106 European Journal of Gastroenterology & Hepatology 2015, Vol 27 No 1
gastric alterations in dyspeptic patients. In any case, regardless of the design, and the diagnostic intention behind the study, a method offering an area under the receiver operating characteristic curve lower than 0.70 is considered poor or failed. Even taking the higher range of the 95% confidence intervals for the sensitivity and specificity achieved by GastroPanel in our population, between 20 and 30% of patients would be misdiagnosed either in clinical or screening settings.
Acknowledgements Conflicts of interest
There are no conflicts of interest.
References 1 Korpela S, Sipponen P, Härkonen M, Peetsalu A, Syrjänen K. Accuracy of GastroPanel test in detection of atrophic gastritis. Eur J Gastroenterol Hepatol 2014; 27:102–104. 2 McNicholl AG, Forné M, Barrio J, de la Coba C, González B, Rivera R, et al. Helicobacter pylori Study Group of the Asociación Española de Gastroenterología (AEG). Accuracy of GastroPanel for the diagnosis of atrophic gastritis. Eur J Gastroenterol Hepatol 2014; 26:941–948. 3 Malfertheiner P, Megraud F, O’Morain CA, Atherton J, Axon AT, Bazzoli F, et al. European Helicobacter Study Group. Management of Helicobacter pylori infection: the Maastricht IV/Florence Consensus Report. Gut 2012; 61:646–664. 4 McNicholl AG, Gisbert JP. Response to: Misleading results in diagnosis of atrophic gastritis. Eur J Gastroenterol Hepatol 2014; 27:104–105. 5 Massarrat S, Haj-Sheykholeslami A, Mohamadkhani A, Zendehdel N, Aliasgari A, Rakhshani N, et al. Pepsinogen II can be a potential surrogate marker of morphological changes in corpus before and after H. pylori eradication. Biomed Res Int 2014; 2014:481607. 6 Biohit Oyj; 2010. Available at: http://www.gastropanel.com. [Accessed 14 August 2014]. 7 Dinis-Ribeiro M, Yamaki G, Miki K, Costa-Pereira A, Matsukawa M, Kurihara M. Meta-analysis on the validity of pepsinogen test for gastric carcinoma, displasia or chronic atrophic gastritis screening. J Med Screen 2004; 11:141–147.
Criticism of: diagnostic accuracy of abdominal ultrasound in the screening of esophageal varices in patients with cirrhosis Abd Elrazek M.A. Abd Elrazek, Department of Gastroenterology and Hepatology, Faculty of Medicine, Al-Azhar University, Cairo, Egypt Correspondence to Abd Elrazek M.A. Abd Elrazek, PhD, MD, Medicine of Liver Transplantation, Department of Gastroenterology and Hepatology, Al Azhar Faculty of Medicine, Al-Azhar University, Cairo, Egypt E-mail: [email protected] Received 9 August 2014 Accepted 12 August 2014
I recently came across an article entitled ‘Diagnostic accuracy of abdominal ultrasound in the screening of esophageal varices in patients with cirrhosis’ published in European Journal of Gastroenterology & Hepatology in August 2014 by Sort et al. [1]. I appreciate the effort of Sort and colleagues in their study. However, in this communication, I would like to put forth a critical analysis of several points that I hope will help everybody involved in the field.
