Introduction The Baveno VI report has recently recommended that screening endoscopy can be safely avoided in patients with a liver stiffness measurement (LSM) <20 kPa and platelet count >150. Our study aims to validate this and explore the use of other non-invasive markers of portal hypertension including spleen size, AST to platelet ratio index (APRI) and LSPS (Liver stiffness x spleen size/platelet count).
Method There were 4648 fibroscans performed from March 2013 to November 2016 at the Aberdeen Royal Infirmary. To improve test reliability, only fibroscan results with ≥60% success rate with an interquartile range ≤30% of the median value were included in this study. Patients with LSM ≥14 kPa underwent electronic medical records review. Those with endoscopy and platelet within 12 months and 3 months of the fibroscan respectively were identified. AST and USS of these patients were also recorded in this study. Clinically significant varices (CSV) were defined as Grade II varices requiring endoscopic treatment or beta-blocker prophylaxis.
Results There were 605 patients with LSM ≥14 kPa after excluding duplicated scans and scans with lower reliability. 290 of these patients with a LSM ≥14 kPa had endoscopy within 12 months of their fibroscan tests. The mean age was 59±13 years and the commonest aetiology was alcohol-related liver disease (33%) followed by non-alcoholic fatty liver disease (32%). 53 of the patients (18%) had CSV. 42 patients were started on prophylactic beta-blocker, 7 patients had primary variceal ligation and 4 patients had presented with acute variceal bleed requiring emergency variceal ligation. The total number of patients (n=) included in the statistical calculation for each screening test is different as not all patients had their AST and USS checked. The result is summarised in the table below.
Conclusion This study has shown that a combination of platelet >150 and LSM <20 kPa as recommended by the Baveno VI report has a high negative predictive value for the presence of clinically significant varices. 45 endoscopies (16%) in this study could have been safely avoided. Splenomegaly was previously thought to be a sensitive sign of portal hypertension. Nevertheless, splenomegaly taken alone has not shown to be a sensitive screening test in this study. Our study has shown that LSPS <2 is a sensitive predictive marker of CSV in patients with liver disease of various etiologies. In hospitals without the facilities of fibroscan machines, APRI can be utilised as an alternative screening test with a high negative predictive value.
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