Abd Elbaser, E. (2021). Non-invasive Screening of Esophageal Varices in Patients with Liver Cirrhosis. Afro-Egyptian Journal of Infectious and Endemic Diseases, 11(4), 318-319. doi: 10.21608/aeji.2021.204975
Elsayed S Abd Elbaser. "Non-invasive Screening of Esophageal Varices in Patients with Liver Cirrhosis". Afro-Egyptian Journal of Infectious and Endemic Diseases, 11, 4, 2021, 318-319. doi: 10.21608/aeji.2021.204975
Abd Elbaser, E. (2021). 'Non-invasive Screening of Esophageal Varices in Patients with Liver Cirrhosis', Afro-Egyptian Journal of Infectious and Endemic Diseases, 11(4), pp. 318-319. doi: 10.21608/aeji.2021.204975
Abd Elbaser, E. Non-invasive Screening of Esophageal Varices in Patients with Liver Cirrhosis. Afro-Egyptian Journal of Infectious and Endemic Diseases, 2021; 11(4): 318-319. doi: 10.21608/aeji.2021.204975
Non-invasive Screening of Esophageal Varices in Patients with Liver Cirrhosis
Tropical Medicine Department, Zagazig University, Egypt.
Abstract
A new study in this issue of the Afro-Egyptian journal of infectious and endemic diseases investigated the use of the PAPAS score (Platelet/Age/ Phosphatase/AFP/AST) for predicting EVs in HCV-related cirrhotic patients. This study included patients at different stages of cirrhosis (compensated and decompensated) who underwent screening EGD to detect the presence of EVs. The PAPAS score and other non-invasive scores (APRI, FIB4, Lok Scor) were calculated and compared their accuracy in predicting the development of EVs. The results of this study showed that patients with EVs have a significantly higher PAPAS score than those without EVs. The PAPAS index showed higher diagnostic accuracy than the other tests (APRI, FIB-4, and Lok Score). PAPAS index AUCs were 0.939 for diagnosis of EVs with 86% sensitivity, 93.33% specificity, 95.2% PPV, 73.7% NPV, and AUC 0.746 for detecting Large EVs with 94.87% sensitivity, 86.43% specificity, 71.2% PPV, 86.7% NPV, indicating its usefulness in identifying patients with large varices who require endoscopy.
Highlights
This study introduced a new noninvasive score that may be –hopefully- helpful for the early prediction of HRVs, but the several concerns raised in this study need to be reevaluated in future researches.
Given the invasiveness of the Esophago-Gastro-Duodenoscopy (EGD), non-tolerability, and cost, non-invasive evaluation of the patients with compensated cirrhosis is warranted. The last Baveno VI consensus has reported that compensated cirrhotic patients who have platelets count > 150.000/mm3 and liver stiffness measurement (LSM < 20 KPs) are less likely to have high-risk varices (HRVs) and can safely avoid screening EGD [1]. Other blood tests were investigated for the same purpose. Our group has assigned a new blood based score including the platelet count, serum albumin and bilirubin levels (ALBL-PLT). It was showed that ALBL-PLT score of more than three has a good predictive value in predicting HRVs among compensated cirrhotic patients. The sensitivity of the ALBL-PLT score in predicting HRVs is 100%, specificity of 78%, positive predictive value (PPV) is 80% and a negative predictive (NPV) value of 100% and AUC is 0.894. By applying this score, 84 (41.1%) patients can avoid EGD with none of them had HRVs on endoscopy [2]. In a similar cohort of patients, it was proved the beneficial effect of the ALBL-PLT score in predicting HRVs among cirrhotic patients [3]. However, most of the results of the non-invasive tests are modest and not satisfactory to replace EGD screening.