Studies dealing with esophageal varices, which report that approximately half of the patients with liver cirrhosis have esophageal varices and that one-third of all patients with varices will develop variceal hemorrhage, a major cause of morbidity and mortality in patients with cirrhosis, especially those waiting for liver transplantation, are highly important as many patient lives can be saved through surgery. Although Sort and colleagues have reported many noninvasive methods to predict varices, currently none can replace endoscopic screening; further, they did not mention the two important noninvasive studies cited in PubMed–NCBI and taken as references in the evidence-based clinical information resource UpToDate: Primary and pre-primary prophylaxis against variceal hemorrhage in patients with cirrhosis (http://www. uptodate.com/contents/primary-and-pre-primary-prophylaxisagainst-variceal-hemorrhage-in-patients-with-cirrhosis). (1) The ratio of platelet count to spleen size (expressed as a SD score) and clinical prediction rules that include platelet count, spleen size, and albumin have been shown to predict varices in children [2]. (2) In addition, a study using two-dimensional ultrasound (US) of the lower esophagus in patients with chronic liver disease found that patients with varices had a higher mean esophageal wall thickness compared with patients who did not have varices: 7.3 ± 3.3 mm in those with esophageal varices, 8.65 ± 1.98 mm in those with risky esophageal varices, and 3.7 ± 0.5 mm in those without varices. The overall accuracy was 95% [3]. Further, the second study mentioned that the sonographic image of portal hypertension (spleen size, portal vein diameter, splenic vein diameter, and the presence of collaterals) was not correlated with the degree of esophageal varices in many patients. However, in our study we performed examination of the esophagi of 673 patients to demonstrate esophageal wall thicknesses, which was very helpful in evaluation of the degree of esophageal varices. Moreover, in our experience and as per many published studies, portal vein (PV) pressure is not always correlated with PV diameter; the only method for evaluating PV pressure is by an intravascular invasive measure [4–7]. In addition, the spleen should be measured in two different spans, longitudinal × transverse diameters, and not only a longitudinal diameter greater than 12 cm could be indicative of splenomegaly, as reported in the study by Sort and colleagues. However, Sort and colleagues reported on page 3 of their article the following sentence: ‘The results indicate that if abdominal US were used to exclude patients at a low risk of LV from the endoscopic screening program, the number of endoscopies with this indication would decrease by 27%, but 14.9% of patients would be misclassified’. Accordingly,
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Letters to the Editor 107
more than 70%, or two-thirds, of all patients requiring diagnostic upper endoscopy will not depend on their US criteria even with laboratory assisted criteria. In all, 14.9% of patients would be misclassified without additional laboratory criteria as reported in the positive group, indicated by upper gastrointestinal endoscopy. However, in the negative group, US criteria of portal hypertension would reduce the number of endoscopies performed by 43% without additional laboratory criteria. Additionally, the study is only useful in the compensated group, whereas most of our patients waiting for liver transplantation are of the decompensated group worldwide, reported in the discussion on page 5 of the article by Sort and colleagues: ‘The reduction is achieved mainly in patients with compensated cirrhosis, in whom 43% of the examinations may be avoided; in decompensated cirrhosis, it does not seem to yield any benefit’. The statistical approach used in the study by Abd Elrazek and colleagues was data mining advanced computing technology. A descriptive model was generated using a decision tree algorithm (RapidMiner, version 4.6; Rapid-I, Berlin, Germany). The decision tree decides the most significant independent variable at each stage of predicting dependent variables [9]. Accordingly, esophageal wall thickness was determined to be the only accurate parameter. However, other sonographic criteria (PV diameter, collaterals, and spleen size) were not correlated to the degree of each esophageal degree. These statistical results were confirmed by another paper entitled ‘Prediction analysis of esophageal variceal degrees using data mining: is validated in clinical medicine?’ published in Global Journal of Computer Science and Technology Software & Data Engineering [8]. A recent study accepted in the European Journal of Gastroenterology & Hepatology entitled ‘Screening esophagus during routine US: medical and cost benefits’ has confirmed all the data mentioned above [10]. I hope that our critical analysis covers all scientific aspects and is of help to everybody involved in the field.
Acknowledgements Conflicts of interest
There are no conflicts of interest.
