SAAG and Platelet Count/Splenic Diameter Ratio as Non Invasive Predictors of Esophageal Varices in Cirrhosis

Deepak, Nandan (2007) SAAG and Platelet Count/Splenic Diameter Ratio as Non Invasive Predictors of Esophageal Varices in Cirrhosis. Masters thesis, Stanley Medical College, Chennai.


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INTRODUCTION: Portal hypertension commonly accompanies the presence of liver cirrhosis, and the development of esophageal varices is one of the major complications of portal hypertension. The prevalence of esophageal varices in patients with liver cirrhosis may range from 60% to 80%, and the reported mortality from variceal bleeding ranges from 17% to 57%. Cirrhotic patients with Portal Hypertension who develop esophageal varices are at a very high risk of variceal bleeding and Variceal rupture is a common cause of death in cirrhosis. Esophageal varices appear only after the hepatic venous pressure gradient (HVPG) has increased to at least 10 to 12 mm Hg.1/3 of gastrointestinal bleedings reveal pre-existent cirrhosis. In patients with cirrhosis the incidence of esophageal varices increases by nearly 5% per year, and the rate of progression from small to large varices is approximately 5 to 10 % per year. The risk of variceal rupture is greatest in the 2 years following diagnosis. In the 2 years following the first detection of esophageal varices, risk of variceal bleeding ranges between 20% to 30% and results in a mortality of 25% to 50% within a week of the first bleeding episode. Therefore, portal hypertensive bleeding prevention remains at the forefront of the long-term management of cirrhotic patients. As there is clear evidence that primary prevention of variceal rupture is cost effective in reducing death rate, screening for esophageal varices (EV) is recommended. Prophylactic treatment in patients with non selective Beta blockers in varices that has never bled appears to decrease the incidence of bleeding by 40 to 50 % and prolong survival. So endoscopic screening for varices in patients with cirrhosis is desirable, some have suggested this should be repeated every other year. AIMS AND OBJECTIVES: 1. To identify non invasive parameters for prediction of esophageal varices in newly diagnosed patients with cirrhosis. 2. To assess the Predictive value of Platelet count/ splenic diameter ratio in predicting esophageal varices in cirrhotic patients. 3. To assess the usefulness of SAAG (Serum Ascitic Albumin Gradient) in predicting esophageal varices in patients with cirrhosis. 4. To assess the predictive value of combining two parameters; Platelet count/ splenic diameter ratio and Serum ascitic albumin gradient (SAAG) in patients with decompensated liver disease presenting as ascites. MATERIALS AND METHODS: Type of Study: Cross sectional study. Sample: Liver clinic, Gastroenterology Department, and Medicine Out Patient Department and In patient wards of Stanley Medical College, Chennai. Duration of study: 2005 August - 2006 July. Inclusion Criteria: All newly diagnosed cases of cirrhosis liver, based on physical examination, biochemical parameters, ultrasound abdomen and upper GI endoscopy. Exclusion Criteria: • Present or previous history of portal hypertensive bleeding. • Patients with hepatocellular carcinoma. • Portal vein thrombosis. • Previous or current treatment with β blockers, diuretics or other vasoactive drugs. • Budd Chiari Syndrome. SUMMARY AND CONCLUSIONS: Hundred patients with newly diagnosed cirrhosis without prior history of bleed were subjected to clinical evaluation. All patients underwent biochemical tests, like liver function tests, complete blood counts, renal function tests, prothrombin time, ultrasonography of the abdomen to confirm the presence of cirrhosis and to record the spleen bipolar diameter, portal vein size, ascites and presence of collaterals and Ascitic fluid analysis in patients with ascites. Upper GI endoscopy was done in all patients to confirm the presence of varices and also to grade them. We tried to identify non invasive parameters for predicting esophageal varices in Cirrhotic patients. We assessed the role of Platelet count/Splenic diameter ratio and SAAG for predicting esophageal varices in cirrhotic patients. Presence of varices increases as patients progress to decompensated liver disease. (Child Pugh grade B & C). Decrease in platelet count was found to be an predictor of esophageal varices in patients with cirrhosis. Ultrasound parameters Spleen bipolar diameter and portal vein size also predict the presence of esophageal varices. When a cut off value of Platelet count/ splenic diameter ratio of ≤ 909 was applied in order to take in to consideration the decrease in platelet count due to hypersplenism; it was found to be a good predictor of presence and grade of esophageal varices. The sensitivity of PC/SD Ratio of ≤909 in predicting presence of esophageal varices was 88 % with it’s positive predictive value was 93 %. Value of Serum ascitic albumin gradient (SAAG) more than 1.1g/dl is found to be a predictor for presence and grade of esophageal varices. The sensitivity of SAAG > 1.1g/dl in predicting the presence of varices in the subgroup of patients with ascites was 81 %and it’s positive predictive value was100 %. When the cut off value of SAAG was taken as 1.20± .05 gm/dl it was noted that the test achieved 100 % specificity and sensitivity ranging from 77.8 to 81.5 %. If only SAAG was taken in to account, varices were diagnosed in 61 % of the cirrhotic patients with ascites. When Platelet count/ Splenic diameter ratio cut off of ≤ 909 was also applied, varices were diagnosed in 66 %. Combining these two non invasive parameters in subgroup with ascites can increase the reliability of predicting esophageal varices. So these parameters can be used to regularly follow up the cirrhotic patients with ascites for the progression of grade of varices at specific intervals. The use of Platelet count/ Splenic diameter ratio, SAAG and combination of these two non invasive parameters in appropriate subgroups of cirrhotic patients for screening and follow up of esophageal varices can substantially reduce the cost of health care and discomfort for patients as well as reduce burden on endoscopy units.

Item Type: Thesis (Masters)
Uncontrolled Keywords: Serum Ascitic Albumin Gradient (SAAG) ; Platelet Count ; Splenic Diameter Ratio ; Non Invasive Predictors ; Esophageal Varices ; Cirrhosis.
Subjects: MEDICAL > General Medicine
Depositing User: Subramani R
Date Deposited: 23 Mar 2018 04:04
Last Modified: 24 Mar 2018 05:11

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