalışmaya 2009-2015 yılları arasında
Gaziantep Üniversitesi Tıp Fakültesi Gastroenteroloji Bilim Dalı’nda takip
edilen, hepatit B ve/veya hepatit C virüsü nedeniyle karaciğer sirozu tanısı
konulan 324 hasta alındı. Hastaların
demografik, klinik, laboratuvar, radyolojik (dalak boyutu, portal ven çapı,
portal ven akımı) ve endoskopik bulguları retrospektif olarak dosya taraması
ile elde edilerek varis ile ilişkisi değerlendirildi.
Bulgular: Çalışmaya alınan 324 hastanın 178
(%54.9)’i erkek, 146 (%45.1)’sı kadın olup yaş ortalaması 57.4±11.2 (27-87)
idi.164’ü kronik hepatit B, 160’ı ise kronik hepatit C’ye bağlı siroz idi.
Hastaların 69 (%21.3)’unda özofagus varisi saptanmazken, 255 (%78.7) hastada
özofagus varisi mevcuttu. 255 hastanın 97 (%29.9)’sinde grade 1, 129
(%39.8)’unda grade 2, 29 (%9.0)’unda ise grade 3 özofagus varisi görüldü.
Özofagus varisi olan ve olmayan gruplar arasında dalak boyutu, portal ven çapı,
trombosit sayısı, trombosit sayısı/dalak boyutu oranı arasında anlamlı fark
bulundu (p=0001). Varis varlığını predikte eden trombosit sayısı/dalak boyutu
oranı cutoff değeri ≤846 (sensitivite %90, spesifite %91) olarak saptandı.
Trombosit sayısı/dalak boyutu oranı 846 ve altındaki değerler için varis
varlığını göstermedeki pozitif prediktif değeri %97.4 olup negatif prediktif
değeri %71.5 bulundu.
Sonuç: Sirozlu hastalarda özofagial varis varlığını yüksek sensitivite ve
spesifitesi ile predikte edebilecek bir parametre olarak trombosit sayısı/dalak boyutu oranı yeni ve non-invaziv bir belirteç olarak
kullanılabilir.
Anahtar Kelimeler
siroz ; portal hipertansiyon özofagus varisi non- invaziv belirteç
Kaynakça
- 1. Popper H. Pathologicaspects of cirrhosis. Am J Pathol. 1977;87(1):228-264.
- 2.Sherlock S, Dooley J. Hepaticcirrhosis. In: Disease of the liver disease and biliary system. 2th ed, London, Blackwell scientific pub. 2002;371.
- 3.Graham DY, Smith JL. The course of patients after variceal hemorrhage. Gastroenterology 1981;80:800-809.
- 4. De Franchis R, on behalf of the Baveno V Faculty. Revising consensus in portal hypertension: report of the Baveno V consensus workshop on methodology of diagnosis and therapy in portal hypertension. J Hepatol. 2010;53:762-768.
- 5. Wyllie R, Kay M. Esophagogastroduodenoscopy, colonoscopy and related techniques. In: Pediatric gastrointestinal disease. Wyllie R, Hyams JS (eds). Philadelphia, Saunderscompany. 1993;966-998.
- 6. Giannini E, Zaman A, Kreil A, Floreani A, Dulbecco P, Testa E, et al. Platelet count/ spleen diameter ratio for the non invasive diagnosis of esophageal varices: results of a multicenter, prospective, validation study. Am J Gastroenterol. 2006;101:2511-2519.
- 7. Kazemi F, Kettaneh A, N’kontchou G, Pinto E, Ganne-Carrie N, Trinchet JC, et al. Liver stiffness measurement selects patients with cirrhosis at risk of bearing large oesophageal varices. J Hepatol. 2006;45:230-235.
- 8. Perri RE, Chiorean MV, Fidler JL, Fletcher JG, Talwalkar JA, Stadheim L, et al. A prospective evaluation of computerized tomographic (CT) scanning as a screening modality for esophageal varices. Hepatology. 2008;47:1587-1594.
- 9. Schuppan D, Afdhal NH, Liver cirrhosis. Lancet. 2008;371:838-851.
- 10. Giannini E, Botta F, Borro P, Risso D, Romagnoli P, Fasoli A, et al. Platelet count/spleen diameter ratio: proposal and validation of a non-invasive parameter of oesophageal varices in patients with liver cirrhosis. Gut. 2003;52:1200-1205.
