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Platelet count/spleen diameter ratio as a predictor of esophageal varices in cirrhotic patients
Ângelo Zambam de Mattos*, Angelo Alves de Mattos**,
, Francisco Barrera Martínez
,**
, Arnoldo Riquelme Pérez*, Marco Arrese Jiménez*
* Gastroenterologist and Post-Graduate Student in Hepatology of Universidade Federal de Ciencias da Saúde de Porto Alegre (UFCSPA), Brazil
** Head Professor of the Department of Gastroenterology and of the PostGraduate Course of Hepatology of Universidade Federal de Ciencias da Saúde de Porto Alegre (UFCSPA), Brazil
* Department of Gastroenterology, Pontificia Universidad Católica de Chile
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Dear Editor</span><p id="p0005" class="elsevierStylePara elsevierViewall">This letter regards the very interesting paper published in Annals of Hepatology 2009&#59; 8&#40;4&#41;&#58; 325-30 by Barrera&#44; <span class="elsevierStyleItalic">et al&#46;</span><a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> The authors emphasize an important matter&#44; which is the burden of frequently en-doscopying cirrhotic patients in order to verifying for the presence of esophageal varices &#40;EV&#41; and indicating the proper prophylaxis to avoid bleeding&#46; They evaluate the platelet count&#47;spleen diameter ratio &#40;PC&#47;SD&#41;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2</span></a><span class="elsevierStyleSup">&#8211;</span><a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> in 67 patients as a non-invasive parameter to predict the presence of high risk esophageal varices &#40;HREV&#41;&#44; defined by them as those classified as large or with red wale signs&#46; We conducted a quite similar study&#44; currently in press in Arquivos de Gastroenterologia&#44; with 164 cirrhotics from Santa Casa Hospital&#44; Porto Alegre&#44; Brazil&#46;</p><p id="p0010" class="elsevierStylePara elsevierViewall">In the paper by Barrera&#44; <span class="elsevierStyleItalic">et al&#46;</span>&#44; PC&#47;SD had a sensitivity of 76&#46;9&#37;&#44; a specificity of 74&#46;2&#37;&#44; a positive predictive value &#40;PPV&#41; of 71&#46;4&#37; and a negative predictive value &#40;NPV&#41; of 77&#46;8&#37; for the diagnosis of HREV&#44; using a cut-off point of 830&#46;8&#46; In our study&#44; on the other hand&#44; PC&#47;SD had a sensitivity of 77&#46;5&#37;&#44; a specificity of 45&#46;5&#37;&#44; a PPV of 79&#46;5&#37;&#44; a NPV of 42&#46;6&#37; and an accuracy of 68&#46;9&#37; for the diagnosis of EV&#44; using the cut-off point of 909&#46; Another difference between the results of the studies is that&#44; even being significantly different between the 2 groups in the univariate analysis in both studies&#44; PC&#47;SD did not prove to be an independent marker of EV in the multivariate analysis we made&#44; while PC&#47; SD and age were associated to HREV in the multi-variate analysis of the paper published by Barrera&#44; <span class="elsevierStyleItalic">et al&#46;</span> In our study&#44; the only independent variable associated to EV in the multivariate analysis was platelet count &#40;p&#60;0&#46;05&#41;&#46;</p><p id="p0015" class="elsevierStylePara elsevierViewall">The previous differences in results may be explained by differences in the design of the studies&#46; The major difference in their designs probably is that we evaluated PC&#47;SD for the prediction of varices of any kind&#44; since the latest AASLD guideline&#44;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> which took place after Baveno IV&#44;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> recommends prophylaxis with beta-blockers even for patients with small varices and without red wale signs&#44; as long as in patients with Child B or C classes&#46; On the other hand&#44;</p><p id="p0020" class="elsevierStylePara elsevierViewall">Barrera&#44; <span class="elsevierStyleItalic">et al&#46;</span>&#44; evaluated the index for the diagnosis of HREV&#46; The other important difference in design is that we used the 909 cut-off point proposed by Giannini&#44; <span class="elsevierStyleItalic">et al&#46;</span>&#44; for the PC&#47;SD in the analysis&#44; while Barrera&#44; <span class="elsevierStyleItalic">et al&#46;</span>&#44; calculated their own cut-off point in a ROC-curve&#46;</p><p id="p0025" class="elsevierStylePara elsevierViewall">Besides&#44; there were some differences in the studied samples that could have contributed to explain the differences found in some of the results&#46; Barrera&#44; <span class="elsevierStyleItalic">et al&#46;</span>&#44; used a sample composed by men in only 43&#46;3&#37;&#44; with a mean age of 66 years and a Child class distribution of A - 46&#46;2&#37;&#44; B - 38&#46;8&#37; and C - 15&#37;&#46; We had a sample with a 56&#46;7&#37; male proportion&#44; with a mean age of 56&#46;6 years and with a Child class distribution of A - 57&#46;6&#37;&#44; B - 37&#46;7&#37; and C - 4&#46;6&#37;&#46; In our study&#44; cirrhosis was caused by viral hepatitis in 43&#46;9&#37; of cases&#44; by alcohol abuse in 29&#46;3&#37;&#44; by viral hepatitis and alcohol in 10&#46;4&#37; and by other causes in 16&#46;5&#37;&#59; Barrera&#44; <span class="elsevierStyleItalic">et al&#46;</span>&#44; found only 7&#46;5&#37; of viral hepatitis as cause of cirrhosis&#44; while alcohol abuse was its cause in 26&#46;9&#37;&#44; autoimmune hepatitis in 11&#46;9&#37;&#44; primary biliary