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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They evaluate the platelet count/spleen diameter ratio (PC/SD)<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2</span></a><span class="elsevierStyleSup">–</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 (HREV), defined by them as those classified as large or with red wale signs. We conducted a quite similar study, currently in press in Arquivos de Gastroenterologia, with 164 cirrhotics from Santa Casa Hospital, Porto Alegre, Brazil.</p><p id="p0010" class="elsevierStylePara elsevierViewall">In the paper by Barrera, <span class="elsevierStyleItalic">et al.</span>, PC/SD had a sensitivity of 76.9%, a specificity of 74.2%, a positive predictive value (PPV) of 71.4% and a negative predictive value (NPV) of 77.8% for the diagnosis of HREV, using a cut-off point of 830.8. In our study, on the other hand, PC/SD had a sensitivity of 77.5%, a specificity of 45.5%, a PPV of 79.5%, a NPV of 42.6% and an accuracy of 68.9% for the diagnosis of EV, using the cut-off point of 909. Another difference between the results of the studies is that, even being significantly different between the 2 groups in the univariate analysis in both studies, PC/SD did not prove to be an independent marker of EV in the multivariate analysis we made, while PC/ SD and age were associated to HREV in the multi-variate analysis of the paper published by Barrera, <span class="elsevierStyleItalic">et al.</span> In our study, the only independent variable associated to EV in the multivariate analysis was platelet count (p<0.05).</p><p id="p0015" class="elsevierStylePara elsevierViewall">The previous differences in results may be explained by differences in the design of the studies. The major difference in their designs probably is that we evaluated PC/SD for the prediction of varices of any kind, since the latest AASLD guideline,<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> which took place after Baveno IV,<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, as long as in patients with Child B or C classes. On the other hand,</p><p id="p0020" class="elsevierStylePara elsevierViewall">Barrera, <span class="elsevierStyleItalic">et al.</span>, evaluated the index for the diagnosis of HREV. The other important difference in design is that we used the 909 cut-off point proposed by Giannini, <span class="elsevierStyleItalic">et al.</span>, for the PC/SD in the analysis, while Barrera, <span class="elsevierStyleItalic">et al.</span>, calculated their own cut-off point in a ROC-curve.</p><p id="p0025" class="elsevierStylePara elsevierViewall">Besides, there were some differences in the studied samples that could have contributed to explain the differences found in some of the results. Barrera, <span class="elsevierStyleItalic">et al.</span>, used a sample composed by men in only 43.3%, with a mean age of 66 years and a Child class distribution of A - 46.2%, B - 38.8% and C - 15%. We had a sample with a 56.7% male proportion, with a mean age of 56.6 years and with a Child class distribution of A - 57.6%, B - 37.7% and C - 4.6%. In our study, cirrhosis was caused by viral hepatitis in 43.9% of cases, by alcohol abuse in 29.3%, by viral hepatitis and alcohol in 10.4% and by other causes in 16.5%; Barrera, <span class="elsevierStyleItalic">et al.</span>, found only 7.5% of viral hepatitis as cause of cirrhosis, while alcohol abuse was its cause in 26.9%, autoimmune hepatitis in 11.9%, primary biliary cirrhosis in 14.9%, non-alcoholic steatohepatitis in 14.9% and cryptogenic cirrhosis in 26.9%, which suggests a somewhat different population in the studies. We found EV on endoscopy in 73.2% of our cases, while Barrera, <span class="elsevierStyleItalic">et al.</span>, found them in 85%.</p><p id="p0030" class="elsevierStylePara elsevierViewall">Despite the mentioned differences between both studies, they agree in the most important, their conclusion: PC/SD cannot replace endoscopy in the screening of EV or of HREV in cirrhotic patients.</p><p id="p0035" class="elsevierStylePara elsevierViewall">Reply:</p><p id="p0040" class="elsevierStylePara elsevierViewall">We thank Dr. De Mattos for their interest in our study. Many attempts have been performed to find comfortable and cost-effective methods different from endoscopy for diagnosing esophageal varices. These non-invasive approaches include, among others, the following: platelet count; spleen diameter; platelet count and Child-Pugh score; spider an-giomata, ALT and albumin; CT esophageal study; fibrotest ((c-glutamyltranspeptidase, haptoglobin bilirubin, apolipoprotein A, alpha-2-macroglobu-lin); and fibroscan (transient elastography).<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">1</span></a> We are fully aware of the limitations of these predictors, but among all of these methods, platelet count/spleen diameter ratio has been one of the most consistently evaluated.