Main Article Content
Rupture and bleeding from esophageal varices are major complications of portal hypertension and associated with a high mortality rate. Non-invasive serum markers of liver fibrosis could be used as predictors of esophageal varices in cirrhotic patients. The objective of this study was to assess the performance of Forns index as a noninvasive predictor in diagnosing esophageal varices.
A cross-sectional study was done in 51 cirrhotic patients who were admitted to Adam Malik hospital, Medan. Demographic and clinical data were recorded and laboratory tests were performed, so that Forns index could be calculated. The difference between Forns index and size of esophageal varices as determined by endoscopy was tested by independent-t and Mann-Whitney analysis. The diagnostic performance was assessed using sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), accuracy, likelihood ratios and areas under the receiver operating characteristic curves (AUROC).
Of the 51 patients with esophageal varices included in this study, the size of esophageal varices comprised F2 (37.3%), F3 (33.3), and F1 (29.4%). Most patients were of Child-Plug C type (52.6%). There was a significant difference between Forns index and grade of esophageal varices. The AUROC for Forns index was 0.717 (95% CI: 0.561 - 0.872) and the cut-off >7.92 was highly predictive to diagnose large esophageal varices with a sensitivity of 63.9%, specificity of 73.3%, PPV of 85.2%, NPV of 45.8% and accuracy of 71.7%.
Forns index was significantly increased in large esophageal varices. Forns index is a good noninvasive predictor of esophageal varices in cirrhotic patients.
Biecker E. Portal hypertension and gastrointestinal bleeding: diagnosis, prevention and management. World J Gastroenterol 2013; 19:5035-50.
Ashkenazi E, Kovalev Y, Zuckerman E. Evaluation and treatment of esophageal varices in the cirrhotic patient. IMAJ 2013;15:109-15.
Turon F, Casu S, Hernandez-Gea V, et al. Variceal and other portal hypertension related bleeding. Best Pract Res Clin Gastroenterol 2013;27:649-64.
Stokkeland K, Brandt L, Ekbom A, et al. Improved prognosis for patients hospitalized with esophageal varices in Sweden 1969–2002. Hepatology 2006;43:500-5.
De Franchis R. Evolving consensus in portal hypertension. Report of the Baveno IV consensus workshop on methodology of diagnosis and therapy in portal hypertension. J Hepatol 2005; 43:167-76.
De Franchis R. Revising consensus in portal hypertension: report of the Baveno V consensus workshop on methodology of diagnosis and therapy in portal hypertension. J Hepatol 2010;53:762-8.
Stefanescu H, Grigorescu M, Lupsor M, et al. A new and simple algorithm for the noninvasive assessment of esophageal varices in cirrhotic patients using serum fibrosis markers and transient elastography. J Gastrointestin Liver Dis 2011;20:57-64.
Friedrich-Rust M, Wunder K, Kriener S, et al. Liver fibrosis in viral hepatitis: noninvasive assessment with acoustic radiation force impulse imaging versus transient elastography. Radiology 2009;252:595-604.
Garcia-Tsao G, Sanyal AJ, Grace ND, Carey W and the Practice Guidelines Committee of the American Association for the Study of Liver Diseases, the Practice Parameters Committee of the American College of Gastroenterology. Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis. Hepatology 2007;46:922-38.
Friedrich-Rust M, Ong MF, Martens S, et al. Performance of transient elastography for the staging of liver fibrosis: a meta-analysis. Gastroenterology 2008;134:960-974.
Talwalkar JA, Yin M, Venkatesh S, et al. Feasibility of in vivo MR elastographic splenic stiffness measurements in the assessment of portal hypertension. Am J Roentgenol 2009;193: 122-7.
Grgurevic I, Cikara I, Horvat J, et al. Noninvasive assessment of liver fibrosis with acoustic radiation force impulse imaging: increased liver and splenic stiffness in patients with liver fibrosis and cirrhosis. Ultraschall Med 2011;32:160-6.
Bota S, Sporea I, Sirli R, et al. Spleen assessment by acoustic radiation force impulse elastography (AFRI) for prediction of liver cirrhosis and portal hypertension. Med Ultrason 2010;12:213-7.
Vallet-Pichard A, Mallet V, Nalpas B, et al. FIB-4: an inexpensive and accurate marker of fibrosis in HCV infection: comparison with liver biopsy and fibrotest. Hepatology 2007;46:32-6.
Cross TJ, Calvaruso V, Maimone S, et al. Prospective comparison of Fibroscan, King’s score and liver biopsy for the assessment of cirrhosis in chronic hepatitis C infection. J Viral Hepat 2010;17:546-54.
Farber E, Fischer D, Eliakim R, et al. Esophageal varices: evaluation with esophagography with barium versus endoscopic gastroduodenoscopy in patients with compensated cirrhosis—blinded prospective study. Radiology 2005;237:535-40.
Forns X, Ampurdanes S, Llovet JM, et al. Identification of chronic hepatitis C patients without hepatic fibrosis by a simple predictive model. Hepatology 2002;36:986-92.
Limquiaco J, Daez R, Gloria Rr, et al. Clinical predictors of bleeding from esophageal varices: a retrospective study. Phil J of Gastroenterology 2006;2:103-11.
Shoreibah M, Anand BS, Singal AK. Alcoholic hepatitis and concomitant hepatitis C virus infection. World J Gastroenterol 2014;20:11929-34.
Mifune H, Akaki S, Ida K, et al. Evaluation of esophageal varices by multidetector-row CT: correlation with endoscopic red color sign. Acta Med Okayama 2007;61:247-54.
Sebastiani G, Tempesta D, Fattovich G, et al. Prediction of oesophageal varices in hepatic cirrhosis by simple serum noninvasive markers: results of a multicenter, large-scale study. J Hepatol 2010;53:630-8.
Suk TK. Revision and update on clinical practice guideline for liver cirrhosis. The Korean J Hepatol 2012;18:1-21.