Sirotik hastalarda varis gelişimini ve varis kanamasını öngörmede klinik değerlendirme ve fibrozis belirteçlerinin etkinliği
The efficiency of clinical evaluation and fibrosis markers in predicting varice development and variceal bleeding in cirrhotic patients
Yazar: HAKAN ORAL
Danışman: DOÇ. ONUR KESKİN
Hacettepe Üniversitesi / Tıp Fakültesi / İç Hastalıkları Ana Bilim Dalı
Derece: Tıpta Uzmanlık, 2021
Konu: Gastroenteroloji = Gastroenterology
Dizin: Fibroz = Fibrosis ; Hemorajiler = Hemorrhage ; Hipertansiyon-portal = Hypertension-portal ; Karaciğer hastalıkları = Liver diseases ; Karaciğer sirozu = Liver cirrhosis ; Variköz venler = Varicose veins ; Ölçekler = Scales

Özet:
Siroz hastalarında portal hipertansiyon ilişkili varis gelişimi ve buna bağlı gelişen varis kanama 
sık görülen ve en ölümcül komplikasyonlardan biridir. Bu çalışmada; sirotik hastaların 
laboratuvar, görüntüleme, non-invaziv fibrozis belirteçleri ve mortalite ilişkili çeşitli 
skorlarla varis, yüksek risk varisleri ve varis kanamasını öngörmedeki etkinliği 
araştırılmıştır. Çalışmaya dahil edilen 139 sirotik hastanın 108'inde (%77.6) varis ve 
49'unda (%35.2) yüksek risk varis; varisi olanların 33'ünde (%30.5) varis kanama 
geçirdiği ve 12'sinin (%11.1) 1 yıllık izlemde varis kanaması geçirdiği gözlendi.
Çalışmamızda elde edilen skorlamaların, [(elde edilen parametreler), eşik değer, AUC, 
sensitivite, spesifite, p değeri] değerlerine göre; varis skoru [(charlson komorbidite 
indeksi, hepatik ensefalopati varlığı, PC/SD), 10.6127, AUC 0.776 (0.678-0.874), %75.9, 
%71.0, p<0.001]; varis kanama skoru [(assit varlığı, yaş, dalak boyutu (mm), yüksek 
risk varis varlığı), -9.85, AUC 0.832 (0.750-0.919), %81.8, %69.3, p<0.001]; yüksek risk 
varis skoru [(assit varlığı, PC/SD), -7.9491, AUC 0.727 (0.642-0.812), %75.5, %64.4, 
p<0.001] olarak saptandı. Varis varlığını öngörmede MELD (AUC 0.677), child-pugh 
(AUC 0.662), charlson komorbidite indeksleriyle (AUC 0.662); varis ve varis kanamasını 
öngörmede Lok indeks (AUC 0.656; 0.633) ve Fibro-Q (AUC 0.655; 0.622) skorlarıyla 
anlamlı sonuçlar gözlendi. Çalışmamızda serum LOXL-2 ve ELF skoruyla varis, varis 
kanama açısından anlamlı ilişki saptanmadı. Serum LOXL-2 düzeyiyle total bilirubin (r -
.181, p=0.033), İNR (r -.247, p=0.003), MELD-Na (r -.270, p=0.001), child-pugh (r -.275, 
p=0.001) negatif; albuminle (r .333, p <0.001) pozitif korelasyon saptandı. ELF skoruyla
AST (r .429, p <0.001), ALT (r .207, p=0.015), GGT (r .200, p=0.018), total bilirubin (r 
.313, p <0.001), İNR (r .350, p <0.001), MELD-Na (r .382, p <0.001), child-pugh (r .417, 
p <0.001) pozitif; albumin (r -.487, p <0.001), trombosit (r -.179, p=0.035) negatif yönde 
korelasyon gösterdi. Bu çalışmada; klinik pratikte kullanılabilecek skorlamalar elde 
edilmiş, serum LOXL-2 ve ELF skorunun sirotik hastalarda prognostik serum belirteci 
olarak kullanılabileceği sonucuna ulaşılmıştır.

Abstract:
The development of portal hypertension-related varice and variceal bleeding are one of the most common and fatal complications in patients with cirrhosis. In this study, the efficacy of cirrhotic patients in predicting varices, high-risk varices, and variceal bleeding was investigated by 
laboratory, imaging, non-invasive fibrosis markers, and various mortality-related scores. 
Of the 139 cirrhotic patients included in the study, 108 (77.6%) had varices and 49 (35.2%) 
had high-risk varices; It was observed that 33 (30.5%) of the patients with varices had 
variceal bleeding and 12 (11.1%) had variceal bleeding in the 1-year follow-up. According 
to the scores obtained in our study, [(obtained parameters), threshold value, AUC, 
sensitivity, specificity, p value]; varices score [(charlson comorbidity index, presence of 
hepatic encephalopathy, PC/SD), 10,6127, AUC 0.776 (0.678-0.874), 75.9%, 71.0%, 
p<0.001]; variceal bleeding score [(presence of ascites, age, spleen size (mm), presence 
of high risk varicose), -9.85, AUC 0.832 (0.750-0.919), 81.8%, 69.3%, p<0.001]; high 
risk varices score [(presence of ascites, PC/SD), -7.9491, AUC 0.727 (0.642-0.812), 
75.5%, 64.4%, p<0.001] were revealed. Predicting the presence of varices with MELD 
(AUC 0.677), child-pugh (AUC 0.662), charlson comorbidity indices (AUC 0.662); 
significant results were observed with Lok index (AUC 0.656; 0.633) and Fibro-Q (AUC 
0.655; 0.622) scores in predicting varices and variceal bleeding. In our study, no 
significant correlation was found between serum LOXL-2 and ELF scores and varices and 
variceal bleeding. Serum LOXL-2 level with total bilirubin (r -.181, p=0.033), INR (r -
.247, p=0.003), MELD-Na (r -.270, p=0.001), child-pugh (r - .275, p=0.001) showed 
negative correlation and, with albumin showed positive correlation (r .333, p <0.001).
ELF score with AST (r .429, p <0.001), ALT (r .207, p=0.015), GGT (r .200, p=0.018), 
total bilirubin (r .313, p <0.001), INR (r . .350, p <0.001), MELD-Na (r .382, p <0.001), 
child-pugh (r .417, p <0.001) showed positive correlation and, albumin (r -.487, p <0.001) 
and thrombocyte (r -.179, p=0.035) showed a negative correlation. In conclusion, scorings 
that can be used in clinical practice have been obtained, and it has been concluded that 
serum LOXL-2 and ELF scores can be used as prognostic serum markers in cirrhotic 
patients.