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 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 31  |  Issue : 2  |  Page : 588-593

Correlation of thrombocytopenia with grading of esophageal varices in chronic liver disease patients


1 Department of Tropical Medicine, Faculty of Medicine, Menoufia University, Menoufia, Egypt
2 Department of Clinical Pathology, Faculty of Medicine, Menoufia University, Menoufia, Egypt
3 Department of Tropical Medicine, Menouf Fever Hospital, Menoufia, Egypt

Date of Submission08-May-2016
Date of Acceptance26-Jun-2016
Date of Web Publication27-Aug-2018

Correspondence Address:
Ahmed H El-Daly
Department of Tropical Medicine, Menouf Fever Hospital, Menoufia 32511
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1110-2098.239725

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  Abstract 


Objective
The aim of this study was to determine the correlation of thrombocytopenia with esophageal variceal grading in chronic liver disease patients.
Background
Esophageal varices (EVs) are a serious consequence of portal hypertension in patients with chronic liver disease. Several studies have evaluated possible noninvasive predictors for the presence and size of varices, including platelet count.
Materials and methods
This study included 210 patients who presented with chronic liver disease in Menouf Fever Hospital. The diagnosis was based on history, clinical, laboratory, and imaging data. They were divided into two groups: group I and group II. Group I included 140 patients with EVs and was subdivided into group IA, which included 60 patients with grade I, group IB, which included 40 patients with grade II, and group IC, which included 40 patients with grade III, and group II included 70 patients without EVs. Correlation of thrombocytopenia with the grading of EVs was assessed using Spearman's correlation.
Results
Platelet count was significantly lower in patients with EV grades I, II, and III (mean ± SD; 100.5 ± 19.8, 65.2 ± 13.0, and 60.3 ± 14.1 × 103/mm3, respectively) than in those without EVs (152.1 ± 17.1 × 103/mm3). Moreover, it was significantly lower in patients with grades II and III (large EVs) (65.2 ± 13.0 and 60.3 ± 14.1 × 103/mm3, respectively) than in patients with grade I (small EVs) (100.5 ± 19.8 × 103/mm3) (P < 0.001). The cutoff value of platelet count as a predictor for the presence of EVs was less than or equal to 130 × 103/mm3, with a sensitivity of 95% and specificity of 95%. Moreover, the cutoff value as a predictor for the presence of large EVs was less than or equal to 80 × 103/mm3, with a sensitivity of 91.2% and a specificity of 86.7%. There was a significant negative correlation between platelet count and grading of EVs (r=−0.756; P < 0.001).
Conclusion
Thrombocytopenia is a good noninvasive predictor for the presence and size of EVs in chronic liver disease patients. There was a significant negative correlation between platelet count and grading of EVs.

Keywords: chronic liver disease, esophageal variceal grading, thrombocytopenia


How to cite this article:
El-Din Nouh MA, El-Momen Ali KA, Badawy AM, El-Daly AH. Correlation of thrombocytopenia with grading of esophageal varices in chronic liver disease patients. Menoufia Med J 2018;31:588-93

How to cite this URL:
El-Din Nouh MA, El-Momen Ali KA, Badawy AM, El-Daly AH. Correlation of thrombocytopenia with grading of esophageal varices in chronic liver disease patients. Menoufia Med J [serial online] 2018 [cited 2018 Nov 20];31:588-93. Available from: http://www.mmj.eg.net/text.asp?2018/31/2/588/239725




  Introduction Top


Cirrhosis is the end stage of every chronic liver disease, resulting in the formation of fibrous tissue, disorganization of liver architecture, and nodule formation, which interferes with liver function and results in portal hypertension [1]. Portal hypertension leads to the formation of portosystemic collateral veins. Among them, esophageal varices (EVs) have the greatest clinical impact because their rupture results in variceal hemorrhage that can be fatal [2].

Esophagogastroduodenoscopy is considered the primary modality for the detection and surveillance of EVs and to determine the risk for bleeding [3]. Unfortunately, endoscopy is invasive and expensive. Therefore, there is a clinical demand for a noninvasive sensitive method to assess EVs [4].

Portal hypertension is associated with splenomegaly and thrombocytopenia. The degree of thrombocytopenia is a reflection of the degree of portal hypertension [5]. The major mechanisms for thrombocytopenia in liver cirrhosis are platelet sequestration in the spleen and decreased production of thrombopoitin in the liver [6]. This study was performed to determine the correlation of the thrombocytopenia with esophageal variceal grading in chronic liver disease patients.


