Evaluation of spleen stiffness compared to liver stiffness as non-invasive predictors for esophageal varices in patient with liver cirrhosis (Egyptian study)

Introduction: Patients with liver cirrhosis have high incidence of oesophageal varices with high morbidity and mortality due to bleeding; active surveillance via upper gastrointestinal endoscopic examination may be unnecessary for patients, therefore, the increasing number of non-invasive predictors of oesophageal varices has gained wide attention. Nevertheless, few Meta analyses have involved predicting oesophageal varices using Liver Stiffness measured using fibroscan. Aim of the work: To compare between predictive values of spleen stiffness and liver stiffness as non-invasive predictors of oesophageal varices in patients with liver cirrhosis. Patients and methods: After taking consent, 61 patients with liver cirrhosis attending outpatient clinic at Theodor Biharz Research Institute were assessed by history taking, clinical examination, Complete blood count, serum alanine aminotransferase, serum aspartate aminotransferase, bilirubin, serum albumin, prothrombin concentration, Alpha fetoprotein, abdominal ultrasound, upper gastrointestinal endoscopy and fibroscan. Data was collected and analysed. Results: This study included 61 patients with liver cirrhosis, 38 of them were males, with mean age 58.28 ± 1.18 years. All patients had post hepatitis C cirrhosis, and 6 of them had history of bilharziasis in addition. Using U/S there were 12 patients (19.67%) with mild ascites, 13 patients (21.31%) with moderate ascites and 7patients (11.48%) with marked ascites 53 patients (86.90%) had enlarged spleen, 8 patients (13.10%) showed average spleen with Splenic longitudinal diameter mean (16.08 ± 2.81) cm by U/S, 47 patients (77%) had shrunken liver, 12 patients (19.7 %) showed average liver, 2 patients (3.30%) had enlarged liver with portal vein diameter mean (13.70 ± 2.26) by U/S. Splenic stiffness mean was (59.66 ± 15.15) KPa & liver stiffness mean was (29.46 ± 12.11) KPa by fibroscan. Conclusion: Spleen stiffness is superior to Liver stiffness in predicting oesophageal varices in patients with liver cirrhosis and combination of spleen stiffness and liver stiffness is better than spleen stiffness and/or liver stiffness alone with sensitivity 95% and specificity 40%. *Correspondence to: Zakaria Mahmoud, Theodor Bilharz Research Institute, Mahad Al Abhas Al Bahari, Warraq Al Arab, El Warraq, Giza Governorate, Egypt, Tel: +20-235-401-019; E-mail: ibrahimshalash@yahoo.com key words: oesophageal varices, liver, fibroscan, ultrasound Received: December 05, 2019; Accepted: December 20, 2019; Published: December 23, 2019 Introduction Acute variceal bleeding is the major cause (70%) of upper gastrointestinal bleeding in cirrhotic patients with first episode mortality rate up to 15–20%, The main predictors of bleeding in clinical practice are: large versus small varices, red wale marks, Child Pugh C versus Child Pugh A-B [1]. The gold standard for the diagnosis of oesophageal varices is EGD which must be performed at the time of cirrhosis diagnosis, in absence of varices at baseline endoscopy, EGD should be repeated every 2-3 years, whereas in patients with small varices, every 1-2 years. In the setting of decompensation (large varices), EGD should be performed annually [2]. Endoscopy being invasive may be an unnecessary burden on some patients Therefore, predictors of bleeding should help to identify patients with the highest prevalence of oesophageal varices and improve the yield and cost-effectiveness of endoscopic screening [3]. Aim of the Work: To compare between predictive values of spleen stiffness and liver stiffness as non-invasive predictors of oesophageal varices in liver cirrhosis patients. Patient and methods Patients This study was done on 61 patients diagnosed with liver cirrhosis based on history, clinical, laboratory and radiological data. Excluding patients with history of upper GIT bleeding with endoscopic intervention, Hepatocellular carcinoma, Portal vein thrombosis, and those receiving medical treatment that decrease portal hypertension or directly acting antiviral drugs or patients with history of liver transplantation or Trans jugular intrahepatic Porto systemic shunt. Shawky A (2019) Evaluation of spleen stiffness compared to liver stiffness as non-invasive predictors for esophageal varices in patient with liver cirrhosis (Egyptian study) Volume 4: 2-5 Gastroenterol Hepatol Endosc, 2019 doi: 10.15761/GHE.1000192 Patients were classified into three Groups: • Group 1: included 20 patients with liver cirrhosis and small sized oesophageal varices. • Group 2: included 21 patients with liver cirrhosis and medium or large sized oesophageal varices. • Group 3: included 20 patients with liver cirrhosis without oesophageal varices. Methods After getting the ethical committee approval and a written consent from all patients, they underwent the following: • Full history taking: with special emphasis on possible causes (bilharziasis, hepatitis