A Clinical Prediction Rule and Platelet Count Predict Esophageal Varices in Children

Juan CristÓbal Gana; Dan Turner; Giorgina Mieli–Vergani; Mark Davenport; Tamir Miloh, Yaron Avitzur; Jason Yap; Veronique Morinville; Herbert Brill; Simon C. Ling


Gastroenterology. 2011;141(6):2009-2016. 

In This Article

Abstract and Introduction


Background & Aims: The validation of noninvasive tests to diagnose esophageal varices is a priority in children because repeated endoscopic evaluations are too invasive. We measured the ability of a previously developed noninvasive clinical prediction rule (CPR) to predict the presence of esophageal varices in children.
Methods: We analyzed data from 108 children, younger than age 18, who received endoscopies at 8 centers, to assess portal hypertension from chronic liver disease or portal vein obstruction. Blood test and abdominal ultrasound scan results were obtained within 4 months of endoscopy. Grading of varices identified by endoscopy was confirmed by independent blinded review. Spleen size, based on data from the ultrasound scan, was expressed as a standard deviation score relative to normal values for age.
RESULTS: Of the children studied, 74 had esophageal varices (69%), including 35 with large varices (32%). The best noninvasive predictors of esophageal varices of any size were as follows: platelet:spleen size z-score ratio (area under the receiver operating characteristic curve [AUROC], 0.84; 95% confidence interval [CI] 0.75–0.93), CPR (AUROC, 0.80; 95% CI, 0.70–0.91), and platelet count (AUROC, 0.79; 95% CI, 0.69–0.90). The positive predictive values for the CPR and platelet count were 0.87 and 0.86, the negative predictive values were 0.64 and 0.63, the positive likelihood ratios were 3.06 and 2.76, and the negative likelihood ratios were 0.64 and 0.63, respectively. Based on positive and negative predictive values, the most accurate noninvasive tests were the CPR and platelet counts.
Conclusions: Noninvasive tests such as CPR and platelet count can assist in triaging children for endoscopy to identify esophageal varices.


Many children with chronic liver disease or portal vein obstruction are at risk of variceal bleeding, which is associated with significant morbidity and mortality.[1–8] Guidelines for adults with portal hypertension recommend performing esophagogastroduodenoscopy (EGD) to identify those with varices who may benefit from prophylactic therapy. Treatment with nonselective β-blockade or endoscopic variceal ligation is effective for the prevention of variceal bleeding in cirrhotic adults.[9–11]

Currently, there are inadequate data to support a similar approach in children. EGD is the reference standard test for the diagnosis of varices, but it is considered especially invasive in children, time consuming, expensive, and associated with risk. There is, therefore, a pressing need for a noninvasive test that is reliable enough to target EGD only to those children with the highest risk of varices. The American Association for the Study of Liver Disease and the American College of Gastroenterology recognize this as one of the most important areas for research in portal hypertension.[12]

In a previous retrospective study, we showed that esophageal varices in children could be predicted accurately by a clinical prediction rule (CPR, calculated from platelet count, spleen size z-score, and albumin concentration) and by the ratio of the platelet count and spleen size z-score (P/SSAZ).[13] A lower CPR score means a higher likelihood for the presence of varices. We now present the results of a multicenter prospective study in which we aimed to validate the ability of the CPR and P/SSAZ ratio to predict the presence of esophageal varices in children with portal hypertension. This study was conducted according to the requirements set by the Quality Assessment of Diagnostic Accuracy Studies checklist.[14,15]


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