Aims. To determine the usefulness of platelet count (PC), spleen diameter (SD) and platelet count/spleen diameter ratio (PC/SD ratio) for the prediction of oesophageal varices (OV) and large OV in black African patients with cirrhosis in C？te d’Ivoire. Materials and Methods. Study was conducted in a training sample (111 patients) and in a validation sample (91 patients). Results. Factors predicting OV were sex: ( , ), PC (OR = 12.4, ), SD (OR = 1.04, ) in the training sample. The AUROCs (±SE) of the model (cutoff ≥ 0.6), PC (cutoff < 110500), SD (cutoff > 140) and PC/SD ratio (cutoff ≤ 868) were, respectively; 0.879 ± 0.04, 0.768 ± 0.06, 0.679 ± 0.06, 0.793 ± 0.06. For the prediction of large OV, the model’s AUROC (0.850 ± 0.05) was superior to that of PC (0.688 ± 0.06), SD (0.732 ± 0.05) and PC/SD ratio (0.752 ± 0.06). In the validation sample, with PC, PC/SD ratio and the model, upper digestive endoscopy could be obviated respectively in 45.1, 45.1, and 44% of cirrhotic patients. Prophylactic treatment with beta blockers could be started undoubtedly respectively in 36.3, 41.8 and 28.6% of them as having large OV. Conclusion. Non-invasive means could be used to monitor cirrhotic patients and consider treatment in African regions lacking endoscopic facilities. 1. Introduction Oesophageal varices (OV) due to portal hypertension are a major concern in cirrhotic patients because of the risk of bleeding and related high mortality [1]. The prevalence of OV in newly diagnosed cirrhotic patients is approximately 60–80% and the 1-year rate of first variceal bleeding is approximately 5% for small OV and 15% for large OV [1, 2]. The determination of the presence of OV by upper digestive endoscopy is therefore mandatory in patients with cirrhosis at diagnosis [3]. For long-term followup, guidelines recommend monitoring of cirrhotic patients by routine endoscopy for the detection of the development of OV and to initiate prophylactic measures to prevent the bleeding of OV when they become large [3, 4]. Endoscopy is however a costly, invasive, and time-consuming procedure [5]. It is obvious that in most African countries monitoring cirrhotic patients with endoscopy even at baseline or during followup is a challenge for clinicians due to the lack or not widely implemented and accessible endoscopy units [6]. Several studies have reported that platelet count (PC), spleen diameter (SD) and their ratio (PC/SD), portal vein diameter, and Child-Pugh score were strongly associated with the presence of OV in cirrhotic patients [7–10]. Predictive models derived from these
References
[1]
J. Bosch, J. G. Abraldes, A. Berzigotti, and J. C. Garcia-Pagan, “Portal hypertension and gastrointestinal bleeding,” Seminars in Liver Disease, vol. 28, no. 1, pp. 3–25, 2008.
[2]
G. Garcia-Tsao and J. Bosch, “Management of varices and variceal hemorrhage in cirrhosis,” New England Journal of Medicine, vol. 362, no. 9, pp. 823–832, 2010.
[3]
R. De Franchis, “Evolving Consensus in Portal Hypertension Report of the Baveno IV Consensus Workshop on methodology of diagnosis and therapy in portal hypertension,” Journal of Hepatology, vol. 43, no. 1, pp. 167–176, 2005.
[4]
P. Cales, H. Desmorat, J. P. Vinel et al., “Incidence of large oesophageal varices in patients with cirrhosis: Application to prophylaxis of first bleeding,” Gut, vol. 31, no. 11, pp. 1298–1302, 1990.
[5]
R. Crott, N. Makris, A. Barkun, and C. Fallone, “The cost of an upper gastroduodenal endoscopy: an activity-based approach,” Canadian Journal of Gastroenterology, vol. 16, no. 7, pp. 473–482, 2002.
[6]
K. L. Mandeville, J. Krabshuis, N. G. Ladep, C. J. J. Mulder, E. M. M. Quigley, and S. A. Khan, “Gastroenterology in developing countries: issues and advances,” World Journal of Gastroenterology, vol. 15, no. 23, pp. 2839–2854, 2009.
[7]
A. Zaman, R. Hapke, K. Flora, H. R. Rosen, and K. Benner, “Factors predicting the presence of esophageal or gastric varices in patients with advanced liver disease,” American Journal of Gastroenterology, vol. 94, no. 11, pp. 3292–3296, 1999.
[8]
E. Giannini, F. Botta, P. Borro et al., “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,” Gut, vol. 52, no. 8, pp. 1200–1205, 2003.