References 1 Sort P, Muelas M, Isava A, Llaó J, Porta F, Puig I, et al. Diagnostic accuracy of abdominal ultrasound in the screening of esophageal varices in patients with cirrhosis. Eur J Gastroenterol Hepatol 2014;10.1097/ [#,';']?>; . 2 Gana JC, Turner D, Mieli-Vergani G, Davenport M, Miloh T, Avitzur Y, et al. A clinical prediction rule and platelet count predict esophageal varices in children. Gastroenterology 2011; 141:2009–2016. 3 Abd Elrazek MA, Mahfouz H, Afifi M, Nafady M, Fathy Ael W, El Azeem KA, et al. Detection of risky esophageal varices by two-dimensional ultrasound: when to perform endoscopy. Am J Med Sci 2014; 347:28–33.
4
Kishimoto R, Chen M, Ogawa H, Wakabayashi MN, Kogutt MS. Esophageal varices: evaluation with transabdominal US. Radiology 1998; 206:647–650. 5 Chen M, Kikuchi Y, Chu B, Kishimoto R, Choji K, Miyasaka K. Demonstration of the distal end esophagus by transabdominal ultrasound: technique and normal wall thickness. Br J Radiol 1997; 70:1215–1221. 6 Kane RA, Katz SG. The spectrum of sonographic findings in portal hypertension: a subject review and new observations. Radiology 1982; 142:453–458. 7 Abdel-Wahab MF, Esmat G, Farrag A, El-Boraey Y, Strickland GT, et al. Top of form ultrasonographic prediction of esophageal varices in Schistosomiasis mansoni. Am J Gastroenterol 1993; 88:560–563. 8 Abd Elrazek AE, Mahfouz H. Prediction of esophageal variceal degrees using data mining; is validated in clinical medicine? Global J Comp Sci Tech 2013; 13:1–5. 9 Abd Elrazek AE, Mahfouz HM, Metwally AM, El-Shamy AM. Mortality prediction of nonalcoholic patients presenting with upper gastrointestinal bleeding using data mining. Eur J Gastroenterol Hepatol 2014; 26:187–191. 10 Abd Elrazek AE, Khaled AE, El Sherbiny S, Osmaa AE, Bilasy S. Screening esophagus during routine U/S: medical and cost benefits. Eur J Gastroenterol Hepatol Biohit Oyj; 2010. Available at: http://www. gastropanel.com. [Accessed 14 August 2014].
Management of Budd–Chiari syndrome in children: same debated issues as in adults Andrea Mancusoa,b, aDepartment of Internal Medicine, ARNAS Civico - Di Cristina - Benfratelli Hospital, Piazzale Liotti 4, Palermo, Italy and bDepartment of Hepatology and Gastroenterology, Niguarda Ca' Granda Hospital, Piazza Ospedale Maggiore 3, 20162 Milan, Italy Correspondence to Andrea Mancuso, MD, Department of Internal Medicine, ARNAS Civico - Di Cristina - Benfratelli Hospital, Piazzale Liotti 4, Palermo, Italy Tel: + 39 329 899 7893; fax: + 39 091 609 0252; e-mail: [email protected] Received 19 September 2014 Accepted 23 September 2014
I believe that the recently published paper on the management of Budd–Chiari syndrome (BCS) in children highlights the same debated issues as in adults [1]. The authors report their wide experience of management following the already established step-wise strategy indicated for adults [2]: medical therapy as the first step [3], angioplasty/stenting the second [4], transjugular intrahepatic portosystemic shunt (TIPS) the next step [5,6], and liver transplantation the last step [7]. However, in the present experience, anticoagulation is not used: this choice is beyond the current recommendation [2,4], although recent data report unsatisfactory outcomes on medical treatment only [8]. Moreover, the present, as with other previous experiences, does not get to the bottom of one of the most debated issues on BCS management, that is, timing of treatment [4,7,9,10]. In this respect, two different opinions have been compared: the former suggests moving forward with the step-wise management when no response to therapy is observed [2], although the definition for response to therapy was not stated; the latter proposes a new algorithm in which medical therapy is suggested only for patients without any sign of portal hypertension, whether early interventional treatment is suggested when either any symptom or sign of portal hypertension appears, with the aim of preventing
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
gastric alterations in dyspeptic patients. In any case, regardless of the design, and the diagnostic intention behind the study, a method offering an area under the receiver operating characteristic curve lower than 0.70 is considered poor or failed. Even taking the higher range of the 95% confidence intervals for the sensitivity and specificity achieved by GastroPanel in our population, between 20 and 30% of patients would be misdiagnosed either in clinical or screening settings.