  Materials and Methods Top


The study protocol was approved by the ethical committee of the college & a written consent was obtained from each participant. This study included 210 patients who presented with chronic liver disease in Menouf Fever Hospital. There were 130 (61.9%) male and 80 (38.1%) female patients and their ages ranged from 40 to 65 years. Exclusion criteria included patients with leukopenia, thrombocytopenia, and anemia due to hematological causes, patients treated for bleeding EVs either surgically or endoscopically, patients who received drugs for primary prophylaxis of variceal bleeding, and patients with hepatocellular carcinoma or portal vein thrombosis. All patients were subjected to full history taking, clinical examination, laboratory investigations (complete blood count, liver function tests, viral markers, and renal function tests), abdominal ultrasonography, and upper gastrointestinal endoscopy. They were divided into two groups according to the results of upper gastrointestinal endoscopy: group I and group II. Group I included 140 patients with EVs and was subdivided into three groups: group IA, which included 60 patients with grade I, group IB, which included 40 patients with grade II, and group IC, which included 40 patients with grade III. Group II included 70 patients without EVs. Correlation of thrombocytopenia with the grading of EVs was assessed using Spearman's correlation.

Statistical analysis

  • Descriptive statistics: percentage, mean, and SD
  • Analytic statistics: the χ2-test, Student's t-test, and analysis of variance (f) test.


Values were considered significant if P less than 0.05 and highly significant if P less than 0.001.


  Results Top


There was a statistically significant difference between the studied groups as regards the detection of palpable spleen by means of clinical examination, whereas there was no statistically significant difference as regards other clinical features [Table 1].
Table 1: Comparison between the studied groups as regards clinical features

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There was a statistically significant difference between the studied groups as regards values of platelet count, serum albumin, total bilirubin, international normalized ratio, and prothrombin time, whereas there was no statistically significant difference as regards values of the other laboratory parameters [Table 2].
Table 2: Comparison between the studied groups as regards laboratory parameters

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Platelet count was significantly lower in patients with EVs grades I, II, and III (mean ± SD; 100.5 ± 19.8, 65.2 ± 13.0, and 60.3 ± 14.1 × 103/mm 3, respectively) than in those without EVs (152.1 ± 17.1 × 103/mm 3). Moreover, it was significantly lower in patients with grades II and III (large EVs) (65.2 ± 13.03 and 60.3 ± 14.1 × 103/mm 3, respectively) than in patients with grade I (small EVs) (100.5 ± 19.8 × 103/mm 3) (P < 0.001) [Table 2].

On ultrasonography, there was a statistically significant difference between the studied groups as regards size of the spleen and portal vein diameter, whereas there was no statistically significant difference as regards ascites [Table 3].
Table 3: Comparison between the studied groups as regards ultrasonographic findings

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There was a statistically significant difference between the studied groups as regards child class [Table 4].
Table 4 Comparison between the studied groups as regards child class

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There was a significant negative correlation between platelet count and grading of EVs. [Table 5] and [Figure 1].
Table 5 Spearman correlation between platelet count and grades of esophageal varices

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Figure 1: Scatter plot diagram of correlation between platelet count and grades of esophageal varices.

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The cutoff value of platelet count as a predictor for the presence of varices was less than or equal to 130 × 103/mm 3 with a sensitivity of 95% and specificity of 95% [Table 6] and [Figure 2].
Table 6 Diagnostic validity of platelet count in the diagnosis of the presence of esophageal varices

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Figure 2: Receiver operating characteristic curve for the sensitivity and specificity of platelet count for the diagnosis of esophageal varices.

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The cutoff value of platelet count as a predictor for the presence of large varices was less than or equal to 80 × 103/mm 3 with a sensitivity of 91.2% and a specificity of 86.7% [Table 7] and [Figure 3].
Table 7 Diagnostic validity of platelet count in the diagnosis of large esophageal varices (grades II and III)

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Figure 3: Receiver operating characteristic curve for the sensitivity and specificity of platelet count for the diagnosis of large esophageal varices.

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  Discussion Top


Chronic liver disease is an important cause of morbidity and mortality and represents a major health problem worldwide. Liver cirrhosis is a common disease in Egypt [7] as Egypt has the highest prevalence of hepatitis C virus in the world, estimated nationally at 14.7% [8].

Noninvasive predictors of EVs represent a special importance in developing countries like Egypt where it is not easy to perform screening endoscopies to the huge number of cirrhotic patients [9].

The noninvasive predictive variables include platelet count, splenomegaly, spleen diameter, Child-Pugh, size of the right liver lobe, albumin level, and portal vein diameter. These means are cost-effective, simple, and quick, with no additional burden to patients [10].

In this study, there was a significant statistical difference between the studied groups as regards the presence of palpable spleen by means of clinical examination, whereas there was no significant statistical difference between the studied groups as regards the presence of ascites by means of clinical examination or by means of abdominal ultrasonography. Manohar et al. [11] reported similar findings.

