SUMMARY
Bleeding esophageal varices secondary to liver cirrhosis is the commonest cause of mortality in cirrhosis (Burroughs et al., 2009).
Studies of the natural history of esophageal varices indicate that esophageal varices are present in about half of cirrhotic patients when endoscopy is performed at the time of the diagnosis of cirrhosis. The presence of esophageal varices correlates with the severity of liver disease. Varices are present in 40% of Child A patients, in 85% of Child C patients, and 5%–15% of patients with cirrhosis develop varices every year (Schuppan and Afdhal, 2008).
At least two-thirds of liver cirrhosis patients develop esophageal varices during the course of their disease, however only 30-40% of patients with cirrhosis develop severe upper gastrointestinal bleeding (Tacke et al., 2007).
To reduce the number of endoscopies, many studies were carried out to identify features that may noninvasively predict the presence of EV of any size, or at least of medium-large size at higher risk of bleeding (Berzigotti et al., 2008) , ( de Franchis et al., 2008) and ( Perri et al., 2008).
These studies, performed in patients with compensated or decompensated cirrhosis, focused on clinical, biochemical, and instrumental (ultrasonography, computed tomography, endoscopic capsule) data, identifying single variables or combinations of variables able to predict esophageal varices. However, the accuracy of prediction was suboptimal in all settings, making it inadvisable to adopt a noninvasive screening policy for esophageal varices in clinical practice (D’Amico et al., 2004).
Some studies have found linear relationships between portal hypertension, esophageal varices, and liver stiffness measurement evaluated by transient elastography (Kazemi et al., 2006), ( Vizzutti et al., 2007) thus suggesting transient elastography as a complementary technique in the assessment of portal hypertension.
Insulin resistance exceedingly common in patients with hepatitis C virus (HCV)-related chronic liver disease (Petta et al., 2008) and both experimental (Shintani et al., 2004) and clinical studies (Moucari et al., 2008) suggested that HCV per se is able to decrease insulin sensitivity.
Insulin resistance has been systematically associated with advanced fibrosis and fibrosis progression in several reports (Hui et al., 2003), (Camma et al., 2006), (Petta et al., 2008).
This work is targeted to find a relationship between insulin resistance and (platelet count/spleen diameter ratio) as a predictor of the presence of esophageal varices in patients of liver cirrhosis due to HCV.
We enrolled in the study 50 patients with HCV cirrhosis, consecutively, the 50 patients were divided into 2 groups according to the results of the upper GIT endoscopy: Group I: Included patients with liver cirrhosis and no esophageal varices (10 patients). Group II: included patients with liver cirrhosis and esophageal varices (40 patients), Group II was further subdivided into 2 groups according to the endoscopic grading of esophageal varices. (The North Italian Endoscopic Club for the Study and Treatment of Esophageal Varices.1988), Group IIA: included patients with liver cirrhosis and small sized esophageal varices (Small EV) (16 patients). Group IIB: included patients with liver cirrhosis and (medium and large) sized esophageal varices (Large EV) (24 patients).
Patients were included if they had a diagnosis of HCV cirrhosis (Child-Pugh classes A, B and C) based on history, physical examination, biochemical parameters, radiological findings (Ultrasound), or liver biopsy.
The following data were collected at the time of recruitment: Age, Sex, Weight, height and BMI.
A 12-hour overnight fasting blood sample was drawn at the time of recruitment for CBC and to determine the serum levels of serum bilirubin, serum albumin, AST, , ALT, Serum Creatinine and BUN, prothrombin time and INR, plasma glucose concentration, Fasting serum insulin was determined by an enzyme-linked immunosorbent assay .
IR was determined by the homeostasis model assessment (HOMA) method (Page 38).
Anti-HCV antibodies, Hepatitis viral markers for HBV (HBsAg) were done. HCV RNA was tested at the time of recruitment by qualitative polymerase chain reaction (limit of detection, 50 IU/mL).