cirrhosis in 14&#46;9&#37;&#44; non-alcoholic steatohepatitis in 14&#46;9&#37; and cryptogenic cirrhosis in 26&#46;9&#37;&#44; which suggests a somewhat different population in the studies&#46; We found EV on endoscopy in 73&#46;2&#37; of our cases&#44; while Barrera&#44; <span class="elsevierStyleItalic">et al&#46;</span>&#44; found them in 85&#37;&#46;</p><p id="p0030" class="elsevierStylePara elsevierViewall">Despite the mentioned differences between both studies&#44; they agree in the most important&#44; their conclusion&#58; PC&#47;SD cannot replace endoscopy in the screening of EV or of HREV in cirrhotic patients&#46;</p><p id="p0035" class="elsevierStylePara elsevierViewall">Reply&#58;</p><p id="p0040" class="elsevierStylePara elsevierViewall">We thank Dr&#46; De Mattos for their interest in our study&#46; Many attempts have been performed to find comfortable and cost-effective methods different from endoscopy for diagnosing esophageal varices&#46; These non-invasive approaches include&#44; among others&#44; the following&#58; platelet count&#59; spleen diameter&#59; platelet count and Child-Pugh score&#59; spider an-giomata&#44; ALT and albumin&#59; CT esophageal study&#59; fibrotest &#40;&#40;c-glutamyltranspeptidase&#44; haptoglobin bilirubin&#44; apolipoprotein A&#44; alpha-2-macroglobu-lin&#41;&#59; and fibroscan &#40;transient elastography&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">1</span></a> We are fully aware of the limitations of these predictors&#44; but among all of these methods&#44; platelet count&#47;spleen diameter ratio has been one of the most consistently evaluated&#46;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">2</span></a><span class="elsevierStyleSup">&#8211;</span><a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">4</span></a> This ratio has been developed by Gianini&#44; <span class="elsevierStyleItalic">et al&#46;</span><a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">2</span></a> by combining 2 portal hypertension-dependent variables that can potentiate its accuracy on predicting esophageal varices&#46;</p><p id="p0045" class="elsevierStylePara elsevierViewall">The problem of this ratio is that platelet count is a sensible parameter that can be easily modified by acute events such as bleeding&#44; infection&#44; medications&#44; alcohol&#44; etc&#46; It has also been described that cirrhosis can be associated with lower thrombopoetin levels and increased antibody mediated platelet destruction&#44;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">5</span></a> both of them variables that are not dependent of the presence of portal hy-pertension&#46; On the other hand&#44; spleen bipolar diameter in most of the studies is measured by ultrasound&#46; This is an operator-dependent method that could have low reproducibility if it is not performed with a proper technique&#46; All the above-mentioned factors could explain the variability of the positive predictive value &#40;PPV&#41; and negative predictive value &#40;NPV&#41; among different studies&#46; In spite of this&#44; there are many publications on different populations that support the utility of this ratio on predicting presence of esophageal varices&#44; many of them with similar or superior PPV and NPV to our findings&#46;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">2</span></a><span class="elsevierStyleSup">&#8211;</span><a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">4</span></a> An ongoing Cochrane database meta-analysis will help us to clarify the real value of laboratory and ultrasonography parameters on predicting esophageal varices&#46;</p><p id="p0050" class="elsevierStylePara elsevierViewall">With current data&#44; we think that platelet count&#44; spleen diameter and platelet count&#47;spleen diameter ratio are a useful tool on approaching to portal hypertension&#44; esophageal varices and cirrhosis diagnosis&#44; especially when there is limited access to endoscopy examination&#46; Another utility of these parameters is to help to suspect the diagnosis when clinical history and physical examination findings suggest the presence of initial cirrhosis&#46; In our opinion&#44; endoscopy will never be fully replaced by non-invasive parameters for eso-phageal varices final diagnosis&#46; Hopefully&#44; non invasive parameters could help to categorize patients on high probability&#44; intermediate probability or low probability of esophageal varices&#46; With this categorization&#44; we could expect to give priority for endoscopy exam for intermediate-risk patients&#46; High-risk patients could choose to begin empiric therapy or perform an endoscopy exam for diagnosis according to patient&#8217;s preference and access to endoscopy&#46; Low-risk patients could be given a lower priority for endoscopy exam&#44; as suggested by Burton&#44; <span class="elsevierStyleItalic">et al&#46;</span><a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">6</span></a> The indication of prophylaxis on small esophageal varices is to prevent development of high risk esophageal varices&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">7</span></a> Non-invasive method allows very frequent screening so we decided to focus directly on predicting HREV where beta blocking therapy has demonstrated to improve survival&#46;</p></span></span>"
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ISSN: 16652681
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