Silva Mário Jorge, Bernardes Carlos, Pinto João, Loureiro Rafaela, Duarte Pedro, Mendes Milena, Calinas Filipe
Gastroenterology Department, Hospital de Santo António dos Capuchos, Centro Hospitalar de Lisboa Central, Lisbon, Portugal.
Chronic Diseases Research Center (CEDOC) - Integrated Pathophysiological Mechanisms Research Group, Faculdade de Ciências Médicas, NOVA Medical School, Lisbon, Portugal.
GE Port J Gastroenterol. 2017 Mar;24(2):79-83. doi: 10.1159/000452693. Epub 2016 Nov 18.
Recent studies assessed the predictive value of liver transient elastography, combined or not with platelet count, for the presence of esophageal varices in patients with liver cirrhosis, and multiple cutoffs have been proposed. The Baveno VI consensus states that patients with compensated advanced chronic liver disease, liver stiffness <20 kPa, and a platelet count >150,000 have a very low risk of having varices requiring treatment and can avoid screening endoscopy. We aimed to validate this recommendation in a cohort of cirrhotic patients.
Retrospective analysis of all patients evaluated at the Gastroenterology Department (Centro Hospitalar de Lisboa Central) between September 2009 and October 2015 with a liver stiffness (FibroScan®) compatible with liver cirrhosis as well as upper endoscopy and blood tests within 12 months from elastography. Patients on propranolol ≥80 mg/day or carvedilol ≥12.5 mg/day, as well as those with previous variceal bleeding, variceal endoscopic treatments, or cirrhosis decompensations were excluded. We validated the new Baveno VI recommendation and explored alternative cutoffs.
Ninety-seven patients were analyzed, 76.3% (74/97) male, mean age 54.3 ± 11.2 years. Most patients (55.7%) had no varices and 14.4% had varices requiring treatment. Most patients (78.4%) had cirrhosis related to chronic hepatitis C. If the new Baveno VI recommendation had been applied to this cohort, upper endoscopy would have been avoided in 11.3% (11/97) of patients, none of them with esophageal varices requiring treatment: specificity 100%, sensitivity 13.3%, positive predictive value 100%, and negative predictive value 16.3% for absence of varices requiring treatment. If screening endoscopy had been avoided in those patients with liver stiffness <30 kPa and platelet count ≥120,000, endoscopy would have been avoided in 27.8% (27/97) of patients, none of whom with esophageal varices requiring treatment: specificity 100%, sensitivity 32.5%, positive predictive value 100%, and negative predictive value 20% for absence of varices requiring treatment.
The new Baveno VI criteria identified compensated cirrhotic patients without varices requiring treatment in whom screening endoscopy could have been avoided safely. Further studies are needed to confirm these findings and potentially explore more ambitious but still safe cutoffs for those criteria.
近期研究评估了肝脏瞬时弹性成像单独或联合血小板计数对肝硬化患者食管静脉曲张存在情况的预测价值，并提出了多个临界值。《巴韦诺VI共识》指出，代偿期晚期慢性肝病、肝脏硬度<20 kPa且血小板计数>150,000的患者发生需要治疗的静脉曲张的风险非常低，可避免筛查性内镜检查。我们旨在对一组肝硬化患者验证这一建议。
对2009年9月至2015年10月在里斯本中心医院胃肠病科接受评估的所有患者进行回顾性分析，这些患者的肝脏硬度（FibroScan®）符合肝硬化表现，且在弹性成像后12个月内进行了上消化道内镜检查和血液检查。排除服用普萘洛尔≥80 mg/天或卡维地洛≥12.5 mg/天的患者，以及既往有静脉曲张出血、静脉曲张内镜治疗或肝硬化失代偿的患者。我们验证了新的《巴韦诺VI共识》建议并探索了其他临界值。
分析了97例患者，男性占76.3%（74/97），平均年龄54.3±11.2岁。大多数患者（55.7%）无静脉曲张，14.4%有需要治疗的静脉曲张。大多数患者（78.4%）的肝硬化与慢性丙型肝炎有关。如果将新的《巴韦诺VI共识》建议应用于该队列，11.3%（11/97）的患者可避免上消化道内镜检查，且这些患者均无需要治疗的食管静脉曲张：对于无需要治疗的静脉曲张，特异性为100%，敏感性为13.3%，阳性预测值为100%，阴性预测值为16.3%。如果对肝脏硬度<30 kPa且血小板计数≥120,000的患者避免进行筛查性内镜检查，27.8%（27/97）的患者可避免内镜检查，且这些患者均无需要治疗的食管静脉曲张：对于无需要治疗的静脉曲张，特异性为100%，敏感性为32.5%，阳性预测值为100%，阴性预测值为20%。
新的《巴韦诺VI标准》识别出了无需要治疗的静脉曲张的代偿期肝硬化患者，对这些患者可安全地避免筛查性内镜检查。需要进一步研究来证实这些发现，并可能探索更严格但仍安全的标准临界值。
