282 Abu El Makarem MA et al. y t i v i t i s n e S 1-Sepecificity Figure 1. Receiver operating characteristic curve (roc) of platelet count/ bi- polar spleen diameter ratio and age AUC = area under the curve AUC for ratio = 0.94 ± 0.02, AUC for age = 0.33 ± 0.05 invasive methods have emerged in recent years, assess- ing the potential of various laboratory, clinical, and ul- trasonographic parameters, linked directly or indirectly to portal hypertension, such as splenomegaly, decreased platelet count, and portal vein diameter (8-10, 22, 27-31). Three such methods have been examined extensively: platelet count:spleen diameter ratio (15), Fibrotest (32), and Fibroscan (33). Fibrotest appears to be insufficiently precise, and Fibroscan requires further evaluation; nei- ther test is widely available in Egypt due to financial and technical considerations. In a seminal trial, Giannini and colleagues used the platelet count:spleen diameter ratio as a parameter, linking thrombocytopenia to spleen size to predict portal hypertension (15). Although these inter- national trials; the differences in the populations charac- ters and the need to a well-designed repeated multiple large multi-central trials, before any final recommenda- tion can be concluded, lead to that the conclusions of the Baveno IV consensus workshop on portal hypertension were that, endoscopic screening has been the optimal method of detecting varices (4, 5). For these reasons, we planned the current study to evaluate the use of a similar ratio in Egyptian cirrhotic patients who typically present late and have varying ethnicities, poorer nutritional sta- tus, and significant viral etiology to overcome the draw- backs of previous studies. (We think that this paragraph doesn’t need modification). In our study, the prevalence of EVs was 74.9%, which might be attributed to the late presentation of our pa- tients and the increased incidence of schistosomiasis in our region (25). In addition to age, serum bilirubin, prothrombin activity, platelet count, spleen diameter, and Child-Pugh scores, the platelet count:spleen di- ameter ratio was associated with portal hypertension. These results were confirmed by multivariate logistic regression, which demonstrated that the platelet count: spleen diameter ratio (odds ratio: 1.028, 95% CI: 1.016-1.04, Noninvasive prediction of esophageal varices P = 0.001) and age were independent predictive factors for EVs (odds ratio: 1.205, 95% CI: 1.043-1.392, P = 0.01). Al- though portal vein diameter, as assessed by ultrasonog- raphy, was higher in cirrhotic patients with EVs, this correlation failed to reach statistical significance (P = 0.07), as did mean portal blood flow velocity; these data are consistent with results of other large trials (8, 10-14). Moreover, performing Doppler sonographic examina- tion requires sophisticated skills and equipment, limit- ing its value in the identification of patients with cirrho- sis who are at risk of variceal bleeding (34). Our analysis of the area under the ROC curve (AUROC) revealed that the cutoff of the platelet count:spleen diameter ratio (939.7) was the optimal value for accurate prediction of EVs with an AUC of 0.95; this value corresponded to posi- tive and negative predictive values of 96% and 100%, re- spectively. It has been reported that a negative predictive value (NPV) of 100% is desirable for screens to minimize the oversight of individuals who are at risk (13, 17). This finding is consistent with the initial study by Giannini et al. (15), who used a cutoff of 909 with an AUROC curve of 0.981, corresponding to positive and negative predic- tive values of 95.6% and 100%, respectively, for the pres- ence of varices. The same ratio has also been examined by many groups in many countries in patient populations that differed from the group in which it was developed, generating consistent results—suggesting that the ratio is generalizable (35-38). We believe that this ratio is valu- able and unique—a hypothesis that is supported by many clinical, financial, and statistical findings. Clinically, the increase in spleen size in patients with chronic liver dis- ease is nearly always a manifestation of portal hyperten- sion (39, 40); conversely, although thrombocytopenia can result from immune-mediated mechanisms or lower thrombopoietin synthesis (16, 41), in most cases it is usu- ally caused by splenic pooling of platelets due to portal hypertension (15, 42). This model is supported by our results, in which thrombocytopenia was attributed to hypersplensim in all patients. Integrating platelet count and spleen size in a ratio allowed us to determine the ex- tent of thrombocytopenia that most likely resulted from hypersplenism. Financially, the ratio is easy to calculate and can be used at the bedside, Biannual calculation of the ratio will not generate additional costs in the man- agement of cirrhotic patients, because platelet count is assessed routinely and abdominal ultrasonography is usually performed at least semiannually to monitor he- patocellular carcinoma (43). In fact, spleen bipolar mea- surements consistently show high reproducibility and low intra- and interobserver variability (44, 45). Statistically, the platelet count:spleen diameter ratio and age were the only parameters that were indepen- dently associated with the presence of EVs in the multi- variate analysis. The AUROC curves for age and platelet count:spleen diameter ratio were 0.31 and 0.95, respec- tively, indicating that the ratio can be used as the sole predictive factor for EVs. Notably, in a subset analysis, Hepat Mon. 2011;11(4):278-284