120
J Gandhara Med Dent Sci
October - December 2026
ORIGINAL ARTICLE
How to cite this article
:
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DIAGNOSTIC ACCURACY OF NON-INVASIVE PARAMETERS FOR DETECTING ESOPHAGEAL
VARICES IN CIRRHOTIC PATIENTS IN
A RESOURCE-LIMITED SETTING
ABSTRACT
OBJECTIVES
This study evaluates the ability of selected non-invasive markers—portal vein
diameter (>13 mm),
aspartate aminotransferase (AST), AST-to-platelet ratio
index (APRI), platelet-to-spleen diameter ratio, spleen size, and INR to detect
oesophageal
varices
in cirrhotic patients accurately.
The
goal is
to
reduce
reliance on invasive procedures and lower healthcare costs, particularly in
resource-limited settings.
METHODOLOGY
This
cross-sectional,
prospective
study
included
165
patients
undergoing
screening endoscopy, ultrasonography, and laboratory investigations (selected
via
a
non-probability,
consecutive
sampling
technique).
The
study
was
conducted at Aga Khan University Hospital, Karachi, from 1
st
April 2024 to
30
th
September 2024. Factors associated with oesophageal varices were rst
analysed
using
univariable
logistic
regression
analyses.
The
predictive
performance
of
the
nal
model
was
evaluated
using
sensitivity,
specicity,
positive
and
negative
predictive
values,
and
overall
accuracy.
Statistical
signicance was set at p < 0.05.
RESULTS
Spleen
size
remained
signicantly
associated
with
oesophageal
varices
(p-
value = 0.025). Other variables, including age, gender, PVD >13 mm, Ascites,
AST, APRI, platelet-to-splenic diameter ratio, and INR, were not independently
associated. The model achieved an overall accuracy of 80%, sensitivity of 84%,
specicity of 67%,
and positive predictive value of 90%, while the negative
predictive value was 55% in predicting oesophageal varices.
CONCLUSION
Among the evaluated non-invasive parameters,
spleen size demonstrated the
most
consistent
association
with
the
presence
of
oesophageal
varices,
remaining an independent predictor on multivariable analysis. The predictive
model
incorporating
non-invasive
markers
achieved
good
overall
accuracy
with high sensitivity, indicating its usefulness in identifying patients at high risk
for
oesophageal
varices,
although
specicity
and
negative predictive
value
were moderate.
KEYWORDS:
Oesophageal
Varices,
Chronic
Liver
Disease,
Portal
Vein
Diameter, Non-Invasive Parameters, Diagnostic Accuracy
INTRODUCTION
Global
prevalence
of
hepatic
cirrhosis
from
autopsy
studies
ranges
from
4.5%
to
9.5%
of
the
general
population.
1
Hence,
we
estimate
that
more
than
fty
million
people
in
the
world,
in
the
adult
population,
would
be
aected
by
chronic
liver
disease
(CLD).
In
2001, the estimated worldwide mortality from cirrhosis
was 771,000 people, ranking 14th and 10th as the leading
cause of death in the world and in developed countries,
respectively.
2
Out
of
the
causes
of
death
from
CLD,
gastrointestinal
bleeding
accounts
for
most
of
the
preventable
mortality
cases,
largely
driven
by
the
development of oesophageal varices secondary to portal
hypertension.
Clinically,
portal
hypertension
increases
resistance
to
blood
ow,
forcing
the
development
of
portosystemic
collaterals
as
the
liver's
architecture
becomes
distorted
by
chronic
brosis.
3,4
The
most
prominent causes of cirrhosis are chronic viral Hepatitis,
prolonged
excessive
alcohol
consumption
and
Non-
alcoholic
fatty
liver
disease,
with
great
regional
variation.
5
In Pakistan, studies attribute Hepatitis as the
predominant cause of cirrhosis, with Hepatitis C Virus
responsible for 41%-52%, followed by Hepatitis B Virus
(HBV)
for
30%
of
the
cases.
6
Several
studies
have
demonstrated that parameters obtainable through routine
laboratory
investigations
and
imaging,
such
as
AST/ALT ratio, INR, spleen size, portal vein diameter,
ascites
and
platelet-to-spleen
diameter
ratio,
correlate
with
the
presence
of
oesophageal
varices
in
cirrhotic
patients,
oering
potential
tools
for
non-invasive
screening.