Acknowledgements Conflicts of interest
There are no conflicts of interest.
References 1 Korpela S, Sipponen P, Härkonen M, Peetsalu A, Syrjänen K. Accuracy of GastroPanel test in detection of atrophic gastritis. Eur J Gastroenterol Hepatol 2014; 27:102–104. 2 McNicholl AG, Forné M, Barrio J, de la Coba C, González B, Rivera R, et al. Helicobacter pylori Study Group of the Asociación Española de Gastroenterología (AEG). Accuracy of GastroPanel for the diagnosis of atrophic gastritis. Eur J Gastroenterol Hepatol 2014; 26:941–948. 3 Malfertheiner P, Megraud F, O’Morain CA, Atherton J, Axon AT, Bazzoli F, et al. European Helicobacter Study Group. Management of Helicobacter pylori infection: the Maastricht IV/Florence Consensus Report. Gut 2012; 61:646–664. 4 McNicholl AG, Gisbert JP. Response to: Misleading results in diagnosis of atrophic gastritis. Eur J Gastroenterol Hepatol 2014; 27:104–105. 5 Massarrat S, Haj-Sheykholeslami A, Mohamadkhani A, Zendehdel N, Aliasgari A, Rakhshani N, et al. Pepsinogen II can be a potential surrogate marker of morphological changes in corpus before and after H. pylori eradication. Biomed Res Int 2014; 2014:481607. 6 Biohit Oyj; 2010. Available at: http://www.gastropanel.com. [Accessed 14 August 2014]. 7 Dinis-Ribeiro M, Yamaki G, Miki K, Costa-Pereira A, Matsukawa M, Kurihara M. Meta-analysis on the validity of pepsinogen test for gastric carcinoma, displasia or chronic atrophic gastritis screening. J Med Screen 2004; 11:141–147.
Criticism of: diagnostic accuracy of abdominal ultrasound in the screening of esophageal varices in patients with cirrhosis Abd Elrazek M.A. Abd Elrazek, Department of Gastroenterology and Hepatology, Faculty of Medicine, Al-Azhar University, Cairo, Egypt Correspondence to Abd Elrazek M.A. Abd Elrazek, PhD, MD, Medicine of Liver Transplantation, Department of Gastroenterology and Hepatology, Al Azhar Faculty of Medicine, Al-Azhar University, Cairo, Egypt E-mail: [email protected] Received 9 August 2014 Accepted 12 August 2014
I recently came across an article entitled ‘Diagnostic accuracy of abdominal ultrasound in the screening of esophageal varices in patients with cirrhosis’ published in European Journal of Gastroenterology & Hepatology in August 2014 by Sort et al. [1]. I appreciate the effort of Sort and colleagues in their study. However, in this communication, I would like to put forth a critical analysis of several points that I hope will help everybody involved in the field.