[9]
M. Cottone, E. Sciarrino, and M. P. Marceno, “Ultrasound in the screening of patients with cirrhosis with large varices,” British Medical Journal, vol. 287, no. 6391, p. 533, 1983.
[10]
A. Zaman, T. Becker, J. Lapidus, and K. Benner, “Risk factors for the presence of varices in cirrhotic patients without a history of variceal hemorrhage,” Archives of Internal Medicine, vol. 161, no. 21, pp. 2564–2570, 2001.
[11]
E. G. Giannini, A. Zaman, A. Kreil et al., “Platelet count/spleen diameter ratio for the noninvasive diagnosis of esophageal varices: results of a multicenter, prospective, validation study,” American Journal of Gastroenterology, vol. 101, no. 11, pp. 2511–2519, 2006.
[12]
A. Sarangapani, C. Shanmugam, M. Kalyanasundaram, B. Rangachari, P. Thangavelu, and J. K. Subbarayan, “Noninvasive prediction of large esophageal varices in chronic liver disease patients,” Saudi Journal of Gastroenterology, vol. 16, no. 1, pp. 38–42, 2010.
[13]
S. Sen and W. J. H. Griffiths, “Non-invasive prediction of oesophageal varices in cirrhosis,” World Journal of Gastroenterology, vol. 14, no. 15, pp. 2454–2455, 2008.
[14]
S. K. Sharma and R. Aggarwal, “Prediction of large esophageal varices in patients with cirrhosis of the liver using clinical, laboratory and imaging parameters,” Journal of Gastroenterology and Hepatology, vol. 22, no. 11, pp. 1909–1915, 2007.
[15]
N. Chalasani, T. F. Imperiale, A. Ismail et al., “Predictors of large esophageal varices in patients with cirrhosis,” American Journal of Gastroenterology, vol. 94, no. 11, pp. 3285–3291, 1999.
[16]
R. Madhotra, H. E. Mulcahy, I. Willner, and A. Reuben, “Prediction of esophageal varices in patients with cirrhosis,” Journal of Clinical Gastroenterology, vol. 34, no. 1, pp. 81–85, 2002.
[17]
A. Agha, E. Anwar, K. Bashir, V. Savarino, and E. G. Giannini, “External validation of the pPlatelet count/spleen diameter ratio for the diagnosis of esophageal varices in hepatitis C virus-related cirrhosis,” Digestive Diseases and Sciences, vol. 54, no. 3, pp. 654–660, 2009.
[18]
F. H. Ng, S. Y. Wong, C. K. Loo, K. M. Lam, C. W. Lai, and C. S. Cheng, “Prediction of oesophagogastric varices in patients with liver cirrhosis,” Journal of Gastroenterology and Hepatology, vol. 14, no. 8, pp. 785–790, 1999.
[19]
K. C. Thompoulos, C. Labropoulou-Karatza, K. P. Mimidis, E. C. Katsakoulis, G. Iconomou, and V. N. Nikolopoulou, “Non-invasive predictors of the presence of large oesophageal varices in patients with cirrhosis,” Digestive and Liver Disease, vol. 35, no. 7, pp. 473–478, 2003.
[20]
M. E. Mendy, T. Welzel, O. A. Lesi et al., “Hepatitis B viral load and risk for liver cirrhosis and hepatocellular carcinoma in the Gambia, West Africa,” Journal of Viral Hepatitis, vol. 17, no. 2, pp. 115–122, 2010.
[21]
V. Madhava, C. Burgess, and E. Drucker, “Epidemiology of chronic hepatitis C virus infection in sub-Saharan Africa,” Lancet Infectious Diseases, vol. 2, no. 5, pp. 293–302, 2002.
[22]
G. Sebastiani, D. Tempesta, G. Fattovich et al., “Prediction of oesophageal varices in hepatic cirrhosis by simple serum non-invasive markers: Results of a multicenter, large-scale study,” Journal of Hepatology, vol. 53, no. 4, pp. 630–638, 2010.
[23]
D. A. Vuitton, R. Piarroux, and S. Bresson-Hadni, “Nonviral infectious diseases of the liver,” in Gastroenterology and Hepatology, M. Cremer, G. Krejs, G. Ramadori, and J. Rask-Madsen, Eds., pp. 644–667, McGraw-Hill, London, UK, 1999.
[24]
M. P. Sharma and V. Bhatia, “Abdominal tuberculosis,” Indian Journal of Medical Research, vol. 120, no. 4, pp. 305–315, 2004.