A new study in this issue of the Afro-Egyptian journal of infectious and endemic diseases investigated the use of the PAPAS score (Platelet/Age/ Phosphatase/AFP/AST) for predicting EVs in HCV-related cirrhotic patients. This study included patients at different stages of cirrhosis (compensated and decompensated) who underwent screening EGD to detect the presence of EVs. The PAPAS score and other non-invasive scores (APRI, FIB4, Lok Scor) were calculated and compared their accuracy in predicting the development of EVs. The results of this study showed that patients with EVs have a significantly higher PAPAS score than those without EVs. The PAPAS index showed higher diagnostic accuracy than the other tests (APRI, FIB-4, and Lok Score). PAPAS index AUCs were 0.939 for diagnosis of EVs with 86% sensitivity, 93.33% specificity, 95.2% PPV, 73.7% NPV, and AUC 0.746 for detecting Large EVs with 94.87% sensitivity, 86.43% specificity, 71.2% PPV, 86.7% NPV, indicating its usefulness in identifying patients with large varices who require endoscopy.
This is the first study that showed promising benefits of applying the PAPAS score among cirrhotic patients secondary to chronic HCV. However, several concerns in this study need to be raised, first; this study included decompensated cirrhotic patients, while non-invasive tests target those with compensated cirrhosis to determine who are at high risk to undergo screening endoscopy and save those who are at low risk, the decompensated patients always have HRVs and the results of this study showed that 100% of decompensated cirrhotic patients have HRVs. Second; this study defined the HRVs as varices with red signs only, but the
AASLD has accurately defined the HRVs as large or moderate sized varices and small sized varices with red signs or in patients with decompensated cirrhosis [1]. Third; this study showed that no significant difference in the platelet count among patients with small and large EVs, this is surprising, because the different non-invasive scores included the platelets count as an important indicator of portal hypertension and high risk varices (HRVs) [4-6]. Another important point in this study, the PAPAS score was originally described in those with chronic HBV to evaluate the fibrosis state. This is the first study for its evaluation in HCV after Ozel, et al.; 2015 who reported that PAPAS score was not superior to other score in prediction of fibrosis among patients with chronic hepatitis C [7].
In conclusion, this study introduced a new noninvasive score that may be –hopefully- helpful for the early prediction of HRVs, but the several concerns raised in this study need to be reevaluated in future researches.
References
Garcia-Tsao G, Abraldes JG, Berzigotti A, Bosch J. Portal hypertensive bleeding in cirrhosis: Risk stratification, diagnosis, and management: 2016 practice guidance by the American Association for the study of liver diseases. Hepatology. 2017; 65(1):310-35.
Abd Elbaser ES, Sharaf AL, Farag AA. Prediction of high-risk esophageal varices in patients with compensated cirrhosis using albumin-bilirubin-platelet score. Eur J Gastroenterol Hepatol. 2021 Aug 16.
Alsebaey A, Elmazaly MA, Abougabal HM. Prediction of esophageal varices in patients with HCV-related cirrhosis using albumin-bilirubin, platelets-albumin-bilirubin score, albumin-bilirubin-platelets grade, and GAR. Egyptian Liver Journal. 2020;10(1):1-8.
Lin ZH, Xin YN, Dong QJ, Wang Q, Jiang XJ, Zhan SH, et al. Performance of the aspartate aminotransferase-to- Platelet ratio index for the staging of hepatitis C-related fibrosis: an updated meta- analysis. Hepatology. 2011;53:726-36
Sterling RK, Lissen E, Clumeck N, Sola R, Correa MC, Montaner J, et al. Development of a simple noninvasive index to predict significant fibrosis patients with HIV/HCV co-infection. Hepatology. 2006;43:1317-25.
Lok AS, Ghany MG, Goodman ZD, Wright EC, Everson GT, Sterling RK, et al. Predicting cirrhosis in patients with hepatitis C based on standard laboratory tests: results of the HALT-C cohort. Hepatology. 2005;42(2):282-92.
Ozel BD, Poyrazoğlu OK, Karaman A, Karaman H, Altinkaya E, Sevinç E, et al. The PAPAS index: a novel index for the prediction of hepatitis C-related fibrosis. European Journal of Gastroenterology & Hepatology. 2015;27(8):895-900.
View on SCiNiTO
Top