<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">2</span></a><span class="elsevierStyleSup">–</span><a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">4</span></a> This ratio has been developed by Gianini, <span class="elsevierStyleItalic">et al.</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.</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, infection, medications, alcohol, etc. It has also been described that cirrhosis can be associated with lower thrombopoetin levels and increased antibody mediated platelet destruction,<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. On the other hand, spleen bipolar diameter in most of the studies is measured by ultrasound. This is an operator-dependent method that could have low reproducibility if it is not performed with a proper technique. All the above-mentioned factors could explain the variability of the positive predictive value (PPV) and negative predictive value (NPV) among different studies. In spite of this, there are many publications on different populations that support the utility of this ratio on predicting presence of esophageal varices, many of them with similar or superior PPV and NPV to our findings.<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">2</span></a><span class="elsevierStyleSup">–</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.</p><p id="p0050" class="elsevierStylePara elsevierViewall">With current data, we think that platelet count, spleen diameter and platelet count/spleen diameter ratio are a useful tool on approaching to portal hypertension, esophageal varices and cirrhosis diagnosis, especially when there is limited access to endoscopy examination. 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. In our opinion, endoscopy will never be fully replaced by non-invasive parameters for eso-phageal varices final diagnosis. Hopefully, non invasive parameters could help to categorize patients on high probability, intermediate probability or low probability of esophageal varices. With this categorization, we could expect to give priority for endoscopy exam for intermediate-risk patients. High-risk patients could choose to begin empiric therapy or perform an endoscopy exam for diagnosis according to patient’s preference and access to endoscopy. Low-risk patients could be given a lower priority for endoscopy exam, as suggested by Burton, <span class="elsevierStyleItalic">et al.</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.<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.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Dear Editor" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2010-04-23" "fechaAceptado" => "2010-06-04" "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bs0005" "bibliografiaReferencia" => array:13 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1." 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 2 | 0 | 2 |
| 2024 October | 6 | 4 | 10 |
| 2024 September | 12 | 11 | 23 |
| 2024 August | 22 | 10 | 32 |
| 2024 July | 13 | 2 | 15 |
| 2024 June | 23 | 4 | 27 |
| 2024 May | 19 | 6 | 25 |
| 2024 April | 10 | 5 | 15 |
| 2024 March | 29 | 4 | 33 |
| 2024 February | 29 | 12 | 41 |
| 2024 January | 26 | 7 | 33 |
| 2023 December | 10 | 6 | 16 |
| 2023 November | 16 | 4 | 20 |
| 2023 October | 27 | 2 | 29 |
| 2023 September | 16 | 2 | 18 |
| 2023 August | 31 | 3 | 34 |
| 2023 July | 31 | 2 | 33 |
| 2023 June | 33 | 7 | 40 |
| 2023 May | 50 | 3 | 53 |
| 2023 April | 50 | 3 | 53 |
| 2023 March | 43 | 12 | 55 |
| 2023 February | 40 | 1 | 41 |
| 2023 January | 27 | 5 | 32 |
| 2022 December | 27 | 8 | 35 |
| 2022 November | 16 | 7 | 23 |
| 2022 October | 17 | 10 | 27 |
| 2022 September | 34 | 8 | 42 |
| 2022 August | 18 | 8 | 26 |
| 2022 July | 25 | 11 | 36 |
| 2022 June | 18 | 9 | 27 |
| 2022 May | 23 | 18 | 41 |
| 2022 April | 31 | 12 | 43 |
| 2022 March | 43 | 14 | 57 |
| 2022 February | 33 | 9 | 42 |
| 2022 January | 53 | 6 | 59 |
| 2021 December | 32 | 9 | 41 |
| 2021 November | 9 | 9 | 18 |
| 2021 October | 6 | 8 | 14 |
| 2021 September | 15 | 10 | 25 |
| 2021 August | 10 | 6 | 16 |
| 2021 July | 14 | 7 | 21 |
| 2021 June | 6 | 7 | 13 |
| 2021 May | 16 | 5 | 21 |
| 2021 April | 59 | 15 | 74 |
| 2021 March | 10 | 11 | 21 |
| 2021 February | 10 | 10 | 20 |
| 2021 January | 7 | 10 | 17 |
| 2020 December | 10 | 6 | 16 |
| 2020 November | 7 | 9 | 16 |
| 2020 October | 4 | 5 | 9 |
| 2020 September | 7 | 8 | 15 |
| 2020 August | 9 | 6 | 15 |
| 2020 July | 6 | 0 | 6 |
| 2020 June | 7 | 2 | 9 |
| 2020 May | 0 | 3 | 3 |
| 2020 April | 1 | 3 | 4 |
| 2020 March | 3 | 4 | 7 |
| 2020 February | 3 | 1 | 4 |
| 2020 January | 3 | 2 | 5 |
| 2019 December | 4 | 7 | 11 |
| 2019 November | 2 | 2 | 4 |
| 2019 October | 0 | 1 | 1 |
| 2019 September | 0 | 1 | 1 |
| 2019 August | 2 | 2 | 4 |
| 2019 July | 10 | 7 | 17 |
| 2019 June | 1 | 4 | 5 |
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