7
In recent literature, platelet countto-spleen
Zainab Abbasi
1
, Maria Danish Khan
2
, Angbeen Aqeel
3
, Samar Fatima
4
, Tahir Munir
5
Abbasi Z, Khan MD, Aqeel A, Fatima
S, Munir T.
Diagnostic Accuracy of
Non-Invasive Parameters for
Detecting Esophageal Varices in
Cirrhotic Patients in a Resource-
Limited Setting. J Gandhara Med Dent
Sci. 2026;13(4): 120-125.
Date Submission:
22-04-2026
Date Revised:
08-07-2026
Date Acceptance:
19-09-2026
2
Research Associate, Department of
Research, Aga Khan University
Hospital, Karachi
3
Post Graduate Resident, Department
of Internal Medicine, Aga Khan
University Hospital, Karachi
4
Assistant Professor, Department of
Medicine, Aga Khan University
Hospital, Karachi
5
Senior Instructor, Department of
Medicine Statistics, Aga Khan
University Hospital, Karachi
Correspondence
1
Zainab Abbasi, Fellow Medical
Oicer, Department of
Gastroenterology, Aga Khan
University Hospital, Karachi
+92-332-3610770
zainababbasi@aku.edu
http://doi.org/10.37762/jgmds.13-4.921
121
J Gandhara Med Dent Sci
October - December 2026
diameter ratio has emerged as a promising predictor with
favourable
diagnostic
performance
in
resource-limited
clinical
settings.
8
Despite
this,
to
the
best
of
our
knowledge,
the
utility
of
individual
non-invasive
parameters
such
as
portal
vein
diameter
>13
mm,
aspartate aminotransferase (AST), AST-to-platelet ratio
index (APRI), and spleen size for predicting oesophageal
varices has not been analysed in Pakistan within a single
study.
Considering
a
high
disease
burden
in
Pakistan
causing nancial implications for the healthcare system
and
in
order
to
minimise
unnecessary
reliance
on
endoscopies, this
study
was
conducted to evaluate
the
diagnostic accuracy of the readily measurable variables.
METHODOLOGY
The
study
was
a
cross-sectional,
prospective
study
conducted after ERC exemption was granted () at
Aga
Khan University Hospital, Karachi, from 1
st
April 2024
to 30
th
September 2024. All male/female patients aged
between 18 and 85 years who visited the daycare facility
at
the
Endoscopic
Suite
of
Aga
Khan
University
Hospital, Karachi and were diagnosed with chronic liver
disease via abdominal ultrasound as per the operational
definition
and
undergoing
screening
upper
GI
(gastrointestinal) endoscopy were included in this study.
Patients
with
a
history
of
variceal
bleeding
and
intervention,
cirrhotic
patients
with
hepatocellular
carcinoma and patients undergoing liver transplantation
were
excluded
from
the
study.
People
who
did
not
consent or who were critically ill were also excluded.
A
total of 165 patients fulfilling the eligibility criteria were
enrolled
prospectively
using
a
non-probability,
consecutive technique. Sample size was calculated using
Dr
Lin
Naing's
calculator,
taking
sensitivity
71.8%,
specificity 55%, prevalence as 64% and margin of error
as 0.13%. All stable participants visiting the Ultrasound
department at AKUH for CLD follow-up were referred
to the Endoscopic suite department at AKUH for their
screening
endoscopy,
and
subsequently
necessary
laboratory investigations were carried out. The record of
patients'
demographic
data
(age,
gender),
laboratory
investigations
(CBC,
LFTs,
INR),
and
initial
ultrasonography
ndings
measured
using
a
46
MHz
curvilinear probe (portal vein diameter, ascites, spleen
size)
is
carried
out
by
a
qualied
sonographer
or
radiology resident. All saved images and electronically
mapped
callipers
are
sent
via
the
PACS
(Picture
Archiving
and
Communication
System)
hub
to
be
blindly reviewed and ocially validated by a Specialist
outer
-margin
to
outer
-margin
tracking.
