Noninvasive prediction of esophageal varices diameter ratios, and higher bipolar spleen diameters (Tables 1, 2, 3). Although patients with EVs had higher por- tal vein diameter PVDs and mean portal blood velocity, these findings were not significant (p = 0.07, p = 0.9; re- spectively) (Table 3). Factors Associated with EVS by Multivariable Analysis In the multivariate ordinal regression analysis, the presence of EVs was associated significantly with plate- let count: spleen diameter ratio (odds ratio; 1.028, 95% Table 4. Best-fitting multiple logistic regression predictors of esophageal varices Platelet count/bipolar spleen diameter ratio Table 5. Predictive accuracy of the best cutoff value of platelet count/ bipolar spleen diameter ratio in the diagnosis of esophageal varices Predictor Age Cutoff value 939.7 Sensitivity 100% a NPV = negative predictive value b PPV = positive predictive value CI: 1.016-1.04, P = 0.001) and age (odds ratio; 1.205, 95% CI: 1.043-1.392, P = 0.01) (Table 4). The area under the ROC curve for the platelet count/ bipolar spleen diameter ra- tio was 0.94 ± 0.02 (Figure 1), which represents the overall diagnostic accuracy of the ratio in predicting EVs. Thus, on random selection of an individual with EVs versus no EVs, the score of the former will be lower 94% of the time. Table 5 shows the sensitivity, specificity, PPV, and NPV of the ratio at various cutoff levels. At a score of 939.7, the ratio has high sensitivity (100%), robust negative predic- tive value NPV (100%), and high specificity (86.3%) and positive predictive value PPV (95.6%). In a separate analysis, the platelet count/bipolar spleen diameter ratio was significantly higher in compensated cirrhotics (Child-Pugh class A) without EVs compared with those with EVs (1802 ± 987 and 770 ± 146.6, respective- ly; p = 0.0001). In this analysis, the ratio maintained high sensitivity (100 %), robust NPV (100%), and high specificity (81.8%) and PPV (97%), with an overall diagnostic accuracy of 87.2% (Table 6). Notably, none of the thrombocytopenic patients showed any evidence of thrombocytopenia for etiologies other than hypersplenism, as evidenced by the normal results for ANA, ASMA, gamma-globulin levels and bone marrow aspiration (data not shown). Discussion Management of EVs is an everyday challenge. Current guidelines recommend that all patients should undergo endoscopic screening for varices when cirrhosis is diag- nosed, after which patients with medium and large va- rices should be treated to prevent bleeding. For all other patients, regular periodic evaluation is required (22). In Egypt, however, the management of patients with liver 0.633 0.150 Specificity 86.3% Regression coefficient Odds ratio 1.028 1.205 95% CI 1.016-1.041 1.043-1.392 p-value 0.001 0.01 Abu El Makarem MA et al. 281 cirrhosis complicated by the interplay between clinical, economic, social, and cultural factors and the generally poor compliance to both follow-up and treatment strat- egies. Endoscopic follow-up, which is recommended by international guidelines, is not feasible in most patients for many reasons. Liver diseases are common in Egypt due to the higher prevalence of viral hepatitis (23, 24) and increased incidence of schistosomiasis (25); more- over, most patients present in the late phase of liver dis- ease. Further, the majority of patients is uninsured and must pay for expenses out of pocket, unaware of the risk NPV a 100% PPV b 95.6% Accuracy 96.5% Table 6. Validation of cutoff value of platelet count/ bipolar spleen diam- eter ratio in the diagnosis of esophageal varices in patients with compen- sated liver cirrhosis Sensitivity Specificity 100% 81.8 % a NPV = negative predictive value b PPV = positive predictive value NPV a 100 % PPV b 70 % Accuracy 87.2 % of the variceal bleeding, and they are apparently healthy asymptomatic compensated patients. Compliance can also be limited, because it requires that patients who are asymptomatic undergo a procedure repeatedly that is perceived to be unpleasant. Endoscopic follow-up is also impractical due to the fear of infection; despite efforts to ensure sterilization, there remains a risk of re-infection by another subtype of the same virus infect the patient or another viral hepatitis with increased risk of decompensation in compensated patients (26). Finally, endoscopy units are not available in all hospitals, particularly in rural areas, necessitating other easier modalities for the diagnosis and monitor- ing of portal hypertension. Thus, a method of predicting the presence of EVs noninvasively is in great demand to avoid unnecessary endoscopy and improve the cost- effectiveness of management; the latter is a particularly important consideration in many African and Middle Eastern countries, including Egypt, where liver cirrho- sis is highly prevalent. Ideally, a method for identifying patients with varices should be simple, noninvasive, in- expensive, reproducible, accurate, and readily available; have high sensitivity and specificity; follow the natural history; reflect the effect of the treatment accurately; and indicate the prognosis and possibility of the suc- cess of a treatment. Several noninvasive and minimally Hepat Mon. 2011;11(4):278-284