الفهرس 
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Abstract
Liver cirrhosis is a chronic irreversible liver disease. Portal hypertension is a frequent complication of liver cirrhosis. Esophageal varices (EV) are frequently seen in cirrhotic cases with portal hypertension, with variceal bleeding being the most fatal complication of liver cirrhosis and portal hypertension.
Esophago-gastro-duodenoscopy (EGD) is considered to be necessary for all cirrhotic patients to evaluate the risk of variceal bleeding. Three factors identify patients at a high risk of bleeding from varices: large variceal size, red color signs on the varices and advanced liver disease (Child-Pugh class B or C).
The increased flow of patients on endoscopy units might not meet the demands of cost-effectiveness for patients and hospitals. Some studies have evaluated possible non-invasive markers of EV in cirrhotic patients. The studies concluded that by selecting patients for endoscopic screening based on a few non-endoscopic variables reduces the number of unnecessary endoscopies.
The aim of this work was to study serum N-terminal pro-C type natriuretic peptide (NT pro-CNP) and its relation to the risk of variceal bleeding in hepatitis-C virus-related liver cirrhosis patients. The study was carried out on 80 subjects: 60 patients with HCV-related liver cirrhosis and 20 healthy control subjects. The 60 cases were divided into 3 groups as follows; 20 patients with HCV-related liver cirrhosis and EV which have previously bled (Group-I), 20 patients with HCV-related liver cirrhosis and EV which have not yet bled (Group-II), and 20 patients with HCV-related liver cirrhosis without EV (Group-III).
The diagnosis of liver cirrhosis was based on clinical, biochemical and ultrasonographic data. The liver condition was scored according to Child-Pugh classification and scoring system. Upper gastro-intestinal tract endoscopy was done to determine the presence of varices and grade it. Calculation of non-invasive parameters predicting the presence of EV as FIB-4 scoring system and platelet count to spleen diameter ratio. Laboratory investigations were done to all participants and included complete urine analysis, complete blood count, and determination of prothrombin time and calculation of the international normalized ratio (INR). Serum sample was obtained for the determination of serum levels of urea, creatinine, albumin, total and direct fractions of bilirubin, as well as serum activities of alanine transaminase (ALT), aspartate transaminase (AST). Serum Hepatitis-C virus antibodies (HCV-Ab), serum hepatitis-B virus surface antigen (HBsAg), serum hepatitis-B virus core antibody (HBc-Ab), indirect haemagglutinin test for schistosomiasis, ANA, ASMA and LKMA were also determined. Serum NT pro-CNP level was measured using an enzyme immunoassay.
The present study was able to demonstrate a significantly higher serum level of NT pro-CNP in cirrhotic cases with EV than cirrhotic cases without EV. Correlation studies revealed positive relations of serum NT pro-CNP level with Child score in all cirrhotic cases particularly those without EV. Furthermore, a positive relation of serum NT pro-CNP with serum levels of both total and direct fraction of bilirubin in all cases, and an inverse relation with serum albumin in cirrhotic cases without varices were also found. In addition, a positive relation of NT pro-CNP with serum creatinine was evident in cirrhotic cases without EV.
When comparing the diagnostic performance of serum NT pro-CNP in differentiating cirrhotic patients with EV (groups I and II) from cirrhotic patients without EV (group III), a ROC curve generated cut-off value at ≥3.95 (AUROC =0.739), showed a diagnostic sensitivity of 65%, specificity of 75%, positive and negative predictive values of 83.87% and 51.72% respectively, with an overall accuracy of 68.33%.