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Original Article
ARTICLE IN PRESS
doi:
10.25259/ANAMS_255_2024

Study of right liver lobe diameter to the serum albumin ratio as a marker of esophageal varices in patients with cirrhosis of liver

Department of Medical Gastroenterology, Gandhi Medical College, Secunderabad, Hyderabad, India

* Corresponding author: Dr. Snehitha Nalluri, Department of Medical Gastroenterology, Gandhi Medical College, Secunderabad, Hyderabad, India. snehitha.nalluri@gmail.com

Licence
This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-Share Alike 4.0 License, which allows others to remix, transform, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.

How to cite this article: Kulkarni HS, Tumma T, Suman SK, Nalluri S, Porika SK. Study of right liver lobe diameter to the serum albumin ratio as a marker of esophageal varices in patients with cirrhosis of liver. Ann Natl Acad Med Sci (India). doi: 10.25259/ANAMS_255_2024

Abstract

Objectives

To evaluate the effectiveness of the right liver lobe diameter to serum albumin (RLL/Alb) ratio as a non-invasive marker for predicting the presence and size of esophageal varices in cirrhotic patients, an area with limited research in India.

Material and Methods

This study involved cirrhotic patients who met specific inclusion and exclusion criteria. All participants underwent a comprehensive biochemical workup, esophagogastroduodenoscopy, and abdominal ultrasonography to measure the RLL/Alb ratio. Data were collected, tabulated, and analyzed.

Results

A total of 150 patients (117 males, 33 females) with an average age of 47.81 ± 8.99 years participated in the study. Alcohol consumption was the predominant cause of cirrhosis (64%). Patients were distributed across Child-Pugh classes A (34%), B (34%), and C (32%). Esophageal varices (EV) were absent in 21.3% of patients, while 24.6%, 40%, and 14% had grade I, II, and III EV, respectively. The mean RLL/Alb ratios for no varices, grades I, II, and III were 3.14 ± 0.69, 4.99 ± 0.57, 5.62 ± 0.83, and 7.63 ± 0.49, respectively. A strong positive correlation was observed (r = 0.8633).

Conclusion

The RLL/Alb ratio shows promise as a reliable, non-invasive tool for identifying and grading EVs in liver cirrhosis patients, especially valuable in settings where endoscopy resources are limited. This study highlights the need for accessible markers of varices in the Indian population, where research on this parameter is limited.

Keywords

Cirrhosis
Esophageal varices
Right liver lobe/albumin

INTRODUCTION

Cirrhosis is the end stage for numerous etiologies of chronic liver diseases. It is defined by global hepatic fibrosis and nodular alteration of the hepatic architecture1. India contributed to 18.3% of global deaths due to liver diseases in 2015.2 With the rising prevalence of steatotic liver disease in Southeast Asia,3 Liver cirrhosis is expected to rise exponentially.

High portal pressures in cirrhosis cause the opening up of portosystemic collaterals leading to varices. The presence of esophageal varices (EVs) and variceal bleeding represents an important stage in the natural history of the condition. At diagnosis, EVs are seen in 40% of patients with compensated cirrhosis and in 60% of cases with decompensation.4,5

The annual occurrence of initial variceal bleeding is approximately 4%.6,7 The large size of varices and high intravariceal pressure are risk factors for bleeding EVs.8,9 Annually, bleeding is seen in 1–2% of patients with no varices, 5% in cases with small varices, and 15–20% of patients with large varices.10 Development of newer varices is approximately 8% per year.11 There is a 5% to 8% chance of death at 1 week and 20% at 6 weeks12 after an acute episode of bleeding.

In patients with compensated cirrhosis and no varices, repeat endoscopy should be done once every 2-3 years, while small varices warrant endoscopy every 1-2 years and yearly screening in cirrhosis with decompensation. Although BAVENO VII13 consensus recommends that screening endoscopy be done if liver stiffness measurement (LSM) ≥20 kPa or thrombocyte count ≤150 × 109/L, LSM has limited availability, and thrombocytopenia alone cannot be relied upon.

The rising incidence of cirrhosis and improved patient survival are putting significant pressure on endoscopists and creating financial strain on patients. This increasing demand for endoscopy services is challenging due to issues with accessibility, affordability, and medical risks. reliable, non-invasive markers are required to help detect EVs and potentially reduce the need for endoscopic procedures.

We aimed to identify a novel non-invasive parameter ie., liver size and serum albumin level ratio (RLL/Alb), that can become a potential marker of presence of EVs and their size.

MATERIAL AND METHODS

This study was conducted at a teaching institution located in Southern India. Institutional ethical committee clearance was obtained for the study.

Inclusion criteria

  • 1.

    Patients aged ≥ 18 years with a definite diagnosis of liver cirrhosis, admitted to the Department of Gastroenterology.