Studies dealing with esophageal varices, which report that approximately half of the patients with liver cirrhosis have esophageal varices and that one-third of all patients with varices will develop variceal hemorrhage, a major cause of morbidity and mortality in patients with cirrhosis, especially those waiting for liver transplantation, are highly important as many patient lives can be saved through surgery. Although Sort and colleagues have reported many noninvasive methods to predict varices, currently none can replace endoscopic screening; further, they did not mention the two important noninvasive studies cited in PubMed–NCBI and taken as references in the evidence-based clinical information resource UpToDate: Primary and pre-primary prophylaxis against variceal hemorrhage in patients with cirrhosis (http://www. uptodate.com/contents/primary-and-pre-primary-prophylaxisagainst-variceal-hemorrhage-in-patients-with-cirrhosis). (1) The ratio of platelet count to spleen size (expressed as a SD score) and clinical prediction rules that include platelet count, spleen size, and albumin have been shown to predict varices in children [2]. (2) In addition, a study using two-dimensional ultrasound (US) of the lower esophagus in patients with chronic liver disease found that patients with varices had a higher mean esophageal wall thickness compared with patients who did not have varices: 7.3 ± 3.3 mm in those with esophageal varices, 8.65 ± 1.98 mm in those with risky esophageal varices, and 3.7 ± 0.5 mm in those without varices. The overall accuracy was 95% [3]. Further, the second study mentioned that the sonographic image of portal hypertension (spleen size, portal vein diameter, splenic vein diameter, and the presence of collaterals) was not correlated with the degree of esophageal varices in many patients. However, in our study we performed examination of the esophagi of 673 patients to demonstrate esophageal wall thicknesses, which was very helpful in evaluation of the degree of esophageal varices. Moreover, in our experience and as per many published studies, portal vein (PV) pressure is not always correlated with PV diameter; the only method for evaluating PV pressure is by an intravascular invasive measure [4–7]. In addition, the spleen should be measured in two different spans, longitudinal × transverse diameters, and not only a longitudinal diameter greater than 12 cm could be indicative of splenomegaly, as reported in the study by Sort and colleagues. However, Sort and colleagues reported on page 3 of their article the following sentence: ‘The results indicate that if abdominal US were used to exclude patients at a low risk of LV from the endoscopic screening program, the number of endoscopies with this indication would decrease by 27%, but 14.9% of patients would be misclassified’. Accordingly,
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Letters to the Editor 107
more than 70%, or two-thirds, of all patients requiring diagnostic upper endoscopy will not depend on their US criteria even with laboratory assisted criteria. In all, 14.9% of patients would be misclassified without additional laboratory criteria as reported in the positive group, indicated by upper gastrointestinal endoscopy. However, in the negative group, US criteria of portal hypertension would reduce the number of endoscopies performed by 43% without additional laboratory criteria. Additionally, the study is only useful in the compensated group, whereas most of our patients waiting for liver transplantation are of the decompensated group worldwide, reported in the discussion on page 5 of the article by Sort and colleagues: ‘The reduction is achieved mainly in patients with compensated cirrhosis, in whom 43% of the examinations may be avoided; in decompensated cirrhosis, it does not seem to yield any benefit’. The statistical approach used in the study by Abd Elrazek and colleagues was data mining advanced computing technology. A descriptive model was generated using a decision tree algorithm (RapidMiner, version 4.6; Rapid-I, Berlin, Germany). The decision tree decides the most significant independent variable at each stage of predicting dependent variables [9]. Accordingly, esophageal wall thickness was determined to be the only accurate parameter. However, other sonographic criteria (PV diameter, collaterals, and spleen size) were not correlated to the degree of each esophageal degree. These statistical results were confirmed by another paper entitled ‘Prediction analysis of esophageal variceal degrees using data mining: is validated in clinical medicine?’ published in Global Journal of Computer Science and Technology Software & Data Engineering [8]. A recent study accepted in the European Journal of Gastroenterology & Hepatology entitled ‘Screening esophagus during routine US: medical and cost benefits’ has confirmed all the data mentioned above [10]. I hope that our critical analysis covers all scientific aspects and is of help to everybody involved in the field.
Acknowledgements Conflicts of interest
There are no conflicts of interest.
