Correlation Between Esophageal Varices and Lok Score as a Non-invasive Parameter in Liver Cirrhosis Patients

ORIGINAL ARTICLE

  

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Iqbal Sungkar, Leonardo Basa Dairi, Gontar Alamsyah Siregar

  Division of Gastroentero-hepatology, Department of Internal Medicine Faculty of Medicine, University of Sumatera Utara/ Adam Malik General Hospital, Medan

  Corresponding author:

Gontar Alamsyah Siregar Division of Gastroentero-hepatology, Department of Internal Medicine, Adam Malik General

Hospital. Jl. Bunga Lau No. 17 Medan Indonesia. Phone/facsimile: +62-61-8365742. E-mail: gontarsiregar@gmail.

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  Background: Bleeding from gastro-esophageal varices is the most serious and life-threatening complication

of cirrhosis. Endoscopic surveillance of esophageal varices in cirrhotic patients is expensive and uncomfortable

for the patients. Therefore, there is a particular need for non-invasive predictors for esophageal varices. The aim

of the present study was to evaluate association of esophageal varices and Lok Score as non-invasive parameter

in liver cirrhosis patients.

  Method: This is a cross-sectional study of patients admitted at the Adam Malik hospital Medan between

September to December 2014 with a diagnosis of cirrhosis based on clinical, biochemical examination, ultrasound,

and gastroscopy. Lok Score was calculated for all patients, tabulated and analyzed.

  Results: Among 76 patients with esophageal varices, 55.3% was due to hepatitis B virus (HBV). The majority

of patients were Child C with only 13,2% being Child Pugh class A. Majority of the population had F2 esophageal

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esophageal varices, in which Lok Score is higher in large esophageal varices compared with small esophageal

varises (0.92 ± 0.14 vs. 0.70 ± 0.29; p = 0.001). Lok Score with cut-off point of > 0.9141 was highly predictive

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value of 84%, negative predictive value 58%, and accuracy was 73.7%.

  Conclusion: /RN 6FRUH ZDV VLJQL¿FDQWO\ DVVRFLDWHG ZLWK HVRSKDJHDO YDULFHV /RN 6FRUH LV D JRRG QRQ LQYDVLYH predictor of large esophageal varices in cirrhotic patients.

  Keywords: Lok Score, non-invasive parameter, esophageal varices $%675$.

  Latar belakang: Perdarahan dari varises gastro-esophageal adalah komplikasi yang paling serius dan

menyebabkan kematian pada penderita sirosis hati. Surveilans Endoskopi varises esofagus pada pasien sirosis

mahal dan tidak nyaman untuk pasien. Oleh karena itu, dibutuhkan adanya parameter non-invasif sebagai

prediktor varises esofagus. Tujuan dari penelitian ini adalah untuk mengevaluasi hubungan varises esofagus

dan Lok Score sebagai parameter non-invasif pada pasien sirosis hati.

  Metode: Penelitian potong lintang dari pasien yang dirawat di Rumah Sakit Adam Malik Medan antara

EXODQ 6HSWHPEHU KLQJJD 'HVHPEHU GHQJDQ GLDJQRVLV VLURVLV EHUGDVDUNDQ NOLQLV ELRNLPLD XOWUDVRQRJUD¿

dan gastroskopi. Lok Score dihitung untuk semua pasien, ditabulasi, dan dianalisis.

  Hasil: Di antara 76 pasien sirosis hati dengan varises esofagus, 55.3% disebabkan oleh infeksi hepatitis B

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Pugh kelas A. Mayoritas populasi penelitian memiliki varises esofagus F2 (42,1%), F1 (32,9), dan F3 (25%).

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Simpulan: Terdapat hubungan yang bermakna antara Lok Score dengan besar varises esofagus. Lok Score

merupakan parameter non-invasif yang baik dalam memprediksi adanya varises esofagus berukuran besar

pada pasien sirosis hati.

  Kata kunci: Lok Score, parameter non-invasif, varises esofagus ,1752'8&7,21

  Liver cirrhosis is a chronic liver disease characterized E\ LQÀDPPDWLRQ QHFURVLV DQG UHJHQHUDWLRQ SURFHVV LQ WKH IRUP RI ¿EURVLV DQG WKH IRUPDWLRQ RI QRGXOHV LQ the surrounding of liver parenchyma. Cirrhosis of the liver is an advanced stage of any chronic liver disease and this condition can lead to multiple complications due to portal hypertension. At the time RI GLDJQRVLV RI OLYHU FLUUKRVLV DSSUR[LPDWHO\ RI patients with liver cirrhosis have undergone varying degrees of esophageal varices. Esophageal varices is a major complication that often appear in more than

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  7KHUHIRUH VFUHHQLQJ of esophageal varices in patients with cirrhosis of the liver is highly recommended in every consensus.

