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Cirrhosis is a consequence of almost all progressive chronic liver diseases, approximately 10%-20% of patients with chronic hepatitis C virus infection have cirrhosis at first clinical presentation, and as many as 20%-30% of those who don’t have cirrhosis will eventually develop this condition and its complications within one or more decades. Development of oesophageal varices is a major complication that may occur in up to 90% of cirrhotic patients, Esophageal varices may lead to variceal bleeding that is a life threatening event that has an incidence of 5% in patients with small oesophageal varices and up to 15% in those with large esophageal varices. Mortality per bleeding episode is around 10%- 20%. Therefore, the current screening method is endoscopy at 2-3 years in patients without esophageal varices and at 1-2 years in those with small varices, this approach is invasive. That is why selection of patients with large esophageal varices at high risk for bleeding has become an issue of growing importance screening for esophageal varices in cirrhotic patients is a strong recommendation in all consensus statement. In this respect, several clinical, biological, ultrasonographic and elastrographic methods have been proposed as non-invasive alternatives to endoscopy. In this study we aimed to study and evaluate the accuracy, safety and applicability of different noninvasive modalities to predict the presence and size of esophageal varices in Egyptian cirrhotic patients due to hepatitis C virus infection with no history of oesophageal varices bleeding as an alternative to endoscopy especially in rural & distal areas.This is a cross sectional hospital based study applied on 150 volunteerd patients who agreed to participate in this study from a total number of 2500 patients who were attending hepatology & gastroenterology unit at Dar EL-Shefa hospital one of the hospitals of Egyptian ministry of health during the period from january 2016 to june 2018. The study subjects were patients with liver cirrhosis due to HCV infection based on clinical, laboratory, ultrasound, and fibro scan findings at the hepatology outpatient clinics who have never suffered from variceal bleeding. . Inclusion criteria:
1- Adult male and female patients ≥ 18 years.
2- Hepatitis C virus infection.
3- Liver cirrhosis without moderate or massive ascites, mild pelvic ascites could be recruited.
4- BMI <35.
Exclusion criteria for the recruited patients:
1- Patients age <18 years.
2- Other causes of liver cirrhosis except HCV.
3- BMI > 35.
4- Liver cirrhosis with moderate or massive ascites.
5- History of upper GIT bleeding or hepatocellular carcinoma.
6- Refusal to participate in the study.
7-Patients were classified into three Groups according to upper GI endoscopy findings and laboratory data into:
group I: included 50 patients with liver cirrhosis and without esophageal varices. group II: included 50 patients with liver cirrhosis and small esophageal varices (Grade I&II).
group III: included 50 patients with liver cirrhosis and large esophageal varices (Grade III & IV).
II. Methods After getting a written informed consent from all patients, they were asked to undergo the following: 1. history taking with special emphasis on previous history of schistosomiasis, history of viral hepatitis or exposure to risk factors (such as anti-schistosomiasis injections, blood transfusion or previous surgical operations), history of jaundice, disturbed conscious level, bleeding tendency, hematemesis or melena. 2. Clinical examination for stigmata of liver cell failure or signs of portal hypertension were obtained. 3. Laboratory investigations included: Complete blood count, serum alanine aminotransferase (ALT), serum aspartate aminotransferase (AST), total and direct bilirubin, serum albumin, prothrombin time and concentration, Alpha feto protein, serum ammonia level and HCV Ab. Noninvasive parameters for each patient will be measured including:
A modified Child-Pugh score was calculated it is used to assess the prognosis of chronic liver disease, mainly cirrhosis, FIB 4 Index, AST/ALT Ratio, Platelet: Spleen Ratio, Aspartate Aminotransferase to Platelet Ratio Index (APRI), MELD score, Abdominal ultrasonography & Doppler ultrasonography, Upper Gastrointestinal Endoscopy, Liver stiffness measurement by Transient Ultrasound Elastography (fibro scan) and spleen stiffness measurement and The results were tabulated and statistically analysed. And the results showed that most of the non-invasive tested parameters showed a statistically significant predictive association with the presence and size of oesophageal varices especially the use of liver stiffness measurement using the fibroscan which showed that there was a statistically significant increase in fibroscan among small and large varices group – group (2&3) with a mean of 52.82±13.8 and a range of 33-75 than among no varices group – group (1) with a mean of 26.62±6.05 and range of 17-39 with a p-value of 0.000. The ROC curve showed that the best cut off point for fibroscan as a predictor for the presence of oesophageal varices among the studied groups was > 35, with AUC of 98.6 %, sensitivity of 90.9%, specificity of 96%, positive predictive value of 97.8% and negative predictive value of 84.2%. The results also showed that there was a highly statistically significant increase in fibroscan results among the studied groups with the increase in oesophageal varices size, it was found to be higher among large varices group-group(3) with a mean of 64.20±9.56 and a range of 44—75 than among small varices group – group (2) with a mean of 41.67±5.91 and a range of 33-50 than among no varices group – group (1) with a mean of 26.62±6.05 and a range of 17-39 with a p-value of 0.000 (HS<0.01).The ROC curve showed that the best cut off point for the fibro scan as a predictor for the size of oesophageal varices among the studied groups was > 50, with AUC of 98.1%, sensitivity of 89.8 %, specificity of 100%, positive predictive value of 100% and a negative predictive value of 90.9%. These results showed that fibroscan can be used as a valuable bed side non-invasive test for the prediction for the presence and size of oesophageal varices among HCV cirrhotic patients with high risk of oesophageal varices bleeding in rural and distal areas where the endoscopy screening is somehow costy and not available in all medical facilities.