At
the
same
time, the portal vein is
routinely measured inner
-
wall
to inner
-
wall to prevent overestimating pathology, and
the presence/absence of oesophageal varices is assessed
on
esophagogastroduodenoscopy
performed
by
the
consultant gastroenterologist. Data were analysed using
RStudio
(version
4.1.2;
Boston,
USA).
Descriptive
statistics were used to summarise patient characteristics.
Categorical variables, including gender, vein status, and
presence
of
ascites,
were
reported
as
frequencies
and
percentages.
Continuous
variables,
such
as
age,
PVD,
and spleen size, were assessed for normality using the
Shapiro-Wilk
test
and
were
found to be
non-normally
distributed; therefore, medians with interquartile ranges
were reported. Comparisons between patients with and
without oesophageal varices were performed using the
Chi-square or Fisher's exact test for categorical variables
and
the
Wilcoxon
rank-sum
test
for
continuous
variables.
Factors
associated
with
oesophageal
varices
were rst examined using univariable logistic regression
analyses.
Variables
with
p-values
<0.25
in
the
univariable
analyses
were
included
in
a
multivariable
logistic
regression
model
to
adjust
for
potential
confounders.
Odds
ratios
(ORs)
with
95%
CIs
were
reported
to
quantify
the
strength
of
associations.
The
predictive performance of the nal model was evaluated
using
sensitivity,
specicity,
positive
and
negative
predictive
values,
and
overall
accuracy.
Statistical
significance was set at p < 0.05.
RESULTS
A total of 165 patients were included in the study. The
median age of participants was 61.0 years [Q1: 52.0, Q3:
70.0].
Of
the
total,
97
(58.8%)
were
males,
and
68
(41.2%) were females. The presence of dilated veins was
observed in 77 (46.7%) patients. The median portal vein
diameter (PVD) was 12.2 mm [9.8, 14.0]; PVD <13 mm
was found in 96 (58.2%) patients, while PVD >13 mm
was present in 77 (46.7%). The median spleen size was
137 mm [117, 156]. Ascites was present in 69 (41.8%)
of
patients,
whereas
96
(58.2%)
had
no
ascites.
The
median
AST level
was 50.0 U/L [35.0, 85.0], and the
median APRI score was 1.40 [0.81, 3.23]. The platelet-
to-splenic diameter ratio had a median value of
629 [419,
1180], and the median INR was 1.30 [1.10, 1.60]. (Table
1)
Consultant
Radiologist
trained
in
hepatic
parameters.
Organ lengths (like the liver, kidneys, and spleen) are
obtained at their maximum longitudinal dimension using
Diagnostic Accuracy of Non-Invasive Parameters for Detecting Esophageal
122
J Gandhara Med Dent Sci
October - December 2026
Table:1 Shows Baseline Demographic, Clinical, and Laboratory
Characteristics of the Study Population (N = 165)
Variable
Overall (N=165)
Age
Median [Q1, Q3]
61.0[52.0,70.0]
Gender
Female
68 (41.2%)
Male
97 (58.8%)
Vein
No
88 (53.3%)
Yes
77 (46.7%)
PVD Size (mm)
Median [Q1, Q3]
12.2[9.80,14.0]
PVD <13MM
No
69 (41.8%)
Yes
96 (58.2%)
PVD >13MM
No
88 (53.3%)
Yes
77 (46.7%)
Spleen Size (mm)
Median [Q1, Q3]
137[117,156]
Ascites
Absent
96 (58.2%)
Presence
69 (41.8%)
AST
Median [Q1, Q3]
50.0[35.0,85.0]
APRI
Median [Q1, Q3]
1.40[0.813,3.23]
Platelet to Splenic Diameter
Median [Q1, Q3]
629[419,1180]
INR
Median [Q1, Q3]
1.30[1.10,1.60]
Among the 165 patients, 129 (78.2%) had oesophageal
varices, while 36 (21.8%) did not. The median age was
slightly lower among patients with varices (60.0 years
[50.0,
70.0])
compared
to
those
without
(63.5
years
[53.8, 75.3]), though this dierence was not statistically
significant
(p
=
0.073).
