serological, radiological and biochemical profile of ... · esophageal varices (ev) which are...

Objective To compare the serological, radiological and biochemical profile of cirrhotic patients with and without esophageal varices.Patients and Methods

statistically significant serological difference in patients with and without varices. Patients with varices had elevated INR (p< 0.001; OR, 16.89. 95% CI: 10.97-25.99), low albumin (p< 0.001; OR, 4.70. 95% CI: 3.08-7.17) and high bilirubin (p<

stThis two year cross sectional study started on 1 0.001; OR, 1.87. 95% CI: 1.34-2.60). No January 2010 was carried out at Chanka Medical statistically significant difference was noted in College Teaching Hospital, Larkana, Pakistan and patients with and without varices in context to included 739 patients with cirrhosis. All patients ascites. The mean platelet count of patients with underwent endoscopic and ultrasonological varices was 93502 ± 51195 as compared to evaluation. Viral serology, liver function test, 166783 ± 61181 (p< 0.001). international normalized ratio and platelet count Conclusion were performed. Categorical variables were Patients of esophageal varices had biochemical compared in patients with and without varices by and radiological features of advanced liver chi square test and numerical variable by t-test. disease. There was no difference in viral serology P<0.05 was considered statistically significant. of patients with and without varices. (Rawal Med J Results 2012;37:377-382).Patients with varices had spleen size (< 0.001) of Key words 15.58±2.74 cms and portal vein diameter (p< Cirrhosis, varices, splenomegaly. 0.001) of 13.60±2.25 mms. There was no

INTRODUCTION NSAID and steroids also increases the risk of ,Cirrhosis of liver patients develop complications bleeding.

including portal hypertension manifesting as All cirrhotic patients should be screened for 4

esophageal varices (EV) which are dilated, tortuous presence of varices at the time of diagnosis. The and fragile vessels that connect portal venous and aim of this surveillance is early detection of varices systemic venous circulation and located in sub so that prevention of bleeding and improval of mucosa of lower esophagus. The most dangerous survival can be instituted by timely therapeutic or

5presentation of EV is upper gastrointestinal endoscopic interventions. The major limitation of bleeding. At the time of diagnosis, 30% of cirrhotic this guideline is un-availability of endoscopy and patients have EV that increase to 90%, after 10 cost of procedure in developing and under years. developed countries. The aim of this study was to Chances of bleeding from esophageal varices observe the difference in biochemical, radiological depend on the liver function, size of varices, and serological profile of patients with and without concomitant use of drugs, and aging. Within first varices. This study may help us find factors from year of diagnosis, 30% of cirrhotic bleed and the which we can predict varices early and refer, only single important factor determining the survival selected cases for upper GI endoscopy.after bleed is severity of liver dysfunction. Larger the varix, more the risk of bleed. Annual risk of PATIENTS AND METHODSbleeding in cirrhotics without endoscopically This cross-sectional study was carried out for two visible varices is 1-2%, that increase to 5% for those years from January 2010 to December 2011 at with varices less than 5 mm and 15-20% for those Department of Medicine, Chandka Medical College

2with varices greater than 5 mm. Concomitant use of (CMC), Larkana, Pakistan. With purposive

Original Article

377

Serological, radiological and biochemical profile of cirrhotic patients with and without esophageal varices

Shaikh Khalid Muhammad, Iftikhar Ali Shah, Majid Ahmed Shaikh

CMC Teaching Hospital, SMBBMU, Larkana, Pakistan

Rawal Medical Journal: Vol. 37. No. 4, October-December 2012

sampling, all patients of liver cirrhosis admitted or bilirubin (<2 mg/dl, 2-3 mg/dl, >3 mg/dl), serum visiting Hepatology clinic of CMC were enrolled. albumin (>3.5 g/dl, 2.8-3.5 g/dl, <2.8 g/dl), INR Patients younger than 15 years and older than 75 (<1.7, 1.7-2.2, >2.2) and platelet count years, those already on nitrate or propranolol or had (<150,000/µL, <100,000/µL, 50,000/µL, received endoscopic intervention for variceal >150,000/µL) were compared in patients with and hemorrhage, previous TIPSS or Shunts, without varices by Chi-square test and T-test, when ultrasonography proven hepato cellular carcinoma and where applicable. Odd ratios (OR) and 95% or alpha feto protein ?10 times the normal limit, Confidence Interval (CI) were calculated. p<0.05) hemodynamically unstable patients, patients with was considered to be statistically significant. advanced chronic disorders as COPD, CCF and hematological disorders, and patients with medical RESULTScontraindications to upper gastrointestinal A total of 739 patients were studied with mean age endoscopy like shock, atlanto-axial subluxation, or of 45.81±15.13 years and 481 (65.1%) were male. non correctable coagulation disorder were excluded Varices were documented in 52.6% patients, most from the study. being in grade 3 and belonged all CTP classes (Table Informed written consent was taken from each 1).participant. Detailed history and examination of all

