Platelet count/spleen diameter ratio: proposal and validation of a non-invasive parameter to predict the presence of oesophageal varices in patients with liver cirrhosis

E Giannini, F Botta, P Borro, D Risso, P Romagnoli, A Fasoli, M R Mele, E Testa, C Mansi, V Savarino, R Testa, E Giannini, F Botta, P Borro, D Risso, P Romagnoli, A Fasoli, M R Mele, E Testa, C Mansi, V Savarino, R Testa

Abstract

Background and aims: Cirrhotic patients frequently undergo screening endoscopy for the presence of oesophageal varices (OV). In the future, this social and medical burden will increase due to the greater number of patients with chronic liver disease and their improved survival. In this study, our aims were (1) to identify clinical, biochemical, and ultrasonographic parameters which might non-invasively predict the presence of OV in patients with liver cirrhosis; (2) to evaluate the reproducibility of the obtained results in a different, although related, further group of patients; and (3) to assess the predictiveness of the identified rules in patients with compensated cirrhosis.

Methods: In the first part of the study we retrospectively evaluated the presence of OV in 145 cirrhotic patients, and in the second part we evaluated the reproducibility of the study results in a subsequent group of 121 patients. Finally, we evaluated these parameters in a subgroup of 145 patients with compensated disease. All 266 patients underwent a complete biochemical workup, upper digestive endoscopy, and ultrasonographic measurement of spleen bipolar diameter. Platelet count/spleen diameter ratio was calculated for all patients.

Results: The prevalence rates of OV were 61% and 58% in the first and second groups of patients, respectively. In the first part of the study, we found that platelet count, spleen diameter, platelet count/spleen diameter ratio, and Child- Pugh class were significantly different among patients with or without OV, although the platelet count/spleen diameter ratio was the only parameter which was independently associated with the presence of OV in a multivariate analysis. A platelet count/spleen diameter ratio cut off value of 909 had 100% negative predictive value for a diagnosis of OV. This result was reproduced in the second group of patients as well as in patients with compensated disease. In a cost-benefit analysis, screening cirrhotic patients according to the "platelet count/spleen diameter ratio strategy" was far more cost effective compared with the "scope all strategy".

Conclusions: The platelet count/spleen diameter ratio is the only parameter which is independently associated with the presence of OV, and its negative predictive value is reproducible. Its use is of value even in the subgroup of patients with compensated disease, and it is also cost effective.

Figures

Figure 1
Figure 1
Receiver operating characteristic curve showing the platelet count/spleen diameter ratio cut off with the best sensitivity and specificity on the basis of the presence of any oesophageal varices.
Figure 2
Figure 2
Dot diagram showing patient distribution on the basis of the presence/absence of oesophageal varices (OV) and a platelet count/spleen diameter ratio cut off of 909 in 145 patients with compensated cirrhosis. NOV, no oesophageal varices.
Figure 3
Figure 3
Flow chart showing cost-benefit analysis of the “scope all strategy” compared with the “platelet count/spleen diameter ratio strategy”. A unitary cost of 150 Euros for each diagnostic upper digestive endoscopy is applied, with no extra costs for abdominal ultrasonography. The prevalence of oesophageal varices in the study population is 60%. OV, oesophageal varices; NOV, no oesophageal varices.