B,C , etc....) and complications of liver cirrhosis ( jaundice, ascites, etc....) • Clinical examination: with special stress on stigmata of liver cell failure and signs of portal hypertension (ascites, splenomegaly, etc....) • Laboratory investigations including: Complete blood count, serum alanine aminotransferase, serum aspartate aminotransferase, total and direct bilirubin, serum albumin, prothrombin time and concentration, Alpha fetoprotein. • Abdominal ultrasonography Using real time scanning device (Philips) • Upper Gastrointestinal Endoscopy Using Pentax EMK 1000 to evaluate the presence and degree of varices. Classification of oesophageal varices was according to the recent classification of oesophageal varices [4]: Grade 1: Small straight varices not disappearing with insufflation. Grade 2: Medium sized varices occupying less than one third of the lumen. Grade 3: Large sized varices occupying more than one third of the lumen. Spleen stiffness (SSM) & Liver stiffness (LS) measurement Using Fibroscan (Echosens 502) that was performed by the same operator, 10 successful acquisitions and a success rate of at least 60% was considered reliable. Interpretation of results of Fibroscan was done. Data collection Data were screened, for normality assumption test and homogenecity of variance. Normality test of data using Shapiro-Wilk test was used. Additionally, testing for the homogenecity of variance revealed that there was no significant difference (P > 0.001). Statistical analysis The statistical analysis was conducted by using statistical SPSS Package program version 20 for Windows (SPSS, Inc., Chicago, IL). All statistical analyses were significant at level of probability (P ≤ 0.001) Limitation Technical limitations of liver elastography also apply to spleen elastography. Dedicated devices or software are required. Results This study included 61 liver cirrhosis patients, 38 of them were males, patients mean age was 58.28 ± 1.18 years. All patients had post hepatitis C cirrhosis, and 6 of them had history of bilharziasis in addition. 30 patients (49.20%) were child A, 12patient (19.70%) were child B and 19 patients (31.10%) were child C with mean child score of 7.64 ± 2.67. 14 patients (9.80%) had moderate ascites and 6 patients (23%) had marked ascites by clinical examination, while by U/S there were 12 patient (19.67%) with mild ascite,13 patient (21.31%) had moderate ascites and 7patients (11.48%) had marked ascites 53 patients (86.9%) had enlarged spleen, 8 patients (13.1%) showed average spleen with Splenic longitudinal diameter mean (16.08 ± 2.81) cm by U/S, 47 patients (77%) had shrunken liver, 12 patients (19.70.00%) showed average liver, 2 patients (3.30%) had enlarged liver, portal vein diameter mean was (13.70 ± 2.26) by U/S. Splenic stiffness mean was (59.66 ± 15.15) KPa & liver stiffness mean was (29.46 ± 12.11) KPa by fibroscan. Participants were divided into three groups Group 1: 20 patients with liver cirrhosis and small sized oesophageal varices. (8 Child class A, 2 Child class B, 10 Child class C) Group 2: 21 patients with liver cirrhosis and medium to large oesophageal varices. 4 patients with medium sized OV, 17 patients had large sized OV, 5 patients showed gastric varices in addition to oesophageal varices (10 Child class A, 3 Child class B, 8 Child class C) Group 3: 20 patients with liver cirrhosis and without oesophageal varices. (12 Child class A, 7 Child class B, 1 Child class C), There was no significant difference between the three groups on comparing WBC count, hemoglobin level, AFP, T. Bilirubin results average values in each group (Table 1). Patients who had OV (group 1) and (group had statistically significant higher INR and prothrombin concentration, lower red blood cell count and platelets count compared to patients without O.V. (group with P value < 0.05. Patients who had medium and large O.V (group 2) had statistically significant lower serum albumin level and total Proteins compared to those without O.V with P value < 0.05, while patients with small sized (group 1) had no statistically significant difference in serum albumin level when compared to patients without O.V (Table 2). Splenic diameter and portal vein diameter measured by U/S were significantly higher in patients with O.V (group 1 and 2) than in patients without O.V (Table 3). Patients with O.V in group 1 and group2 had statistically significant higher mean of spleen stiffness measured by TE compared to patients without O.V in group 3 with P value 0.0001 but when comparing patients with small sized OV (group 1) with patients who had medium and large sized OV there was no statistically significant difference regarding mean of spleen stiffness. Patients with O.V in group 1 and group 2 had statistically significant higher mean of liver stiffness measured by TE compared to patients without O.V in group 3 with p value 0.0001 and when comparing patients with small sized OV (group 1) with patients who had medium and large sized OV there was also statistically significant difference