[25]
H. B. El-serag, “Hepatocellular carcinoma,” The New England Journal of Medicine, vol. 365, no. 12, pp. 1118–1127, 2011.
[26]
M. H. Jagasia and E. R. Arrowsmith, “Complications of hematopoietic neoplasms,” in Wintrobe's Clinical Hematology, J. P. Greer, J. Foerster, N. J. Luckens, F. Paraskevas, and B. Glader, Eds., pp. 1933–1934, Lippincott Williams and Wilkins, New York, NY, USA, 2004.
[27]
M. H. Steinberg, “Management of sickle cell disease,” New England Journal of Medicine, vol. 340, no. 13, pp. 1021–1030, 1999.
[28]
J. J. Heidelbaugh and M. Bruderly, “Cirrhosis and chronic liver failure: Part I. Diagnosis and evaluation,” American Family Physician, vol. 74, no. 5, pp. 756–762, 2006.
[29]
K. Ito and D. G. Mitchell, “Imaging diagnosis of cirrhosis and chronic hepatitis,” Intervirology, vol. 47, no. 3–5, pp. 134–143, 2004.
[30]
K. Beck, Color Atlas of Laparoscopy, W. B. Sanders, London, UK, 1984.
[31]
S. K. Das, L. Dhanya, and D. M. Vasudevan, “Biomarkers of alcoholism: An updated review,” Scandinavian Journal of Clinical and Laboratory Investigation, vol. 68, no. 2, pp. 81–92, 2008.
[32]
G. Battaglia, P. Bocus, S. Merigliano et al., “Endoscopic diagnosis and classification of varices of the gastro-intestinal tract,” Acta Endoscopica, vol. 30, no. 5, pp. 537–554, 2000.
[33]
B. Anderhub, General Sonography: A Clinical Guide, Mosby, Saint Louis, Mo, USA, 1995.
[34]
J. Weinreb, S. Kumari, G. Phillips, and R. Pochaczevsky, “Portal vein measurements by real-time sonography,” American Journal of Roentgenology, vol. 139, no. 3, pp. 497–499, 1982.
[35]
L. J. Myers and D. A. Well, Research Design and Statistical Analysis, Lawrence Erlbaum, NJ, USA, 2003.
[36]
J. A. Hanley and B. J. McNeil, “A method of comparing the areas under receiver operating characteristic curves derived from the same cases,” Radiology, vol. 148, no. 3, pp. 839–843, 1983.
[37]
J. N. Mandekar and S. Mandekar, “Statistical methods in diagnostic medicine using SAS software,” SAS User's Group International (SUGI), Paper 211.30, http://www2.sas.com/proceedings/sugi30/211-30.pdf.
[38]
W. D. Hong, Q. H. Zhu, Z. M. Huang et al., “Predictors of esophageal varices in patients with HBV-related cirrhosis: A retrospective study,” BMC Gastroenterology, vol. 9, article no. 11, 2009.
[39]
R. Barikbin, A. Hekmatnia, N. Omidifar, M. Farghadani, and P. Adibi, “Prediction severity of esophageal varices: A new cutoff point for Platelet count/spleen diameter ratio,” Minerva Gastroenterologica e Dietologica, vol. 56, no. 1, pp. 1–6, 2010.
[40]
Z. Karasu, F. Tekin, G. Ersoz et al., “Liver fibrosis is associated with decreased peripheral platelet count in patients with chronic hepatitis B and C,” Digestive Diseases and Sciences, vol. 52, no. 6, pp. 1535–1539, 2007.
[41]
J. Goulis, T. N. Chau, S. Jordan et al., “Thrombopoietin concentrations are low in patients with cirrhosis and thrombocytopenia and are restored after orthotopic liver transplantation,” Gut, vol. 44, no. 5, pp. 754–758, 1999.
[42]
J. R. Burton, S. Liangpunsakul, J. Lapidus, E. Giannini, N. Chalasani, and A. Zaman, “Validation of a multivariate model predicting presence and size of varices,” Journal of Clinical Gastroenterology, vol. 41, no. 6, pp. 609–615, 2007.
[43]
L. Langmead and D. S. Rampton, “Review article: Herbal treatment in gastrointestinal and liver disease benefits and dangers,” Alimentary Pharmacology and Therapeutics, vol. 15, no. 9, pp. 1239–1252, 2001.
[44]
G. Bedu-Addo and I. Bates, “Causes of massive tropical splenomegaly in Ghana,” Lancet, vol. 360, no. 9331, pp. 449–454, 2002.
[45]
F. Ogasawara, H. Fusegawa, Y. Haruki, K. Shiraishi, N. Watanabe, and S. Matsuzaki, “Platelet activation in patients with alcoholic liver disease,” Tokai Journal of Experimental and Clinical Medicine, vol. 30, no. 1, pp. 41–48, 2005.