Table 1. Demographic profile of cirrhotic patients patients was carried out. Blood samples were to evaluated for esophageal varices (n=739).central laboratory CMC for detection of serum

bilirubin, albumin, international normalized ratio (INR), alanine aminotransaminase (ALT), asparate aminotransaminase (AST), platelet count and ELISA for HBsAg, Anti-HCV Ab and Anti-HDV Ab. Ultrasound (US) examination of abdomen was done for liver size, portal vein (PV) size, spleen size and the presence of ascites. It was done by a senior radiologist with more than 10 years experience, at CMC Teaching Hospital using Toshiba SSA-70 U/S machine. Endoscopic evaluation of all patients was done by a gastroenterologist having 10 year experience in endoscopy and were graded as; Grade 1: Varix is flush with the wall of the esophagus, Grade 2: Protrusion of the varix but not more than half way to the lumen center, Grade 3: Protrusion more than halfway to the center and Grade 4: The varices are so large that they meet at the midline. All data were meticulously recorded and analyzed using SPSS v 19. Means and SD (standard deviation) of numeric response variables as age, serum bilirubin, serum albumin, INR, ALT, AST, platelet count, portal vein diameter and splenic size were calculated. Frequencies and percentages of categorical response variables such as age, gender, CTP classes (A, B & C), liver size (normal, decreased, increased), portal vein diameter (normal, dilated), ascites (present, absent) spleen size (?13cms, ?15cms, mild splenomegaly, moderate splenomegaly, massive splenomegaly) serum

Patients with varices were 10 year older than those not having varices. There was no statistically difference in gender distribution in patients with and without varices. Mean CTP score in patients with varices was 9.20±1.93 as compared to 6.42±1.91 (p<0.001). Most of the patients with varices were in CTP class C (OR 8.78, 95% CI: 6.01-12.8), as detailed in Table 2.

378

Serological, radiological and biochemical profile of cirrhotic patients


Radiological comparison showed that patients with 95% CI: 1.21-1.64) and enlarged spleen (p<0.004, varices had dilated portal vein (p<0.001, OR 1.41, OR 1.70, 95% CI: 1.18-2.44) (Table 3).

379

Table 2. Comparision of demographic profile of patients with and without esophageal varices

Table 3. Comparison of radiological profile of patients with and without esophageal varices

Patients with varices had statistically significant decreased serum albumin. elevation of AST, ALT, serum bilirubin, INR and



380

Table 4. Comparision of biochemical profile of patients with and without esophageal varices

The mean platelet count of patients without varices documented in 117 (30.1%) patients with varices was 166783±61181/µL as compared to (p<0.001, OR 37.20, 95% CI: 13.60-102.10) as 93502±51195/µL in patients with varices shown in Table 4.(p<0.001). Platelet count <50,000/µL was

Table 5. Comparision of viral serological profile of patients with and without esophageal varices



and platelet count of <100,000/µL were strong non The serological comparison showed no statistically 14significant difference in cirrhotic patients with and invasive predictors of portal hypertension.

without varices (Table 5). Endoscopy should be performed in cirrhotics who meet this criterion of portal hypertension, as these

DISCUSSION are the patients who will benefit from beta-blocker Researchers worldwide have evaluated the therapy. Similar, observations were reported by

15-19biochemical and radiological markers for prediction several other investigators. of varices non invasively. Most of them evaluated In our study, most of our cirrhotics with varices were

7spleen size, ascites, platelet count and serum male, but others did not find this. One possible albumin. All of them were of the view that explanation can be our social circumstances which s p l e n o m e g a l y , p r e s e n c e o f a s c i t e s , is gender biased, where males seek more attention. thrombocytopenia and hypoalbumenia were Our cirrhotics with varices were 10 year older than

6independent risk factors for presence of varices. cirrhotics without varices, but Sen et al reported that Giannini EG et al reported that varices were cirrhotics with varices were younger than their

9 independent of age, gender and serum transaminase counterparts. One possible explanation can be delay 7level. But, patients with varices had statistically in seeking medical consultation in rural areas,

significantly (p<0.0001) low albumin, high possibly due to poverty and lack of health care bilirubin, thrombocytopenia and splenomegaly as facilities. compared to cirrhotics without varices. Thrombocytopenia and splenomegaly were the CONCLUSIONmost sensitive and application of ratio of both may Based on our study, non invasive radiological and be used as an screening tool for varices in cirrhosis biochemical parameters can be used in resource

and reduce the financial burden of endoscopy units. poor areas (rural) to detect varices non 6,7

endoscopically. It may be more reasonable to refer Low platelet count, splenomegaly and their ratio all patients for endoscopy if at least one radiological could predict esophageal varices and could be used and one biochemical parameter is detected in as surrogate markers for presence of esophageal patients of liver cirrhosis. varices in centers where endoscopic facilities are not

8ACKNOWLEDGEMENTavailable. Similar recommendations have been

9 We are grateful to post graduate trainees of our made by others. Zaman et al reported that platelet department, Dr. Shakeel Ahmed Qazi, Dr. Santosh count less than 80,000/µL and advanced CTP class Kumar, Dr. Rashid Solangi, Dr. Zohaib Soomro, and were associated with presence of large varices and Dr. Jaipal for their contribution in data collection these two parameters may identify the subgroup of and counseling of patients. cirrhotic patients who can benefit most from referral

10for endoscopic screening of varices.Thomopoulos et al reported that platelet count less than 118,000/µL, spleen length >135mm and ascites

11were independent predictors of large varices. Thus, endoscopy can be safely avoided in cirrhotics with none of these features. Similarly, Madhotra et al reported that platelet count less than 68,000/µL and splenomegaly had the highest predictive value for

12 large varix. Sarwar et al reported that, cirrhotic patients with serum albumin < 2.95g/dl, portal vein diameter > 11mm and platelet count <88,000/µL are

13ideal candidates for surveillance endoscopy. Gill et al observed that PV diameter of 13mm, INR of 1.5

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Corresponding author email: [email protected]. Date: Jun 18, 2012 Accept Date: Sep 12, 2012



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