Males
were
more
frequently
affected by varices (60.5%) than females (39.5%), but
this dierence was also not signicant (p = 0.447). The
median
PVD
was
signicantly higher
in patients
with
varices
(12.3
mm
[10.0,
14.0])
than
in
those
without
(10.9 mm [8.85, 13.2], p = 0.027). Similarly, spleen size
was markedly larger among patients with varices (142
mm [124, 161]) compared with those without (113 mm
[91.8,
144],
p
<
0.001).
Although
the
proportion
of
patients
with
ascites
was
higher
in
the
varices
group
(45.7% vs 27.8%), the dierence approached but did not
reach statistical signicance (p = 0.059). No signicant
dierences
were
observed
in
AST
levels
(p
=
0.191),
APRI
scores
(p
=
0.297),
or
INR
values
(p
=
0.319)
between
the
two
groups.
However,
the
platelet-to-
splenic diameter ratio was signicantly lower in patients
with
varices
(582
[419,
1060])
than
in
those
without
(1160 [440, 1600], p = 0.034). (Table 2) In univariable
analysis,
spleen
size
(OR
1.04,
95%
CI
1.021.05,
p<0.001) and platelet-to-splenic diameter ratio (OR 1.34,
95%
CI
1.101.90,
p=0.005)
were
signicantly
associated with higher odds of oesophageal varices. Age
(OR 0.97, 95% CI 0.941.00, p=0.058) and PVD size
(OR
1.13,
95%
CI
1.001.28,
p=0.056)
showed
borderline associations. Ascites showed a trend toward
increased odds of varices (OR 2.19, 95% CI 1.005.11,
p=0.057).
Other
factors,
including
gender,
PVD
>13
mm,
AST,
APRI,
and
INR,
were
not
signicantly
associated
with
oesophageal
varices
in
univariable
analysis.
(Table
3)
After
adjustment
for
all
factors,
spleen
size
remained
signicantly
associated
with
oesophageal
varices
(OR
1.02,
95%
CI
1.011.05,
p=0.025). Other variables, including age, gender, PVD
>13
mm,
Ascites,
AST,
APRI,
platelet-to-splenic
diameter
ratio,
and
INR,
were
not
independently
associated. Ascites, which showed a trend in univariable
analysis, was not signicant in the multivariable model
(OR 1.57, p=0.358). (Table 3) The model achieved an
overall accuracy of 80% (95% CI: 7486%) in predicting
oesophageal varices. It showed high sensitivity (84%),
indicating a strong ability to correctly identify patients
with varices, and moderate specicity (67%), reecting
its
performance
in
correctly
identifying
those
without
varices.
The
positive
predictive
value
was
90%,
suggesting that most patients predicted to have varices
actually had the condition, while the negative predictive
value was 55%, indicating a moderate ability to rule out
disease. (Figure 1)
Table 2: Comparison of Clinical and Laboratory Characteristics
Between Patients with and without Oesophageal Varices
Variable
Age
Median [Q1, Q3]
Gender
Female
Male
PVD Size (mm)
Median [Q1, Q3]
PVD <13MM
No
Yes
PVD >13MM
No
Yes
Spleen Size (mm)
Median [Q1, Q3]
AST
Median [Q1, Q3]
APRI
Median [Q1, Q3]
Platelet to Splenic Diameter
Median [Q1, Q3]
INR
Median [Q1, Q3]
p-value
0.073
0.447
0.027
0.131
0.347
<0.001
0.191
0.297
0.034
0.319
Oesophagal Varices
Yes (N=129)
No (N=36)
60.0 [50.0, 70.0]
63.5 [53.8, 75.3]
51 (39.5%)
17 (47.2%)
78 (60.5%)
19 (52.8%)
12.3 [10.0, 14.0]
10.9 [8.85, 13.2]
58 (45.0%)
11 (30.6%)
71 (55.0%)
25 (69.4%)
66 (51.2%)
22 (61.1%)
63 (48.8%)
14 (38.9%)
142 [124, 161]
113 [91.8, 144]
51.0 [39.0, 85.0]
43.5 [26.8, 101]
1.55 [0.884, 2.97]
1.01 [0.451, 4.92]
582 [419, 1060]
1160 [440, 600]
1.30 [1.10, 1.60]
1.20 [1.10, 1.73]
Diagnostic Accuracy of Non-Invasive Parameters for Detecting Esophageal
