NON-INVASIVE DIAGNOSIS OF ESOPHAGEAL VARICES IN CHILDREN

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NON-INVASIVE DIAGNOSIS OF ESOPHAGEAL VARICES IN CHILDREN

JC Gana, E Roberts, VL Ng, SC Ling
Division of Gastroenterology, Hepatology and Nutrition, Hospital for Sick Children, University of Toronto, Toronto

BACKGROUND: The identification of children at greatest risk of having varices using non-invasive tests would facilitate selection of children for future studies of primary prophylaxis of variceal hemorrhage, but has been inadequately studied.
AIM: To measure the ability of non-invasive tests to predict the presence of esophageal varices in children.
METHODS: In this retrospective study, consecutive children <18y with liver disease or portal hypertension who underwent endoscopy between 2000 and 2006 were identified. Exclusion criteria were previous portal-systemic shunt surgery or transjugular intrahepatic portal-systemic shunt, ligation or sclerotherapy of varices, organ transplantation, upper gastrointestinal bleeding and neoplasia. Bloodwork and abdominal ultrasound scan (USS) data were obtained from tests performed within 1 year of the endoscopy. Varices were graded on a four point scale at endoscopy. Spleen size on USS was expressed as a standard deviation score relative to previously established normal values for age.
RESULTS: Of 87 children with liver disease who underwent endoscopy in the study time period, 51 were eligible for inclusion. Esophageal varices were found in 17 of 51 patients (33%). Parameters found to differ significantly between children with and without varices included platelet/spleen size ratio (p<0.001, Wilcoxon rank sum test), platelet count (p<0.001), INR (p=0.001), AST/ALT ratio (p=0.002) and albumin (p=0.003). When analyzed using Receiver Operating Characteristic (ROC) curves, the best non-invasive predictors of esophageal varices were platelet/spleen size ratio, platelet count, INR, AST/ALT ratio and albumin with areas under the ROC curve of 0.91, 0.88, 0.79, 0.79 and 0.77 respectively. Using cut-off values shown in the table, the sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), positive likelihood ratio (LR+) and negative likelihood ratio (LR-) were calculated for each parameter.

Parameter Cut-off v Sensiti Spec PPV NPV LR+ LR-
Pl/Spl size ratio 148 94 % 7 3% 0.71 0.94 3.44 0.09
Platelet count 136x10⁹ 81 96 0.93 0.9 23 0.18
INR 1.08 76 67 0.59 0.83 2.38 0.35
AST/ALT ratio 1.12 71 68 0.57 0.8 2.27 0.43
Albumin 41.5 77 67 0.59 0.83 2.38 0.35

CONCLUSIONS: Our results suggest for the first time in children that it is possible to identify children at highest risk of varices before undertaking endoscopy. Confirmation of these results is being tested in a current prospective study.

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Parameter	Cut-off v	Sensiti	Spec	PPV	NPV	LR+	LR-
Pl/Spl size ratio	148	94 %	7 3%	0.71	0.94	3.44	0.09
Platelet count	136x10⁹	81	96	0.93	0.9	23	0.18
INR	1.08	76	67	0.59	0.83	2.38	0.35
AST/ALT ratio	1.12	71	68	0.57	0.8	2.27	0.43
Albumin	41.5	77	67	0.59	0.83	2.38	0.35