The current study shows significant statistical differences between the studied groups as regards serum albumin, total bilirubin, prothrombin time, and international normalized ratio. This is in agreement with the findings of Sort et al. [12], who found that patients with large varices had significantly worse hepatic function, as estimated by serum bilirubin, prothrombin time, and serum albumin compared with patients with small varices.

Significant statistical differences between the studied groups as regards spleen size and portal vein diameter were noted in the present work. Moreover, Sudha-Rani et al. [13] reported that increased splenic size and portal vein diameter were significantly associated with the presence of EVs and their values correlated with increasing size of varices.

Platelet count was statistically significantly lower in patients of this study with EVs grades I, II, and III (100.5 ± 19.8, 65.2 ± 13.0, and 60.3 ± 14.1 × 103/mm 3, respectively) than in those without EVs (152.1 ± 17.1 × 103/mm 3). Moreover, it was statistically significantly lower in patients with grades II and III (large EVs) (65.2 ± 13.0 and 60.3 ± 14.1 × 103/mm 3, respectively) than in patients with grade I (small EVs) (100.5 ± 19.8 × 103/mm 3). The same results were obtained by Cherian et al. [14] and Nemichandra et al. [15].

A highly significant negative correlation between platelet count and esophageal variceal grading (r = −0.756; P < 0.001) was found in the present study. This is in agreement with the findings of Tanweer et al. [16] and Sanjay and Chandrashekar [17], who reported that there was an inverse relationship between EVs and platelet count.

In this study, the cutoff value of platelet count as a predictor for the presence of varices was less than or equal to 130 × 103/mm 3 with 95% sensitivity, 95% specificity, 97.8% positive predictive value, and 89.1% negative predictive value. Moreover, the cutoff value of platelet count as a predictor for the presence of large varices was less than or equal to 80 × 103/mm 3 with a sensitivity of 91.2%, a specificity of 86.7%, positive predictive value of 90.1%, and negative predictive value of 88.1%.

Many studies were conducted to evaluate the role of platelet count as a predictor of the presence of varices and/or large varices. Gill et al. [18] studied 140 patients with chronic liver disease; most of them had hepatitis C. Ninety-eight patients had EVs (small, n = 28; medium, n = 40; and large, n = 30), whereas 42 had no EVs. They concluded that platelet count of 100 × 103/mm 3 is a reliable marker for predicting EVs in cirrhotic patients.

Sarwar et al. [19] in another study included 101 patients; 65 patients had EVs, whereas 36 patients had no varices. High-grade varices were seen in 15 patients and 50 patients had low-grade varices. They reported that patients with platelet count less than 88 × 103/mm 3 are more likely to be associated with high-grade varices.

Shaikh et al. [20] investigated 100 patients with chronic liver disease; 72 patients were reactive for antihepatitis C virus. Total of 85 patients had EVs, whereas 15 patients had no varices. They found that platelet count at a cutoff value of 76 × 103/mm 3 had 90% sensitivity and 100% specificity for the detection of EVs. Furthermore, Cherian et al. [14] studied 229 patients. EVs were present in 178 patients (small, n = 97; large, n = 81), and 51 patients had no varices. They reported that platelet count less than 100 × 103/mm 3 was significantly associated with the presence of EVs, and platelet count less than 90 × 103/mm 3 was significantly associated with the presence of large EVs.

Sort et al. [12] investigated 353 patients, 123 had medium/large-sized EVs and 230 had small or no EVs. The results showed that platelet count less than 120 × 103/mm 3 was significantly associated with the presence of large EVs.

Sudha-Rani et al. [13] included 92 patients with cirrhosis. In all, 65 patients had EVs (small, n = 35; large, n = 30), and 27 patients were without varices. They concluded that platelet count less than 140 × 103/mm 3 can be considered as a noninvasive predictor of EVs.

Thomopoulos [21] stated that the discriminating threshold for the presence of varices or large varices differs among studies. A cutoff value of 68 000–140 000/mm 3 has been reported for platelets in different studies. These differences may be due to different populations studied as regards the etiology of cirrhosis and/or the stage of the disease.

The severity of thrombocytopenia increased with the increasing grade of EVs. The platelet count was significantly and inversely correlated with grading of EVs [22]. Hence, we can identify the subset of patients who require prophylactic endoscopic management. Therefore, this reduces the economic burden on the patients and reduces the cost of management of EVs [17].


  Conclusion Top


Thrombocytopenia is considered to be a good noninvasive predictor for the presence and size of EVs in chronic liver disease patients. There was a significant negative correlation between platelet count and grading of EVs.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Sort P, Muelas M, Isava A, Llaó J, Porta F, Puig I, Domínguez-Curell C, Esteve E, Yanguas C, Vida F. Diagnostic accuracy of abdominal ultrasound in the screening of esophageal varices in patients with cirrhosis. European journal of gastroenterology & hepatology. 2014; 26:1335-41.  Back to cited text no. 12
    
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    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]



 

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