References 1 Sort P, Muelas M, Isava A, Llaó J, Porta F, Puig I, et al. Diagnostic accuracy of abdominal ultrasound in the screening of esophageal varices in patients with cirrhosis. Eur J Gastroenterol Hepatol 2014;10.1097/ [#,';']?>; . 2 Gana JC, Turner D, Mieli-Vergani G, Davenport M, Miloh T, Avitzur Y, et al. A clinical prediction rule and platelet count predict esophageal varices in children. Gastroenterology 2011; 141:2009–2016. 3 Abd Elrazek MA, Mahfouz H, Afifi M, Nafady M, Fathy Ael W, El Azeem KA, et al. Detection of risky esophageal varices by two-dimensional ultrasound: when to perform endoscopy. Am J Med Sci 2014; 347:28–33.
4
Kishimoto R, Chen M, Ogawa H, Wakabayashi MN, Kogutt MS. Esophageal varices: evaluation with transabdominal US. Radiology 1998; 206:647–650. 5 Chen M, Kikuchi Y, Chu B, Kishimoto R, Choji K, Miyasaka K. Demonstration of the distal end esophagus by transabdominal ultrasound: technique and normal wall thickness. Br J Radiol 1997; 70:1215–1221. 6 Kane RA, Katz SG. The spectrum of sonographic findings in portal hypertension: a subject review and new observations. Radiology 1982; 142:453–458. 7 Abdel-Wahab MF, Esmat G, Farrag A, El-Boraey Y, Strickland GT, et al. Top of form ultrasonographic prediction of esophageal varices in Schistosomiasis mansoni. Am J Gastroenterol 1993; 88:560–563. 8 Abd Elrazek AE, Mahfouz H. Prediction of esophageal variceal degrees using data mining; is validated in clinical medicine? Global J Comp Sci Tech 2013; 13:1–5. 9 Abd Elrazek AE, Mahfouz HM, Metwally AM, El-Shamy AM. Mortality prediction of nonalcoholic patients presenting with upper gastrointestinal bleeding using data mining. Eur J Gastroenterol Hepatol 2014; 26:187–191. 10 Abd Elrazek AE, Khaled AE, El Sherbiny S, Osmaa AE, Bilasy S. Screening esophagus during routine U/S: medical and cost benefits. Eur J Gastroenterol Hepatol Biohit Oyj; 2010. Available at: http://www. gastropanel.com. [Accessed 14 August 2014].
Management of Budd–Chiari syndrome in children: same debated issues as in adults Andrea Mancusoa,b, aDepartment of Internal Medicine, ARNAS Civico - Di Cristina - Benfratelli Hospital, Piazzale Liotti 4, Palermo, Italy and bDepartment of Hepatology and Gastroenterology, Niguarda Ca' Granda Hospital, Piazza Ospedale Maggiore 3, 20162 Milan, Italy Correspondence to Andrea Mancuso, MD, Department of Internal Medicine, ARNAS Civico - Di Cristina - Benfratelli Hospital, Piazzale Liotti 4, Palermo, Italy Tel: + 39 329 899 7893; fax: + 39 091 609 0252; e-mail: [email protected] Received 19 September 2014 Accepted 23 September 2014
I believe that the recently published paper on the management of Budd–Chiari syndrome (BCS) in children highlights the same debated issues as in adults [1]. The authors report their wide experience of management following the already established step-wise strategy indicated for adults [2]: medical therapy as the first step [3], angioplasty/stenting the second [4], transjugular intrahepatic portosystemic shunt (TIPS) the next step [5,6], and liver transplantation the last step [7]. However, in the present experience, anticoagulation is not used: this choice is beyond the current recommendation [2,4], although recent data report unsatisfactory outcomes on medical treatment only [8]. Moreover, the present, as with other previous experiences, does not get to the bottom of one of the most debated issues on BCS management, that is, timing of treatment [4,7,9,10]. In this respect, two different opinions have been compared: the former suggests moving forward with the step-wise management when no response to therapy is observed [2], although the definition for response to therapy was not stated; the latter proposes a new algorithm in which medical therapy is suggested only for patients without any sign of portal hypertension, whether early interventional treatment is suggested when either any symptom or sign of portal hypertension appears, with the aim of preventing
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