  • 2.

    Patients consenting to participate in the study.

Exclusion criteria

  • 1.

    Patients with conditions that lead to hypoalbuminemia.

  • 2.

    Prior history of bleeding due to portal hypertension.

  • 3.

    Patients diagnosed with hepatocellular carcinoma.

  • 4.

    Patients diagnosed with Portal vein thrombosis.

  • 5.

    Currently or previously treated with beta-blockers, diuretics, or other vasoactive medications.

  • 6.

    Pregnant females.

Data collection

Demographic data, etiology of cirrhosis, and basic hematologic and biochemical investigations were collected for every patient. All patients underwent ultrasonography of the abdomen and esophagogastroduodenoscopy. Esophageal variceal grading was done using Modified Pacquet grading.

Measuring right liver lobe diameter

With the Patient in a supine position, the high-resolution curvilinear probe was placed in the right subcostal area on the mid-clavicular line. The cranio-caudal diameter of the right lobe was measured from the diaphragm to the liver edge during deep inhalation, with the right arm positioned overhead.

RLL/Alb ratio was then calculated by simple division.

SPSS v24 was used for analysis. P value < 0.05 was taken to be statistically significant.

RESULTS

A total of 150 patients were recruited for the study. The mean age among study subjects was 47.81 ± 8.99 years. There were 117 (78%) males and 33 (22%) females [Table 1]. Chronic alcohol intake was the most common etiology in 96 patients (64%); 36 patients (24%) had viral etiology, 9 (6%) were diagnosed to with an autoimmune cause, 4 (6%) with Wilson disease, and 3 (2%) were of unknown etiology [Figure 1].

Table 1: Demography of study population
Gender n
Male 117 (78%)
Female 33 (22%)
Age n
<40 years 27 (18%)
40–60 years 117 (78%)
>60 years 6 (4%)
Etiology of cirrhosis in the study population.
Figure 1:
Etiology of cirrhosis in the study population.

Child-Turcotte-Pugh grades showed that 51 subjects (34%) belonged to grade A, 51 patients (34%) to grade B, and 48 patients(32%) to grade C. Sixty patients had grade 2 varices (40%), 37 patients had grade 1 (24.6%), 32 had no varices (21.3%), and 21 patients had grade 3 varices (14%) [Figure 2].

Esophageal Variceal grades in the study population (N=150).
Figure 2:
Esophageal Variceal grades in the study population (N=150).

The mean measurement of the right liver lobe diameter was 10.82 ± 1.2 cm. The mean serum albumin level was 2.29 ± 0.85 mg/dL. The mean right liver lobe/albumin ratio was 5.22 ± 1.51 [Table 2 and Figure 3].

Table 2: Correlation between the ratio of RLL/Alb vs. variceal grade
Variceal grade RLL/Alb
P-value
Mean (SD) Median Range
0 3.14 (0.69) 3.07 2.3 to 5.26 <0.001
I 4.99 (0.57) 5.04 3.65 to 5.68
II 5.62 (0.83) 5.64 2.67 to 7.62
III 7.62 (0.49) 7.45 6.93 to 8.58

Bold indicates that p value is significant. SD: Standard deviation, RLL/Alb: Ratio of right liver lobe diameter and serum albumin.

Right liver lobe diameter to serum albumin (RLL/Alb) ratio vs. Variceal grades (N=150).
Figure 3:
Right liver lobe diameter to serum albumin (RLL/Alb) ratio vs. Variceal grades (N=150).

The mean right liver lobe diameter was 11.01 ± 1.3 cm in patients with no varices, 10.95 ± 1.18 cm in those with Grade 1 varices, 10.7 ± 1.12 cm for Grade 2 varices, and 10.6 ± 1.35 cm for Grade 3 varices. The difference was not statistically significant (p = 0.6866).

The mean albumin levels were 3.63 ± 0.74 in patients without varices, 2.22 ± 0.32 in those with Grade 1 varices, 1.94 ± 0.35 in patients with Grade 2 varices, and 1.14 ± 0.16 in those with Grade 3 varices. The differences were statistically significant (p < 0.001).

The mean RLL/Alb ratio in patients with no varices was 3.14 + 0.69, grade 1 was 4.99+ 0.57, grade 2 5.62+ 0.83, and grade 3 was 7.63 + 0.49. The correlation coefficient (r) was 0.8633 (positive correlation).

An additional analysis involved constructing a receiver operating characteristic (ROC) curve to know sensitivity and specificity. At an optimal cutoff value of 4.54, the sensitivity and specificity were 93.7% and 95.2%, respectively, with an area under the ROC curve (AUC) of 0.963, indicating statistical significance [Figure 4].