  Lok Score is a serum biomarker used to predict liver

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tinggi pada varises esofagus besar dibandingkan dengan varises esofagus kecil (0,92 ± 0,14 vs. 0,70 ± 0,29;

p = 0,001). Nilai titik potong Lok Score > 0,9141 dalam memprediksi adanya varises esofagus ukuran besar

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sebesar 73,7%.

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  ¹⁴ In ,QGRQHVLD WKH UHVHDUFK RQ WKH DFFXUDF\ RI /RN 6FRUH in predicting the presence of esophageal varices has not EHHQ LQYHVWLJDWHG WKHUHIRUH ZH LQWHQGV WR DVVHVV WKH accuracy of Lok Score as non-invasive examination in predicting the size of esophageal varices in patients with cirrhosis of the liver.

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  This study is an observational study which was done with analytical cross-sectional design. This study was conducted in Gastroentero-hepatologist Ward and

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  DJHG • \HDUV OLYHU FLUUKRVLV SDWLHQWV ZLOOLQJ WR participate in the study and signed the informed consent. The exclusion criterias are previous history variseal EOHHGLQJ PRQWKV SDWLHQWV ZKR KDYH SUHYLRXVO\ received blocker drugs or endoscopic therapy (ligation RU VFOHURWKHUDS\ ! \HDUV SDWLHQWV ZKR KDG SUHYLRXVO\ undergone surgical treatment for portal hypertension 7,36 SDWLHQWV ZLWK QRQ FLUUKRWLF SRUWDO K\SHUWHQVLRQ DQG KHSDWRPD $QDPQHVLV SK\VLFDO H[DPLQDWLRQ

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  (transient elastography - TE) that have been proposed and some of the methods have been validated as non-invasive alternatives to endoscopy. Non-invasive markers of OLYHU ¿EURVLV E\ EORRG VHUXP H[DPLQDWLRQ ZHUH WHVWHG DV predictors of esophageal varices in liver cirrhosis patients with promising results.

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  Child – Pugh A B C

  10 (13.2) 26 (34.2) 40 (52.6) Etiology of liver cirrhosis

  Hepatitis B Hepatitis C Hepatitis B + C Non-B & C Lok Score 42 (55.3)

  4 (5.3) 1 (1.3) 29 (38.2) 0.85 ± 0.23*

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  F3 25 (32.9) 25 (32.9) 51 (67.1) 32 (42.1) 19 (25)

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  6PDOO Q /DUJH Q PHDQ “ 6' PHDQ “ 6' Age 50.40 ± 11.871 49.45 ± 11.618 0.741 Platelet 199.04 ± 145.58 121.75 ± 88.655 0.005* Total bilirubin 3.9732 ± 6.377 6.278 ± 7.84 0.015* AST 79.92 ± 81.361 168.65 ± 120.120 0.027* Albumin 2.808 ± 0.707 2.333 ± 0.678 0.006* PT 3.30 ± 4.683 6.216 ± 5.472 0.025*

  INR 1.21 ± 0.378 1.507 ± 0.426 0.005* ALT 41.24 ± 36.449 67.45 ± 81.979 0.023* Lok Score 0.70 ± 0.29 0.92 ± 0.14 0.001* _a

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  The growing need for upper gastrointestinal tract endoscopy and the limitations to meet these needs as well as the difficulties to perform endoscopy SHULRGLFDOO\ HYHU\ RU \HDUV LQ SDWLHQWV ZLWK KLJK risk esophageal varices prompted some researchers to examine non-invasive methods in predicting the presence of esophagus varices so that the needs of endoscopy and health costs could be reduced.

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  7KHUH DUH VLJQL¿FDQW GLIIHUHQFHV EHWZHHQ WKH PHDQV of Lok Score between patients with large esophageal varices and patients with small esophageal varices which determined by endoscopy. Lok Score is a non- invasive parameters which good at predicting the size of esophageal varices in patients with liver cirrhosis. )XUWKHU VWXGLHV RQ /RN 6FRUH QHHG WR EH GRQH ZKLFK should be combined with another methods of non- LQYDVLYH SUHGLFWRU RI HVRSKDJHDO YDULFHV VR WKDW D non-invasive algorithm to predicting the presence or absence of esophageal varices and their size in liver cirrhosis patients can be formulated.

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  1. Prihartini J. Detection of oesofageal varices in liver cirrhosis using non-invasive parameters. Acta Med Indones

  4. Jensen DM. Endoscopic screening for varices in cirrhosis:

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Correlation Between Esophageal Varices and Lok Score as a Non-invasive Parameter in Liver Cirrhosis Patients Grace ND. Diagnosis and treatment of gastro-intestinal bleeding secondary to portal hypertension. American College of Gastroenterology Practice Parameter Committee. Am J

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