Thomopoulos K C, Labropoulou-Karatza C, Mimidis K P, Katsakoulis E C, Iconomou G, Nikolopoulou V N
Department of Internal Medicine, Division of Gastroenterology. University Hospital of Patras, Patras, Greece.
Dig Liver Dis. 2003 Jul;35(7):473-8. doi: 10.1016/s1590-8658(03)00219-6.
BACKGROUND/AIMS: The usual clinical practice is to screen all patients with established cirrhosis at the time of diagnosis by upper endoscopy for the presence of varices. Patients with large varices should be treated with non-selective beta blockers to reduce the incidence of first variceal bleeding. However, fewer than 50% of cirrhotic patients have varices at screening endoscopy and most have small sized varices, with a low risk of bleeding. The aim of the present study was to determine whether clinical or laboratory non-endoscopic parameters could predict the presence of large oesophageal varices.
PATIENTS/METHODS: Seventeen variables considered relevant to the prevalence of oesophageal varices were tested in 184 patients with cirrhosis, who underwent screening endoscopy. Small varices were regarded as those which flatten with insufflation or slightly protrude into the lumen, while large varices are those which protrude into the lumen or touch each other. None of the patients was on beta blockers or other vasoactive drugs or had a history of variceal bleeding.
Oesophageal varices were present in 92 patients (50%), and large varices in 33 patients (17.9%). Variables associated with the presence of large oesophageal varices on univariate analysis were the presence of ascites and splenomegaly either by clinical examination or by ultrasound (p < 0.01), the presence of spiders (p = 0.02), platelet count (p < 0.0001), and bilirubin (p = 0.01). Factors independently associated with the presence of large oesophageal varices on multivariate analysis were platelet count, size of spleen and presence of ascites by ultrasound. Using mean values as cut-off points, it is noteworthy that only five out of 39 patients (12.8%) with platelets > or = 18(x 10(9)/l), spleen length < or = 135 mm and no ascites had varices. Moreover, all these patients had small sized varices. On the other hand, 15 out of 18 patients (83.3%) with a platelet count < 118 x 10(9)/l, spleen length > 135 mm and ascites had varices. Moreover, five out of those 18 patients had large varices (28.3%).
Thrombocytopenia, splenomegaly and ascites are independent predictors of large oesophageal varices in cirrhotic patients. We suggest that endoscopy could be avoided safely in cirrhotic patients with none of these predictive factors, as large varices are absent in this group of patients.
背景/目的：常规临床实践是在诊断时对所有已确诊肝硬化的患者进行上消化道内镜检查，以筛查是否存在静脉曲张。患有大静脉曲张的患者应使用非选择性β受体阻滞剂进行治疗，以降低首次静脉曲张出血的发生率。然而，在筛查性内镜检查中，不到50%的肝硬化患者有静脉曲张，且大多数患者的静脉曲张较小，出血风险较低。本研究的目的是确定临床或实验室非内镜参数是否可以预测大食管静脉曲张的存在。
患者/方法：在184例接受筛查性内镜检查的肝硬化患者中，对17个被认为与食管静脉曲张患病率相关的变量进行了检测。小静脉曲张被定义为在充气时变平或轻微突入管腔的静脉曲张，而大静脉曲张是指突入管腔或相互接触的静脉曲张。所有患者均未使用β受体阻滞剂或其他血管活性药物，也没有静脉曲张出血史。
92例患者（50%）存在食管静脉曲张，33例患者（17.9%）存在大静脉曲张。单因素分析中与大食管静脉曲张存在相关的变量包括通过临床检查或超声发现的腹水和脾肿大（p<0.01）、蜘蛛痣的存在（p=0.02）、血小板计数（p<0.0001）和胆红素（p=0.01）。多因素分析中与大食管静脉曲张存在独立相关的因素是血小板计数、脾脏大小和超声发现的腹水。以平均值作为切点，值得注意的是，在39例血小板≥18×10⁹/L、脾脏长度≤135mm且无腹水的患者中，只有5例（12.8%）有静脉曲张。此外，所有这些患者的静脉曲张都较小。另一方面，在18例血小板计数<118×10⁹/L、脾脏长度>135mm且有腹水的患者中，有15例（83.3%）有静脉曲张。此外，这18例患者中有5例有大静脉曲张（28.3%）。
血小板减少、脾肿大和腹水是肝硬化患者大食管静脉曲张的独立预测因素。我们建议，在没有这些预测因素的肝硬化患者中，可以安全地避免进行内镜检查，因为这组患者不存在大静脉曲张。
