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Iqbal Sungkar, Leonardo Basa Dairi, Gontar Alamsyah Siregar
Division of Gastroentero-hepatology, Department of Internal MedicineFaculty 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. com
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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:/RN6FRUHZDVVLJQL¿FDQWO\DVVRFLDWHGZLWKHVRSKDJHDOYDULFHV/RN6FRUHLVDJRRGQRQLQYDVLYH
predictor of large esophageal varices in cirrhotic patients.
Keywords:Lok Score, non-invasive parameter, esophageal varices
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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
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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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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%.
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
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Liver cirrhosis is a chronic liver disease characterized
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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
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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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the prevalence of upper gastrointestinal bleeding
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regularly is very expensive and is often associated with complications that can arise from endoscopic
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as well as the limited competence of a doctor to perform endoscopic examination that required non-invasive examination (marker) associated with portal
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esophageal varices in liver cirrhosis patients.
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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
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predictors of esophageal varices in liver cirrhosis patients with promising results.
Lok Score is a serum biomarker used to predict liver
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several studies try to examine Lok Score in predicting esophageal varices. Stefanescu et al examined various non-invasive serum markers in predicting the presence of esophageal varices in patients with cirrhosis of the
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non-invasive examination in predicting the presence
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in predicting the presence of esophageal varices has not
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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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participate in the study and signed the informed consent. The exclusion criterias are previous history variseal
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received blocker drugs or endoscopic therapy (ligation
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undergone surgical treatment for portal hypertension
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conducted to the study subjects.
Statistical analysis to study the relationship between the endoscopy measurement results with the Lok Score was done using independent t-test if the data are normally distributed and using Mann Whitney test if the data are not normally distributed. To assess the
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Child Pugh and ascites with the size of the varicose
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likelihood ratio (LR-).
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There are significant difference in Lok Score means between groups of large esophageal varices
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value of Lok Score in group of large esophageal
YDULFHVZDVVLJQL¿FDQWO\KLJKHUFRPSDUHGZLWKWKH Age (years old) 49,76 ± 11,63* Platelets (x109/L) 111.50 (23-647)**
Aspartate aminotransferase (U/L) Alanin aminotransferase (U/L) Gamma GT (U/L)
72 (12-1075)** 37.5 (8-536)** 68 (10-901)** Total bilirubin (mg/dL) 2.5 (0.25-32.18)** Albumin (gr/dL) 2.49 ± 0.72*
ǻ3URWKURPELQHWLPH37VHFRQG 5.26 ± 5.37* International normalized ratio (INR) 1.41 ± 0.43* Ascites Etiology of liver cirrhosis
Hepatitis B Hepatitis C
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Small esophageal varices F1
Large esophageal varices F2
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*
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transferase; PT: prothombine time; INR: international normalized ratio; ALT: alanine aminotransferase
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small esophageal varices compared to means in large
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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
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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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common cause of liver cirrhosis is chronic hepatitis B
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In this study we found that Child Pugh score in the
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C in this study because this study was conducted at a
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institution are in the late phase of the disease.
Mild to moderate thrombocytopenia occurred in
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of thrombocytopenia is multifactorial including increased sequestration of platelets in the spleen during
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process of platelet destruction due to autoantibodies or immune processes. This study reported that
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between the means of Lok Score between patients with large esophageal varices and small esophageal varices
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Score is expected to could be used as a basis for giving
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esophageal varices bleeding especially in areas with no
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competence of endoscopy.17KHUHIRUHLWQHHGHGDQQRQ
invasive examination (marker) which correlated with
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esophageal varices in liver cirrhosis patients.
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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.
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should be combined with another methods of
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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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4. Jensen DM. Endoscopic screening for varices in cirrhosis:
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management of gastroesophageal varices and variceal
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study. J Hepatol
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Kujovich JL. Hemostatic defects in end stage liver disease.
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disorders and hemostasis in liver disease: pathophysiology and critical assessment of current management. Hepatology
