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I read with interest the study by Alempijevic and Kovacevic and wish to comment on their letter.
Non‐invasive indexes to identify the presence of oesophageal varices in cirrhotic patients may be a useful tool to decrease the number of digestive endoscopies that are performed in these patients. A ratio index can enhance the physiopathological meaning of the single variables, and therefore the specificity of the non‐invasive evaluation. The clinical role of a non‐invasive index depends on (1) the biological plausibility of the proposed ratio, (2) the reproducibility of the variables in the ratio, and (3) the accuracy of identifying or ruling out the presence of oesophageal varices. The right liver lobe diameter/albumin index would seem to be a biologically plausible link between hepatic function and portal hypertension owing to the role of the liver in the synthesis of albumin. However, this ratio lacks both the reproducibility of ultrasound measurement of the right liver lobe diameter and the accuracy at screening for the absence of oesophageal varices. It would be interesting to compare the accuracy of the right liver lobe diameter/albumin ratio with the platelet count/spleen diameter ratio to evaluate the presence or absence of oesophageal varices, considering that the reproducibility of ultrasound measurement of spleen bipolar diameter is well established (Gut 2003;52:1200–5) and that its accuracy in ruling out the presence of oesophageal varices has been confirmed in a multicentre study.1 In particular, the reproducibility of the spleen bipolar diameter was high with an intraobserver expert ultrasound operator coefficient of variation for repeated measurements of 2% and interoperator coefficient of variation of 4%.
With regard to the suggestion that “it is unlikely that these indexes could be used to exclude patients from initial screening endoscopy”, as stated by Alempijevic and Kovacevic, it must be pointed out that the non‐invasive indexes should be used to screen for the presence or absence of oesophageal varices, and thus to provide an endoscopic evaluation in patients with a ratio index that is compatible with the risk of oesophageal varices. Furthermore, any non‐invasive index, including liver stiffness measurement,2 may reflect the various degrees of oesophageal varices, further stressing the role of non‐invasive ratio indexes in preliminary screening to determine the presence or absence of oesophageal varices.