- 11. Garceau AJ, Chalmers TC. The Boston Inter-Hospital Liver Group. The natural history of cirrhosis: I. Survival with oesophageal varices. N Eng J Med. 1963;268:469-473.
- 12. Graham D, Smith JL. The course of patients after variceal hemorrhage. Gastroenterology. 1981;80;800-809.
- 13. Memik F,Dolar E. Karaciğer sirozu. Klinik gastroenteroloji Nobel &GuneşTıp Kitabevleri 2005; 626-33.
- 14. Schepis F, Cammà C, Niceforo D, Magnano A, Pallio S, Cinquegrani M, et al. Which patients should undergo endoscopic screening for oesophageal varices detection? Hepatology. 2001;33:333-338.
- 15. Mifune H, Akaki S, Ida K, Sei T, Kanazawa S, Okada H. Evaluation of esophageal varices by multidetector-row CT: correlation with endoscopic 'red color sign'. Acta Med Okayama. 2007;61(5):247-254.
- 16. Carbonell N, Pauwels A, Serfaty L, Fourdan O, Lévy VG, Poupon R. Improved survival after variceal bleeding in patients with cirrhosis over the past two decades. Hepatology. 2004;40(3):652-659.
- 17. Patriquin H, Lafortune M, Burns P, Dauzat M. Duplex doppler examination in portal hypertension: technique and anatomy. AJR 1987;149:71-77.
- 18. D’Amico G, Garcia-Tsao G, Cale`s P, Escorsell A, Nevens F, Cestari R, et al. Diagnosis of portal hypertension: How and when. In: De Franchis R, ed. Proceedings of the Third Baveno International Consensus Workshop on Definitions, Methodology and Therapeutic Strategies. Oxford: Blackwell-Science, 2001:36-63.
- 19. Berzigotto A, Gilabert R, Abraldes JG, Nicolau C, Bru C, Bosch J, et al. Noninvasive prediction of clinically significant portal hypertension and esophageal varices in patients with compensated liver cirrhosis. Am J Gastroenterol. 2008;103:1159-1167.
- 20. Garcia-Tsao G, Sanyal AJ, Grace ND, Carey W. The Practice Guidelines Committee of the American Association for the Study of Liver Diseases, the Practice Parameters Committee of the American College of Gastroenterology. Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis. Hepatology. 2007;46:922-938.
- 21. D’Amico G, de Franchis R and a cooperative study group: Upper digestive bleeding in cirrhosis: post-therapeutic outcomes and prognostic indicators. Hepatology. 2003;38:599–612.
- 22. Tarzamni MK, Somi MH, Farhang S, Jalilvand M. Portal hemodynamics as predictors of high risk esophageal varices in cirrhotic patients. World J Gastroenterol. 2008;14(12):1898-1902.
- 23. Mangone M, Moretti A, Alivernini F, Papi C, Orefice R, Dezi A, et al. Platelet count/ spleen diameter ratio for non-invasive diagnosis of oesophageal varices: is it useful in compensated cirrhosis? Dig Liver Dis. 2012;44(6):504-507.
- 24. Shastri M, Kulkarni S, Patell R, Jasdanwala S. Portal veinDoppler: a tool for non-invasive prediction of esophageal varices in cirrhosis. J Clin Diagn Res. 2014;8(7):12-25.
- 25. Sheth S, Flamm SL, Gordon FD. AST/ALT ratio predicts cirrhosis in patients with chronic hepatitis C virus infection. Am J Gastroenterol. 1998;93:44-48.
- 26. Dib N, Konate A, Oberti F, Cales P. Non-invasivediagnosis of portal hypertension in cirrhosis. Application to the primary prevention of varices. Gastroenterol Clin Biol. 2005;29:975-987.
- 27. Sarwar S, Khan AA, Alam A, Butt AK, Shafqat F, Malik K, et al. Non-endoscopic prediction of presence of esophageal varices in cirrhosis. J Coll Physicians Surg Pak. 2005;15:528-531.
- 28. Prihatini J, Lesmana LA, Manan C, Gani RA. Detection of esophageal varices in liver cirrhosis using non-invasive parameters. Acta Med Indones. 2005;37:126-131.
- 29. Mangone M, Moretti A, Alivernini F, Papi C, Orefice R, Dezi A, et al. Platelet count/spleen diameter ratio for non-invasive diagnosis of oesophageal varices: is it useful in compensated cirrhosis? Dig Liver Dis. 2012;44(6):504-507.