References

    1. De Franchis R, Primignani M. Natural history of portal hypertension in patients with cirrhosis. Clin Liver Dis 2001;5:645–63.
    1. Garceau AJ, Chalmers TC. The Boston Inter-Hospital Liver Group. The natural history of cirrhosis: I. Survival with oesophageal varices. N Engl J Med 1963;268:469–73.
    1. Graham D, Smith JL. The course of patients after variceal hemorrhage. Gastroenterology 1981;80;800–9.
    1. Rigo GP, Merighi A, Chalen JN, et al. A prospective study of the ability of three endoscopic classifications to predict hemorrhage from esophageal varices. Gastrointest Endosc 1992;38:425–9.
    1. Jensen DM. Endoscopic screening for varices in cirrhosis: findings, implications, and outcomes. Gastroenterology 2002;122:1620–30.
    1. Grace ND, Groszmann RJ, Garcia-Tsao G, et al. Portal hypertension and variceal bleeding: an AASLD single topic symposium. Hepatology 1998;28:868–80.
    1. D’Amico G, Garcia-Tsao G, Calés P, 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.
    1. Calés P, Desmorat H, Vinel JP, et al. Incidence of large oesophageal varices in patients with cirrhosis: application to prophylaxis of first bleeding. Gut 1990;31:1298–302.
    1. D’Amico G, Pagliaro L, Bosch J. The treatment of portal hypertension: A meta- analytic review. Hepatology 1995;22:332–54.
    1. Gorka W, Al Mulla A, Al Sebayel M, et al. Qualitative hepatic venous Doppler sonography versus portal flow-metry in predicting the severity of esophageal varices in hepatitis C cirrhosis. Am J Roentgenol 1997;169:511–5.
    1. Chalasani N, Imperiale TF, Ismail A, et al. Predictors of large esophageal varices in patients with cirrhosis. Am J Gastroenterol 1999;94:3285–91.
    1. Zaman A, Hapke R, Flora K, et al. Factors predicting the presence of esophageal varices or gastric varices in patients with advanced liver disease. Am J Gastroenterol 1999;94:3292–6.
    1. Pilette C, Oberti F, Aubé C, et al. Non-invasive diagnosis of esophageal varices in chronic liver disease. J Hepatol 1999;31:867–73.
    1. Ng FH, Wong SY, Loo CK, et al. Prediction of oesophagogastric varices in patients with cirrhosis. J Gastroenterol Hepatol 1999;14:785–90.
    1. Schepis F, Cammà C, Niceforo D, et al. Which patients should undergo endoscopic screening for esophageal varices detection? Hepatology 2001;33:333–8.
    1. Zaman A, Becker T, Lopidus J, et al. Risk factors for the presence of varices in cirrhotic patients without a history of variceal hemorrhage. Arch Intern Med 2001;161:2564–70.
    1. Madhotra R, Mulcahy HE, Willner I, et al. Prediction of esophageal varices in patients with cirrhosis. J Clin Gastroenterol 2002;34:81–5.
    1. Amarapurkar DN, Parikh SS, Shankaran K, et al. Correlation between splenomegaly and oesophageal varices in patients with liver cirrhosis. Endoscopy 1994;26:563.
    1. Zeijen RNM, Caenepeel P, Stockbrügger RW, et al. Prediction of esophageal varices in liver disease: preliminary results. Gastroenterology 1994;106:A1013.
    1. Lavergne J, Molina E, Reddy KR, et al. Ascites predicts the presence of high grade varices by screening gastroscopy. Gastrointest Endosc 1997;45:AB187.
    1. Garcia-Tsao G, Escorsell A, Zakko M, et al. Predicting the presence of significant portal hypertension and varices in compensated cirrhotic patients. Hepatology 1997;26:360A.
    1. Freeman JG, Darlow S, Cole AT. Platelet count as a predictor for the presence of oesophageal varices in alcoholic cirrhotic patients. Gastroenterology 1999;116:A1211.
    1. Riggio O, Angeloni S, Nicolini G, et al. Endoscopic screening for esophageal varices in cirrhotic patients. Hepatology 2002;35:501–2.
    1. Peck-Radosavljevic M. Thrombocytopenia in liver disease. Can J Gastroenterol 2000;14(suppl D):60–6D.
    1. McCormick PA. The spleen, hypersplenism, and other relationships between the liver and spleen. In: Bircher J, Benhamou J-P, McIntyre N, et al, eds. Oxford Textbook of Clinical Hepatology. Oxford: Oxford University Press, 1999:787–95.
    1. Ong J, Younossi ZM. Clinical predictors of large esophageal varices: how accurate are they? Am J Gastroenterol 1999;94:3103–5.
    1. Fleig WE. To scope or not to scope: still a question. Hepatology 2001;33:471–2.
    1. Rajvanshi P, Kowdley KW. Prediction of varices in patients with cirrhosis. A high- stakes numbers game? J Clin Gastroenterol 2002;34:4–5.
    1. Pugh RN, Murray-Lyon IM, Dawson JL, et al. Transection of the oesophagus for bleeding oesophageal varices. Br J Surg 1973;60:646–9.
    1. De Franchis R, Pascal JP, Ancona E, et al. Definitions, methodology and therapeutic strategies in portal hypertension. A Consensus Development Workshop, Baveno, Lake Maggiore, Italy, April 5 and 6, 1990. J Hepatol 1992;15:256–61.
    1. Harrell FE Jr, Lee KL, Mark DB. Tutorial in biostatistics. Multivariable prognostic models: issues in developing models, evaluating assumptions and adequacy, and measuring and reducing errors. Stat Med 1996;15:361–87.
    1. Hanley JA, McNeil BJ. The meaning and use of the area under receiver operating characteristic (ROC) curve. Radiology 1982;143:29–36.
    1. Metcalf M, Brown N, Peterson S, et al. Health care costs associated with chronic hepatitis B. Am J Health Syst Pharm 1999;56:232–6.
    1. Wong JB, McQuillan GM, McHutchinson JG, et al. Estimating future hepatitis C morbidity, mortality, and costs in the US. Am J Publ Health 2000;90:1562–9.
    1. Valletta EA, Loreti S, Cipolli M, et al. Portal hypertension and esophageal varices in cystic fibrosis. Unreliability of echo-Doppler flowmetry. Scand J Gastroenterol 1993;28:1042–6.
    1. Tamayo SG, Rickman LS, Mathews WC, et al. Examiner dependence on physical diagnostic tests for the detection of splenomegaly: a prospective study with multiple observers. J Gen Intern Med 1993;8:69–75.
    1. Justice AC, Covinsky KE, Berlin JA. Assessing the generalizability of prognostic information. Ann Intern Med 1999;130:515–24.
    1. Christensen E, Fauerholtdt L, Schlichting P, et al. Aspects of the natural history of gastrointestinal bleeding in cirrhosis and the effect of prednisone. Gastroenterology 1981;81:944–52.
    1. D’Amico G, Luca A. Portal hypertension. Natural history. Clinical-hemodynamics correlation. Prediction of the risk of bleeding. Baillieres Clin Gastroenterol 1997;11:243–56.
    1. Laupacis A, Sekar N, Stiell IG. Clinical prediction rules. A review and suggested modifications of methodological standards. JAMA 1997;277:488–94.
    1. De Bac C, Clementi C, Duca F, et al. Liver cirrhosis: epidemiological aspects in Italy. Res Virol 1997;148:139–42.

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