Non Endoscopic Predictors of Oesophageal Varices in Patients with Cirrhosis of the Liver

INTRODUCTION: Portal hypertension is the consequence of an increase in the splanchnic blood flow secondary to vasodilation and increased resistance to the passage of blood through the cirrhotic liver. Development of oesophageal varices is one of the major complications of portal hypertension. Its prevalence varices from 50-60% in patients with cirrhosis of the liver. After varices have developed, about one-third of patients die of bleeding gastrooesophageal varices. The risk of initial bleeding from varices is 25-35% within two years with most first bleeding episodes occurring within one year after detection of varices5. The reported mortality from first episode of variceal bleeding ranges from 40-70%. In 1996, The American Association for the study of liver disease stated that all cirrhotic patients should be screened for the presence of oesophageal varices when portal hypertension is diagnosed. Recently, the Baveno III consensus conference on portal hypertension recommended that all cirrhotic patients should be screened for the presence of oesophageal varices when liver cirrhosis is diagnosed. Repeat endoscopy is recommended at 2-3 years intervals in patients without varices and at 1-2 years interval in patients with small varices to evaluate the development or progression of varices. However, this approach has two major limitations. Endoscopy is an invasive procedure and secondly the cost effectiveness of this approach is also questionable, as only 9-36% patients with cirrhosis are found to have varices on screening endoscopy. It may therefore be more cost effective to routinely screen patients at high risk for the presence of varices, so as to reduce the increasing burden and procedure costs of endoscopy units. Certain biochemical, clinical and ultrasonographic parameters alone or together have good predictive power for non-invasively assessing the risk of bleeding from varices. However, the factors that predict the presence of varices are not as well-defined. Identification of non-invasive predictors of oesophageal varices will enable us to carry out upper GI endoscopy in selected groups of patients, thus avoiding unnecessary intervention and at the same time not missing the patients at risk of bleeding. AIM OF THE STUDY: 1. To identify the clinical, biochemical, haematological and ultrasonographic parameters associated with presence of oesophageal varices in patients with cirrhosis of liver without any previous evidence of GI bleeding. 2. To assess the ability of these parameters as non invasive tools to predict the presence of oesophageal varices. 3. To identify candidates for surveillance endoscopy based on the presence of these parameters. MATERIALS AND METHODS: Study design: Prospective, cross-sectional, randomised analysis study. The study was carried out at the Institute of Internal medicine, Government General, Hospital, Chennai from January 2004 to January 2006. Inclusion criteria : • Patients with cirrhosis of liver without any past history of upper (or) lower gastrointestinal bleed were included in the study. • Diagnosis of cirrhosis was based on a combination of physical findings when present like Gynaecomastia, Ascites, splenomegaly (etc), impaired liver function tests (ie) deranged clotting profile and low serum albumin and irregular liver surface with coarse echoes (or) shrunken liver and ratio of transverse caudate lobe to transverse right lobe width >0.659 an ultrasonographic examination. Exclusion criteria : • Patients with present or previous history of bleed. • Patients on previous/current treatment with Beta blockers, Diuretics (or) anti-platelet drugs. • Patients who had undergone sclerosis (or) band ligation of oesophageal varices, TIPSS (or) surgery for portal hypertension. • Active alcohol abuse (less than six months abstinence). • Patients with serum albumin <1.5 gm. STATISTICAL ANALYSIS: Statistical analysis was performed using SPSS 1.0. 0.1. Results were expressed as mean ±S.D. Qualitative data were tabulated in frequencies and percentages. Quantitative data were given in mean and standard deviation. Association between qualitative data like sex, childs grade, Ascites, palpable spleen, hepatic encephalopathy and grade of varices were analysed using pearson chi-squared test. Association between qualitative data like Jaundice, Prothrombin time, platelet count, serum albumin, SAAG ratio, spleen size, portal vein diameter and grade of varices were analysed using oneway analysis of variance, (ANOVA) F-test and student t-test. All tests were 2 tailed and a `P' value of <0.05 was considered to be significant. `P value <0.001 was considered to be highly significant. Threshold of different variables for the best compromise sensitivityspecificity was determined using the ROC curve. Then, Multivariate analysis of variables with significant correlation was carried out using stepwise logistic regression analysis. SUMMARY: Seventy two patients with cirrhosis of the liver without any previous history of upper GI bleed were studied to identify non endoscopic parameters which could predict the presence of oesophageal varices. Platelet count 1.15cm and childs grade C were found to be independently associated with presence of large varices on endoscopy. Patients with any of these parameters are candidates for surveillance endoscopy.