123
J Gandhara Med Dent Sci
October - December 2026
Table 3: Univariable and Multivariable Logistic Regression
Analyses for Factors Associated with Oesophageal Varices
Factor
Univariable
Multivariable
OR (95% CI), P-value
OR (95% CI), P-value
Age
0.97 (0.94-1.00, p=0.058)
0.99 (0.96-1.03, p=0.628)
Gender
Female
Ref-1.00
-
Male
1.37 (0.65-2.88, p=0.408)
-
Vein
No
Ref-1.00
-
Yes
1.30 (0.62-2.77, p=0.497)
-
PVD
Size
(mm)
1.13 (1.00-1.28, p=0.056)
1.12 (0.87-1.45, p=0.383)
PVD >13MM
No
Ref-1.00
-
Yes
1.50 (0.71-3.25, p=0.292)
-
Spleen
Size (mm)
1.04 (1.02-1.05, p<0.001)
1.02 (1.00-1.05, p=0.025)
Ascites
No
Ref-1.00
Ref-1.00
Yes
2.19 (1.00-5.11, p=0.057)
1.57 (0.61-4.28, p=0.358)
AST
1.10 (0.99-1.30, p=0.219)
1.00 (0.99-1.01, p=0.964)
APRI
0.94 (0.83-1.00, p=0.180)
0.83 (0.63-1.00, p=0.167)
Platelet to
Splenic
Diameter
1.34 (1.10-1.90, p=0.005)
1.02 (099-1.05, p=0.169)
INR
1.02 (0.79-1.63, p=0.876)
-
Figure
1:
Diagnostic
Performance
of
the
Predictive
Model
for
Oesophageal Varices
DISCUSSION
Multiple
clinical
studies
have
provided
signicant
evidence
supporting
the
correlation
between
non-
invasive
predictors
of
oesophageal
varices
in
patients
with chronic liver disease. Early identication of patients
at risk remains a cornerstone of management; however,
reliance on endoscopic screening is often impractical in
resource-limited
settings,
which
results
in
rising
mortality.
This
study
evaluated
the
diagnostic
performance
of
routinely
available
non-invasive
parameters
to
identify
oesophageal
varices
among
cirrhotic
patients
and
demonstrated
that
spleen
size
remained
statistically
signicant
after
multivariable
adjustment.
Previously,
Habibullah
Jan
D
et
al.
and
Sarangapani A et al.
have corroborated these ndings.
9,10
This
nding
is
pathophysiologically
plausible,
as
splenomegaly
directly
reects
sustained
portal
hypertension.
Recent studies and consensus
guidelines
continue to emphasise spleen size as a robust surrogate
marker
of
clinically
signicant
portal
hypertension,
particularly in settings where electrography and hepatic
venous
pressure
gradient
measurements
are
unavailable.
11
Our
results
reinforce
spleen
size
as
a
simple, reproducible, and cost-effective marker that can
be
easily
incorporated
into
routine
ultrasonography
assessment. Portal vein diameter and platelet-to-splenic
diameter ratio demonstrated signicant associations with
oesophageal
varices
on
univariable
analysis;
however,
these
associations
did
not
persist
after
adjustment
for
confounding
factors.
Although
PVD
is
traditionally
considered
a
marker
of
portal
hypertension,
its
diagnostic
reliability
has
been
inconsistent
in
contemporary literature.
12
Since ultrasound ndings are
operator-dependent, its utility is limited as a standalone
predictor. The platelet-to-splenic diameter ratio, which
integrates
thrombocytopenia
and
splenomegaly,
has
been proposed as a non-invasive screening tool in several
studies.
10,13
Failure to be statistically signicant might be
due to the multifactorial nature of thrombocytopenia in
cirrhosis,
including
bone
marrow
suppression,
viral
Hepatitis,
nutritional
deciencies,
and
medication
effects, which can confound its relationship with portal
hypertension,
particularly
in
resource-limited
populations.
Biochemical
markers,
including
AST
levels,
APRI
scores
and
INR,
were
not
signicantly
associated
with
oesophageal
varices.