ROC curve to evaluate the RLL/Alb ratio as a marker for the presence of esophageal varices. ROC: Receiver operating characteristic curve, RLL/Alb: Right liver lobe diameter to serum albumin ratio.
Figure 4:
ROC curve to evaluate the RLL/Alb ratio as a marker for the presence of esophageal varices. ROC: Receiver operating characteristic curve, RLL/Alb: Right liver lobe diameter to serum albumin ratio.

Discussion

Esophageal variceal bleeding, being the second most common decompensation, is a potentially lethal complication of liver cirrhosis. It imposes a heavy economic burden on health care as well as on patients.14 The mortality rate might be underestimated because many patients die before they can reach a hospital. Detecting EVs early and addressing them can help reduce complications. Screening of all patients using endoscopy is invasive and poses a significant financial burden.

Several studies have introduced laboratory and ultrasound-based methods for the non-invasive diagnosis of cirrhosis, including measurements like platelet count, splenomegaly, platelet count-to-splenic diameter ratio, serum albumin levels, and advanced Child-Pugh classification.

Our study was designed to test a novel marker, the right liver lobe diameter to serum albumin ratio, as a marker for the presence of EVs. This novel tool is derived by simple division of two parameters, which can be obtained from routine ultrasonography of the abdomen and serum albumin testing.

In the present study, the mean age of the study group was 47.81+ 8.99. The major age group in our study was between 40-60 years (78%), followed by < 40 years (18%) and > 60 years (4%). Our study comprised mostly male patients (78%), which was similar to a study published by Alempijevic et al.15 (2007).

The most common cause of cirrhosis in our study was chronic alcohol ingestion (64%), followed by viral causes (24%). An epidemiologic study published by Mondal et al.16 (2022) showed Hepatitis B to be the most common cause of cirrhosis. This difference might be explained by the difference in location and demography of the study sample.

Overall, the mean size of the right liver lobe was 10.8 ± 1.2 cm. The mean diameter of the right liver lobe in patients with no varices was 11.01 ± 1.3cm, grade 1 was 10.95 + 1.18 cm, grade 2 was 10.7+ 1.12 cm, and grade 3 was 10.6 ± 1.35 cm. The difference between the classes was not significant (p=0.6866).

In our study, the mean RLL/Albumin ratio was found to be high in grade 3 EVs (7.62 + 0.49), followed by grade 2 (5.62 + 0.83), grade 1 (4.99 + 0.57) and no varices (3.14 + 0.69). ANOVA test results indicated a significant difference (p < 0.001) between the mean values of the ratio across EV grades. With a cutoff ratio of 4.54, the sensitivity and specificity were determined to be 93.7% and 95.2%, respectively. This result may also be influenced by low variation within the groups, homogeneity of the sample, or potential overfitting to this specific group, indicating that larger studies are needed to confirm these findings.

A study by Alempijevic T et al.,15 (2007) reported a cutoff of 4.425 with a sensitivity of 83.1% and specificity of 73.9%.

Chowdhury et al.17 (2022) showed that The RLL/Alb ratio diagnosed the EVs using the cut-off value of 4.01 with 85.3% sensitivity and 68.8% specificity.

Study by Metwally AY et al.18 (2019) showed that at a cut-off of 3.7, the sensitivity, specificity, and accuracy of the RLL/Alb ratio to predict EVs were 95, 76.4, and 90%.

In our study, ANOVA test results indicated a significant difference between the mean ratio values across endoscopic grading levels (p = 0.001). The AUC for the ratio was 0.973, demonstrating statistical significance.

Esmat et al.,19 (2012) Akram et al.,20 (2019) Ravali et al.21 (2023) have investigated the role of the Right liver lobe diameter/Alb ratio for noninvasively predicting the presence of EVs and got a positive correlation, showing it as a promising novel non-invasive tool. Although these markers cannot replace endoscopy, they carry significance in clinical practice, especially in a nation like ours where primary health care is the backbone of the health system.

Conclusion

In conclusion, the RLL/Alb serves as a novel, valuable non-invasive marker for predicting and grading EVs in cirrhotic patients. This approach can minimize the need for endoscopic procedures, reducing both the economic burden and patient risks associated with invasive screening. Given the scarcity of Indian studies focused on non-invasive markers like RLL/Alb, further regional research is essential to validate its effectiveness in diverse populations. Expanding the use of such markers could improve early diagnosis and tailored management in resource-limited settings.

Authors’ contributions

HSK: Conceptualization, methodology and writing-Original draft; TT: Review and Editing; SKS: Data curation; SN: Investigation, visualization, writing-original draft; SKP: Supervision.

Ethical approval

The research/study approved by the Institutional Review Board at Gandhi Medical College, Secunderabad, number IEC/GMC/2021/08/72, dated 26th August 2019.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Use of artificial intelligence (AI)-assisted technology for manuscript preparation

The authors confirm that there was no use of artificial intelligence (AI)-assisted technology for assisting in the writing or editing of the manuscript and no images were manipulated using AI.

