LIVER

Which patients with primary biliary cirrhosis or primary sclerosing cholangitis should undergo endoscopic screening for oesophageal varices detection?

B Bressler, R Pinto, D El-Ashry, E J Heathcote

University Health Network, Toronto Western Hospital, University of Toronto, Toronto, Canada

Correspondence to:
Correspondence to:
Dr E J Heathcote
Toronto Western Hospital, University Health Network, 399 Bathurst Street, 6th Fl Fell Pavilion Rm 170, Toronto, Ontario M5T 2S8, Canada; jenny.heathcote{at}utoronto.ca

Background: Recent guidelines from an AASLD Single Topic Symposium suggest that patients with cirrhosis, including those with primary biliary cirrhosis (PBC) or primary sclerosing cholangitis (PSC), should be screened for oesophageal varices when the platelet count is <140 000/mm³.

Aim: To determine the validity of these guidelines in clinical practice in patients with PBC or PSC.

Methods: Retrospective review of individuals undergoing screening upper endoscopy for oesophageal varices at a single centre. Oesophageal varices were reported as being present or absent.

Results: A total of 235 patients with chronic liver disease, including 86 patients with PBC (n = 79) or PSC (n = 7), 104 patients with chronic viral hepatitis, and 45 with non-alcoholic cirrhosis of differing aetiologies, underwent a single screening endoscopy between 1996 and 2001. Oesophageal varices were detected in 26 (30%) of the PBC/PSC group, 38 (37%) of the viral hepatitis group, and 21 (47%) of the "other" group. Applying multiple logistic regression analysis to the data in the group with PBC/PSC, platelets <200 000/mm³ (odds ratio (OR) 5.85 (95% confidence interval (CI) 1.79–19.23)), albumin <40 g/l (OR 6.02 (95% CI 1.78–20.41)), and serum bilirubin >20 µmol/l (OR 3.66 (95% CI 1.07–12.47)) were shown to be independent risk factors for oesophageal varices. Prothrombin time was unhelpful. The values at these cut offs were not useful in predicting oesophageal varices in the other groups.

Conclusion: We conclude that current guidelines recommended by the AASLD Single Topic symposium are invalid in our cohort of patients with PBC and PSC. Patients with a platelet count <200 000/mm³, an albumin level <40 g/l, and a bilirubin level >20 µmol/l should be screened for oesophageal varices.

Abbreviations: PT, prothrombin time; PBC, primary biliary cirrhosis; PSC, primary sclerosing cholangitis; ROC, receiver operating characteristic; OR, odds ratio

Keywords: primary biliary cirrhosis; primary sclerosing cholangitis; endoscopic screening; oesophageal varices

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