CAN FIBROSCAN + FIB -4 SCORE BE USED AS A RELIABLE PREDICTOR FOR PRESENCE OF ESOPHAGEAL AND GASTRIC VARICES IN NEWLY DIAGNOSED LIVER CIRRHOSIS? – USEFULNESS IN COVID-19 ERA.

noninvasive both signicant patients with chronic hepatitis the formula: ABSTRACT Background: Variceal bleeding is the most dangerous complication of liver cirrhosis. Endoscopy is recommended for diagnosis and surveillance of esophageal and gastric varices. We used a non-invasive scoring method of severity of liver disease and examined whether it can reliably predict the presence and severity of varices. Methods: Study was carried over a period of 12 months including all cirrhosis patients. Fibroscan and FIB-4 score were used to formulate a noninvasive score and compared with endoscopic ndings Results: The presence of varices and its severity correlated with Fibroscan+FIB-4 score. Higher the score, higher the likelihood of varices requiring endoscopic intervention. A score of >6 can be used as cut off to stratify patients requiring endoscopy. Conclusions: Fibroscan + FIB-4 score can be reliably used as a marker of presence of varices, the severity and chances of bleeding from varices. This can be of importance in the present Covid-19 pandemic, where in upper GI endoscopic procedures carry the highest rate of infection to healthcare workers and patients.


INTRODUCTION:
Variceal bleeding is a common and the most serious complication of cirrhosis and is a major cause of mortality. The American Association for the Study of Liver Disease (AASLD) and Baveno V consensus guidelines suggest that all patients who have been diagnosed with cirrhosis undergo screening endoscopy to assess for esophageal and (1) gastric varices . (2) There are many non-invasive methods of assessment of severity of liver disease. Fibroscan works by measuring shear wave velocity. A 50-MHz wave is passed into the liver from a small transducer on the end of an ultrasound probe and the velocity of the sound wave passing through the liver is converted into a liver stiffness measurement; the entire process is often referred to as liver ultrasonographic (3) (4) elastography . The FIB-4 score is a simple noninvasive index which was developed to predict both signicant brosis and cirrhosis in patients with chronic hepatitis C. It is determined using the following formula: FIB-4 = [age × AST/platelet count (109/L) × √ALT].
We intended to use Fibroscan and FIB -4 score to predict the severity of liver disease and assess the presence and severity of varices by endoscopy and formulate a non-invasive scoring method which can reliably predict varices. By the time we write this article after completing the study, we feel this might be immensely useful to assess need for, or obviate immediate prophylactic endoscopy in the present covid era, in view of high risk of infection to the operator and to the patient.

MATERIALS AND METHODS:
The study was carried out in Department of Digestive Health and Diseases, Government Kilpauk Medical College, Chennai. Study period was from June 2019 to May 2020, duration being 12 months.
All newly diagnosed liver cirrhosis patients were included in the study. The diagnosis of liver cirrhosis was established by clinical, biochemical and ultrasound imaging of liver. CT Scan of abdomen was done where Ultrasound was deemed to be inconclusive. The probable etiology of the liver disease was established in all cases included in the study.

DISCUSSION:
The FIB-4 scoring system uses a combination of patient age, platelet count, AST and ALT. The scoring system creates a score -<1.45 has a negative predictive value of over 90% for advanced liver brosis. A score of >3.25 has a positive predictive value of 65% for advanced (5) brosis with a specicity of 97% . The maximum FIB-4 grade was 4 while the minimum was 0. No patient had 0 score as all of them were diagnosed cirrhotic. Of the 50 patients, 11(22%) had a FIB-4 score of 2 , remaining 39(78%) had a score of 4.
Fibroscan grading of severity of liver disease varies with the etiology (6) of the liver cirrhosis but the broad range of values has been taken to assign the broscan score to avoid unclassiable total scores which might present difculty in comparing with endoscopic variceal grades. All 50 patients were classied from F0-F4 based on broscan value and score was assigned. 9 patients had F2 , 16 patients had F3 and 25 patients had F4 grade. They were assigned broscan scores of 2,4 and 6 respectively. None of the patients had F0-1 as all of them has cirrhosis diagnosed prior.
A cumulative score was calculated adding both parameters -11 patients had a cumulative score of 4, 17 had a score of 6, 20 had a score of 8 and 2 patients had a score of 10.
The cumulative non invasive scores i.e, Fibroscan + FIB-4 scores were then compared with endoscopic scores of variceal presence and severity.
Endoscopic assessment of variceal grading of severity was done Risk class prediction as per the North Italian Endoscopic Club (7) Classication and a score was assigned to each patient. The maximum possible score was 8.
On analysis, 11 patients had an endoscopic score of 3-4 and a cumulative non-invasive score of 4.