References

  1. . Sleisenger and Fordtran’s Gastrointestinal and Liver Disease E-Book: Pathophysiology, Diagnosis, Management. Philadelphia: Elsevier; . p. :1164.
  2. , , , , , , et al. Liver cirrhosis mortality in 187 countries between 1980 and 2010: A systematic analysis. BMC Med. 2014;12:1-24.
    [CrossRef] [Google Scholar]
  3. . Epidemiology of metabolic dysfunction-associated steatotic liver disease (MASLD) and alcohol-related liver disease (ALD) Metab Target Organ Damage 2024:1.
    [CrossRef] [Google Scholar]
  4. , , , , , , et al. Which patients with cirrhosis should undergo endoscopic screening for esophageal varices detection? Hepatology. 2001;33:333-8.
    [CrossRef] [PubMed] [Google Scholar]
  5. , . Natural history. Clinical-haemodynamic correlations. Prediction of the risk of bleeding. Baillieres Clin Gastroenterol. 1997;11:243-56.
    [CrossRef] [PubMed] [Google Scholar]
  6. , , , , , , et al. Beta-adrenergic-antagonist drugs in the prevention of gastrointestinal bleeding in patients with cirrhosis and esophageal varices. An analysis of data and prognostic factors in 589 patients from four randomized clinical trials. Franco-Italian Multicenter Study Group. N Engl J Med. 1991;324:1532-8.
    [CrossRef] [PubMed] [Google Scholar]
  7. , , . The treatment of portal hypertension: A meta-analytic review. Hepatology. 1995;22:332-54.
    [CrossRef] [PubMed] [Google Scholar]
  8. , , , , , , et al. Prognostic indicators of risk for first variceal bleeding in cirrhosis: a multicenter study in 711 patients to validate and improve the North Italian Endoscopic Club (NIEC) index. Am J Gastroenterol. 2000;95:2915-20.
    [CrossRef] [PubMed] [Google Scholar]
  9. , , . Predictors of variceal bleeding: An analysis of clinical, endoscopic, and haemodynamic variables, with special reference to intravariceal pressure. Gut. 1989;30:1757-64.
    [CrossRef] [PubMed] [Google Scholar]
  10. , . The clinical course of portal hypertension in liver. Berlin: Springer-Verlag; . p. :15-24.
  11. , . UK guidelines on the management of Variceal haemorrhage in cirrhotic patients. Gut. 2000;46:1-15.
    [CrossRef] [PubMed] [Google Scholar]
  12. , , . Pharmacological treatment of portal hypertension: An evidence based approach. Semin Liver Dis. 1999;19:475-505.
    [CrossRef] [PubMed] [Google Scholar]
  13. , , , , , . Baveno VII - Renewing consensus in portal hypertension. J Hepatol. 2022;76:959-74. Erratum in: J Hepatol 2022;77:271
    [CrossRef] [PubMed] [PubMed Central] [Google Scholar]
  14. , , , . Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis. Am J Gastroenterol. 2007;46:922-38.
    [CrossRef] [Google Scholar]
  15. , , , , , , et al. Right liver lobe/albumin ratio: Contribution to non-invasive assessment of portal hypertension. World J Gastroenterol. 2007;13:5331-5.
    [CrossRef] [PubMed] [PubMed Central] [Google Scholar]
  16. , , . Epidemiology of liver diseases in India. Clin Liver Dis. 2022;19:114-7.
    [CrossRef] [Google Scholar]
  17. , , , , , , et al. RLLB/Alb ratio: a promising noninvasive diagnostic marker in assessing esophageal varices in cirrhotic patients. J Clin Lab Anal. 2022;36:e24589.
    [CrossRef] [PubMed] [PubMed Central] [Google Scholar]
  18. , , , . Right liver lobe diameter/serum albumin ratio in the prediction of esophageal varices in cirrhotic patients. Menoufia Med J. 2019;32:1113.
    [CrossRef] [Google Scholar]
  19. , , . Can we consider the right hepatic lobe size/albumin ratio a noninvasive predictor of oesophageal varices in hepatitis C virus-related liver cirrhotic egyptian patients? Eur J Intern Med. 2012;23:267-72.
    [CrossRef] [PubMed] [Google Scholar]
  20. , , . The right liver lobe size/Albumin concentration ratio in identifying esophageal varices among patients with liver cirrhosis. Middle East J Dig Dis. 2019;11:32-7.
    [CrossRef] [PubMed] [PubMed Central] [Google Scholar]
  21. , , , . Right lobe liver size/Albumin ratio: A noninvasive diagnostic marker in assessing esophageal varices in cirrhotic patients. J Clin Exp Hepatol. 2023;13:S27.
    [Google Scholar]
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