肝硬化患者脾刚度(stiffness)预测食管静脉曲张

StephenW

Liver

Subject Category: Liver

Am J Gastroenterol 2013; 108:1101–1107; doi:10.1038/ajg.2013.119; published online 30 April 2013
Spleen Stiffness in Patients With Cirrhosis in Predicting Esophageal Varices

Praveen Sharma MD, DM1, Vijender Kirnake MD1, Pankaj Tyagi MD, DM1, Naresh Bansal MD, DNB1, Vikas Singla MD, DM1, Ashish Kumar MD, DM1 and Anil Arora MD, DM1

1Department of Gastroenterology and Hepatology, Sir Ganga Ram Hospital, New Delhi, India

Correspondence: Dr Praveen Sharma, MD, DM, Department of Gastroenterology, Sir Ganga Ram Hospital, New Delhi, India. E-mail: [email protected]

Received 10 August 2012; Accepted 4 February 2013
Advance online publication 30 April 2013
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Abstract
OBJECTIVES:


Screening for esophageal varices (EV) is recommended in patients with cirrhosis. Noninvasive tests had shown varying sensitivity (Se) and specificity (Sp) for predicting EV. Splenomegaly is a common finding in liver cirrhosis because of portal and splenic congestion. These changes can be quantified by transient elastography; hence, the aim of this study was to investigate the utility of spleen stiffness (SS) in evaluating EV in comparison with other noninvasive tests.
METHODS:


We measured SS and liver stiffness (LS) by using FibroScan in 200 consecutive cirrhotic patients who met the inclusion criteria. Patients were also assessed by hepatic venous pressure gradient (HVPG), upper gastrointestinal endoscopy, LS–spleen diameter to platelet ratio score (LSPS), and platelet count to spleen diameter ratio (PSR).
RESULTS:


Of 200 patients enrolled, 174 patients had valid LS and SS measurement, and 124 (71%) patients had EV (small, n=46 and large n=78). There was a significant difference in median LS (51.4 vs. 23.9 kPa, P=0.001), SS (54 vs. 32 kPa, P=0.001), LSPS (6.1 vs. 2.5, P=0.001), and PSR (812 vs. 1,165, P=0.001) between patients with EV and those without EV. LS ≥27.3 kPa had an Se of 91%, Sp of 72%, positive predictive value (PPV) of 89%, negative predictive value (NPV) of 76%, and a diagnostic accuracy of 86% in predicting EV. LSPS ≥3.09 had Se and Sp of 89% and 76%, respectively, and a PSR cutoff value of 909 or less had Se of 64%, Sp of 76%, and diagnostic accuracy of 68% in predicting EV. SS ≥40.8 kPa had Se (94%), Sp (76%), PPV (91%), NPV (84%), and diagnostic accuracy of 86% for predicting EV. SS was significantly higher in patients who had large varices (56 vs. 49 kPa, P=0.001) and variceal bleed (58 vs. 50.2 kPa, P=0.001). Combining LS+SS (27.3+40.8 kPa) had Se of 90%, Sp 90%, PPV 96%, NPV 79%, and a diagnostic accuracy of 90%. HVPG (n=52) showed significant correlation with SS (r=0.433, P=0.001), LSPS (r=0.335, P=0.01), and PSR (r=−0.270, P=0.05), but not with LS (r=0.178, P=0.20).
CONCLUSIONS:


Measurement of SS can be used for noninvasive assessment of EV and can differentiate large vs. small varices and nonbleeder vs. bleeder.

StephenW

建议肝硬化患者食管静脉曲张（EV）的筛选。非侵入性试验已表现出不同的灵敏度（SE）和特异性（SP）预测EV。脾肿大是由于门静脉和脾充血常见于肝硬化。这些变化可以量化的瞬时弹性，因此，本研究的目的是评估EV相比，与其他非侵入性测试，调查的效用脾刚度（SS）。
方法：


我们测量SS和使用符合纳入标准在连续200例肝硬化患者肝纤维化的肝脏硬度（LS）。肝静脉压力梯度（HVPG），LS-脾脏长径与血小板比值得分（LSPS）和血小板计数，脾脏长径比（PSR），上消化道内镜检查的患者也进行了评估。
结果：


200例患者，174例患者有有效的LS和SS计量的，124（71％）患者有EV（小，N = 46，大的n = 78）。有显著的差异中位数LS（51.4比23.9千帕，P = 0.001），SS（54与32千帕，P = 0.001），LSPS（6.1比2.5，P = 0.001），PSR（812 VS 1,165，P = 0.001），与EV和EV那些没有患者之间。 LS≥27.3千帕硒的91％，SP的72％，阳性预测值（PPV）为89％，阴性预测值（NPV）为76％，并预测EV的诊断准确率为86％。 LSPS≥3​​.09硒硒和SP分别为89％和76％，和PSR临界值909或更少SP的76％，64％，68％，预测EV和诊断的准确性。 SS≥40.8千帕SE（94％），SP（76％），PPV（91％），净现值（84％），预测EV诊断的准确率达到86％。 SS是明显升高的患者有大的静脉曲张（56比49千帕，P = 0.001）和胃底静脉曲张破裂出血（58比50.2千帕，P = 0.001）。硒结合LS + SS（27.3 +40.8千帕），SP 90％，阳性预测值96％，净现值为79％，90％的诊断准确率为90％。 HVPG组（n = 52），表现出显着的相关性与SS相关（r = 0.433，P = 0.001），LSPS相关（r = 0.335，P = 0.01），和PSR相关（r = -0.270，P = 0.05），但不与LS（ R = 0.178，P = 0.20）。
结论：


测量SS可用于EV的无创性评估，并能区分大与小的静脉曲张和nonbleeder与泄放。