肝硬化患者脾脏硬度值预测食管静脉曲张。
Spleen stiffness in patients with cirrhosis in predicting esophageal varices.
机构信息
Department of Gastroenterology and Hepatology, Sir Ganga Ram Hospital, New Delhi, India.
出版信息
Am J Gastroenterol. 2013 Jul;108(7):1101-7. doi: 10.1038/ajg.2013.119. Epub 2013 Apr 30.
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.
目的
在肝硬化患者中推荐进行食管静脉曲张（EV）筛查。非侵入性检测已显示出不同的敏感性（Se）和特异性（Sp），用于预测 EV。脾肿大是肝硬化的常见表现，因为门静脉和脾充血。这些变化可以通过瞬时弹性成像进行量化；因此，本研究的目的是研究脾脏硬度（SS）在评估 EV 方面的效用，与其他非侵入性检测方法进行比较。
方法
我们对 200 名符合纳入标准的肝硬化患者使用 FibroScan 测量 SS 和肝脏硬度（LS）。还通过肝静脉压力梯度（HVPG）、上消化道内镜、LS-脾脏直径血小板比评分（LSPS）和血小板计数与脾脏直径比（PSR）评估患者。
结果
在纳入的 200 名患者中，有 174 名患者有有效的 LS 和 SS 测量值，124 名（71%）患者有 EV（小 EV，n=46；大 EV，n=78）。EV 患者的 LS（51.4 与 23.9 kPa，P=0.001）、SS（54 与 32 kPa，P=0.001）、LSPS（6.1 与 2.5，P=0.001）和 PSR（812 与 1165，P=0.001）中位数存在显著差异。LS≥27.3 kPa 预测 EV 的 Se 为 91%，Sp 为 72%，PPV 为 89%，NPV 为 76%，诊断准确性为 86%。LSPS≥3.09 预测 EV 的 Se 和 Sp 分别为 89%和 76%，PSR 截断值为 909 或更低时，预测 EV 的 Se 为 64%，Sp 为 76%，诊断准确性为 68%。SS≥40.8 kPa 预测 EV 的 Se 为 94%，Sp 为 76%，PPV 为 91%，NPV 为 84%，诊断准确性为 86%。SS 在大静脉曲张（56 与 49 kPa，P=0.001）和静脉曲张出血（58 与 50.2 kPa，P=0.001）患者中明显更高。结合 LS+SS（27.3+40.8 kPa），Se 为 90%，Sp 为 90%，PPV 为 96%，NPV 为 79%，诊断准确性为 90%。HVPG（n=52）与 SS（r=0.433，P=0.001）、LSPS（r=0.335，P=0.01）和 PSR（r=-0.270，P=0.05）呈显著相关性，但与 LS 无相关性（r=0.178，P=0.20）。
结论
SS 的测量可用于 EV 的非侵入性评估，并可区分大静脉曲张与小静脉曲张以及非出血与出血。
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