Although
these
indices
are
widely
used
for
brosis
assessment
and
prognostication
in
chronic
liver
disease,
emerging
evidence
suggests
that
they
have
limited
utility
in
predicting portal hypertensionrelated complications.
7,14
These
markers
primarily
reect
hepatic
necroinflammatory
activity
and
synthetic
dysfunction
rather than portal pressure, which may account for their
limited
discriminatory
ability
in
identifying
varices
in
this
study.
The
predictive
model
incorporating
non-
invasive
parameters
achieved
good
overall
accuracy
with
high
sensitivity,
indicating
a
strong
capacity
to
identify patients with oesophageal varices. However, the
model
demonstrated
acceptable
but
limited
specicity
and negative predictive value, suggesting that while it is
effective for identifying patients who require endoscopic
evaluation, it may be less reliable for safely excluding
varices.
Similar
diagnostic
performance
patterns
have
been
reported
in
recent
validation
studies
of
non-
invasive models, underscoring the ongoing challenge of
replacing endoscopy with non-invasive tools.
15,16,17,18
Diagnostic Accuracy of Non-Invasive Parameters for Detecting Esophageal
124
J Gandhara Med Dent Sci
October - December 2026
LIMITATIONS
This study is limited by its cross-sectional design, which
precludes
causal
inference,
and
by
its
single-centre
setting,
which
may
limit
generalizability.
The
endoscopy-based
sampling
strategy
may
also
have
introduced
selection
bias,
as
patients
who
underwent
endoscopic assessment may have diered systematically
from
those
who
did
not.
Although
ultrasonography
is
non-invasive,
portal
vein
diameter
measurements
are
operator-dependent
and
may
be
inuenced
by
patient
positioning, respiratory phase, measurement technique,
and interobserver variability; details regarding operator
training,
blinding
to
endoscopic
ndings,
and
measurement
reproducibility
were
not
reported.
In
addition, the study did not include internal or external
validation
of
the
proposed
predictive
threshold
or
diagnostic
performance
estimates.
Advanced
non-
invasive modalities, such as transient elastography, were
unavailable,
and
potentially
relevant
confounding
factors,
including
disease
aetiology,
severity,
and
hemodynamic
or
treatment-related
variables,
may
not
have been fully accounted for. These limitations mean
that
portal
vein
diameter
should
be
interpreted
as
a
supportive screening marker rather than a replacement
for
endoscopic
evaluation.
Future
multicenter
prospective
studies
integrating
dynamic
markers
and
longitudinal
outcomes
are
warranted
to
validate
these
findings and rene non-invasive screening strategies.
CONCLUSIONS
In
this
study,
oesophageal
varices
were
common,
occurring in 129 (78.2%) patients. Portal vein diameter
was signicantly greater in patients with varices than in
those without; however, PVD greater than 13 mm was
not
signicantly
associated
with
varices
in
either
univariable or multivariable analysis. Spleen size was
the
only parameter that remained independently associated
with
oesophageal
varices
after
adjustment
for
other
clinical
and
laboratory
factors.
The
predictive
model
demonstrated
good
sensitivity
and
positive
predictive
value
but
only
moderate
specicity
and
a
limited
negative predictive value.
CONFLICT OF INTEREST:
None
FUNDING SOURCES:
None
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AUTHORS CONTRIBUTION
The authors accept responsibility for all aspects of the work
and will ensure that any concerns regarding the accuracy or
integrity
of any part are properly investigated and resolved.
Zainab
Abbasi
-
Concept
&
Design;
Data
Acquisition;
Data
Analysis/Interpretation; Drafting Manuscript;
Critical Revision;
Final Approval
Maria
Danish
Khan
-
Concept
&
Design;
Data
Acquisition;
Data
Analysis/Interpretation;
Critical
Revision;
Supervision;
Final Approval
Angbeen Aqeel -
Concept & Design; Data Acquisition; Drafting
Manuscript; Final Approval
Samar
Fatima
-
Concept
&
Design;
Drafting
Manuscript;
Critical Revision; Final Approval
Tahir Munir -
Concept & Design; Data Analysis/Interpretation;
Drafting Manuscript;
Final Approval
Diagnostic Accuracy of Non-Invasive Parameters for Detecting Esophageal
