Noninvasive Test Identifies Patients With Cirrhosis who can Avoid Endoscopy
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Application of a novel noninvasive test comprised of albumin, bilirubin and platelets successfully identified patients with cirrhosis who could safely avoid screening endoscopy without the need for liver stiffness measurements by transient elastography compared with the Baveno VI criteria, according to a published study.
“As TE is not widely available, the Baveno VI criteria could not be applied in many clinical settings,” Guan Sen Kew, MD, from the National University Health System in Singapore, and colleagues wrote. “As such, we aim to determine a concise clinical criterion as an alternative noninvasive tool to predict absence of [high-risk varices] among patients with compensated cirrhosis to avoid screening esophagogastroduodenoscopy (EGD).”
The multi-ethnic Asian cohort comprised 352 patients, most of whom were Chinese (68.5%). High-risk varices were present on EGD in 56 patients and 120 patients met the Baveno VI criteria.
Multivariable analysis revealed that an albumin level of 40 g/dL or less (HR = 2.65; 95% CI, 1.34-5.24), bilirubin of 22 µmol/L or more (HR = 2.7; 95% CI, 1.38-5.26), and platelet count of 114,000 µL or less (HR = 3.88; 95% CI, 2.03-7.41) predicted high-risk varices. Application of this “ABP” criteria identified 110 patients, only two of whom had high-risk varices.
The area under the receiver operating characteristic curve (AUROC) of the ABP criteria was slightly higher than the Baveno VI (0.78 vs. 0.73), and the two criteria had similar sensitivity (96% vs. 93%), specificity (36% vs. 39%), positive predictive value (both 22%), and negative predictive value (98% vs. 97%).
“Identification of patients with low probability of having [high-risk varices] is essential to reduce the number of screening EGD with its associated cost and risks,” Kew and colleagues wrote. “Components of our novel ABP criteria, namely serum albumin, serum bilirubin and platelet count, are standard laboratory tests readily available and routinely performed in clinical practice.”
The researchers concluded that prospective validation of this noninvasive criteria should be tested in other populations to confirm its utility. – by Talitha Bennett
Disclosures: The authors report no relevant financial disclosures.
Perspective
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Jamak Modaresi Esfeh, MD
Having noninvasive yet readily available tools to assist limiting the number of patients requiring screening endoscopy for esophageal and gastric varices is ideal. This is an interesting study with an attempt to achieve this goal.
The study authors used a combination of three routinely checked blood tests (platelet count, bilirubin and albumin) to decide who will not benefit from screening endoscopy. In other words, this combination of lab tests was used to rule out the unnecessary endoscopies. The authors used BAVENO VI criteria as their start point and compared their results with the results of liver stiffness measurement using transient elastography (TE) combined with platelet count. Based on BAVENO VI criteria, patients with compensated advanced chronic liver disease (cACLD) who have liver stiffness measurement (LSM) less than 20 kPa and a platelet count greater than 150 × 109 cells/L do not need to undergo screening endoscopy.
However, patient population included in BAVENO VI had virus related cACLD. The diagnostic value of TE for clinically significant portal hypertension (CSPH) secondary to other etiologies remains to be ascertained. In this study, patients with various etiologies of cirrhosis were included. In fact, 32.1% of the patients had NASH cirrhosis.
On the other hand, while TE combined with platelet count is evidence based, to be used as a screening tool for esophageal varices in compensated advanced chronic liver disease, its value is not as well established in gastric varices screening as esophageal type.
Overall, I read this article with great interest and I believe looking for noninvasive tools to screen cirrhotic patients for varices will be more cost effective, as well as less troublesome for the patients.
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