After an overnight fast, all patients underwent an ultrasound examination to evaluate the signs of portal hypertension (portal vein flux and diameter, respiratory variations, and flux of splenic and mesenteric veins, splenomegaly, and ascites). On the same day, upper gastrointestinal endoscopy was performed by two endoscopists working together and unaware of clinical, laboratory, and ultrasonographic data. The size of the varices was determined according to The North Italian Endoscopic Club for the Study and Treatment of Esophageal Varices 1988. Discrepancies between examiners were infrequent and were resolved by discussion.
Exclusion criteria included the following: Patient with other causes of liver cirrhosis, previous or current GIT bleeding or endoscopic treatments for varices (band ligation or sclerotherapy), previous surgery for portal hypertension or trans-jugular intrahepatic portosystemic stent placement, current treatment with beta-blockers, diuretics, or other vasoactive drugs, portal vein or splenic vein thrombosis, hepatocelluar carcinoma and previous and current alcohol abuse.
Thorough history and clinical evaluation with special emphasis on previous history of encephalopathy, liver size, splenomegaly, presence of ascites, jaundice and they were divided according to modified Child-Pugh scoring system.
Continuous variables were summarized and statistically analyzed including mean and standard deviation, P value, independent sample (T) test, ROC curve analysis and others.
Of these 50 patients, 40 (80%) had esophageal varices (Group II) and 10 patients did not have varices (Group I). Mean age of Group I was 58.5±7.64 and that of Group II was 59±10.3. The difference in age among the study groups was statistically non significant (p> 0.05).
Group I included 10 patients, 7 of them were males (70%), and 3 were females (30%), while Group II included 40 patients, 30 of them were males (75%) and 10 were females (25%). The difference in sex distribution among the study groups was statistically non significant (p> 0.05).
There was statistically a highly significant difference between group I compared to group II as regards detection of palpable spleen and ascites by clinical examination. While there was no statistically difference between both groups as regards detection of palpable liver, lower limb oedema and jaundice.
The laboratory parameters of group I compared to group II showed that there was statistically significant difference as regards values of hemoglobin, hematochrite, serum bilirubin, serum albumin level, fasting insulin level and insulin resistance (measured by HOMA-IR index) and platelet count, while there was no statistical significant difference as regards values of the other laboratory parameters included in the study.
According to the Modified Child-Pugh Score: In Group I, 5 patients (50%) were Child A, 3 patients (30%) ware Child B, and only 2 patients (20%) were Child C, while in Group II, 14 patients (15 %) were Child A, 20 patients (50%) were Child B and only 14 patients (35%) were Child C. The presence of varices was statistically highly significant in relation to the advanced Child scoring system [Group I (5.8±1.9) and Group II (9.8±2.3)].
The ultrasonographic findings of group II in comparison to group I showed that there was statistically high significant difference as regards the presence of splenomagaly, ascites and size of spleen.
Patients with large EV (Group IIB) were significantly older than those with small EV (Group IIA).
There was statistically significant difference between group IIA when compared to group IIB, as regards detection of palpable spleen by clinical examination.
There was statistically significant difference as regards values of serum albumin, bilirubin level, platelet count, FIL and HOMA-IR between patients of small EV (Group IIA) and patients of Large EV (Group IIB).
According to the modified Child- Pugh score: In group IIA (16 patients), 5 patients (31.25%) were Child A, 7 patients (43.75%) were Child B and 4 patients (25%) were Child C. while in group IIB (24 patients), 1 patient (4.17%) was Child A, 13 patients (54.17%) were Child B and 10 patients (41.67%) were Child C. The presence of large varices was significantly related to the advanced Child scoring group IIA (7.38±2.3) and group IIB (12.2±1.9) .
There was statistically significant difference between both groups as regards of ultrasongraphic finding including the presence of ascitis and size of the spleen while there was no statistically significant difference as regards other ultrasongraphic findings.
Mean value of platelets count to spleen diameter ratio (in mm) (PC/SD) in patients with esophageal varices in comparison to patients without esophageal varices is statistically significant P value |
