Non-invasive Screening of Esophageal Varices in Patients with Liver Cirrhosis

INTRODUCTION

Given the invasiveness of the Esophago-Gastro-Duodenoscopy (EGD), non-tolerability, and cost, ‎non-invasive evaluation of the patients with compensated cirrhosis is warranted. The last Baveno ‎VI consensus has reported that compensated cirrhotic patients who have platelets count > ‎‎150.000/mm3 and liver stiffness measurement (LSM < 20 KPs) are less likely to have high-risk ‎varices (HRVs) and can safely avoid screening EGD [1]. Other blood tests were investigated for ‎the same purpose. Our group has assigned a new blood based score including the platelet count, ‎serum albumin and bilirubin levels (ALBL-PLT). It was showed that ALBL-PLT score of more ‎than three has a good predictive value in predicting HRVs among compensated cirrhotic patients. ‎The sensitivity of the ALBL-PLT score in predicting HRVs is 100%, specificity of 78%, positive ‎predictive value (PPV) is 80% and a negative predictive (NPV) value of 100% and AUC is 0.894. ‎By applying this score, 84 (41.1%) patients can avoid EGD with none of them had HRVs on ‎endoscopy [2]. In a similar cohort of patients, it was proved the beneficial effect of the ALBL-PLT ‎score in predicting HRVs among cirrhotic patients [3]. However, most of the results of the non-‎invasive tests are modest and not satisfactory to replace EGD screening. ‎

A new study in this issue of the Afro-Egyptian journal of infectious and endemic diseases ‎investigated the use of the PAPAS score (Platelet/Age/ Phosphatase/AFP/AST) for predicting EVs ‎in HCV-related cirrhotic patients. This study included patients at different stages of cirrhosis ‎‎(compensated and decompensated) who underwent screening EGD to detect the presence of EVs. ‎The PAPAS score and other non-invasive scores (APRI, FIB4, Lok Scor) were calculated and ‎compared their accuracy in predicting the development of EVs. The results of this study showed ‎that patients with EVs have a significantly higher PAPAS score than those without EVs. The ‎PAPAS index showed higher diagnostic accuracy than the other tests (APRI, FIB-4, and Lok ‎Score). PAPAS index AUCs were 0.939 for diagnosis of EVs with 86% sensitivity, 93.33% ‎specificity, 95.2% PPV, 73.7% NPV, and AUC 0.746 for detecting Large EVs with 94.87% ‎sensitivity, 86.43% specificity, 71.2% PPV, 86.7% NPV, indicating its usefulness in identifying ‎patients with large varices who require endoscopy. ‎

This is the first study that showed promising benefits of applying the PAPAS score among ‎cirrhotic patients secondary to chronic HCV. However, several concerns in this study need to be ‎raised, first; this study included decompensated cirrhotic patients, while non-invasive tests target ‎those with compensated cirrhosis to determine who are at high risk to undergo screening ‎endoscopy and save those who are at low risk, the decompensated patients always have HRVs and ‎the results of this study showed that 100% of decompensated cirrhotic patients have HRVs.  ‎Second; this study defined the HRVs as varices with red signs only, but the