Advances in Therapy

, Volume 36, Issue 8, pp 2167–2178 | Cite as

Liaoning Score for Prediction of Esophageal Varices in Cirrhotic Patients Who Had Never Undergone Endoscopy: A Multicenter Cross-Sectional Study in Liaoning Province, China

  • Xingshun QiEmail author
  • Yiling Li
  • Ran Wang
  • Lianjie Lin
  • Jing Li
  • Lijun Wang
  • Shuang Zheng
  • Yonghong Sun
  • Lixin Zhao
  • Xiaolin Fu
  • Mengchun Wang
  • Xinping Qiu
  • Han Deng
  • Cen Hong
  • Qianqian Li
  • Hongyu Li
  • Xiaozhong GuoEmail author
Brief Report


Background and Aims

Endoscopy is necessary for assessment of esophageal varices (EVs) in cirrhotic patients, but its use is limited because of the poor compliance of patients and shortage of public health resources at primary hospitals or rural areas, especially in less well developed countries. A multicenter cross-sectional study aimed to establish a novel non-invasive score for prediction of EVs in cirrhotic patients who had never undergone endoscopy.


Patients with liver cirrhosis regardless of acute upper gastrointestinal bleeding (AUGIB) who underwent the first-time upper gastrointestinal endoscopy at 11 hospitals in Liaoning Province, China were considered. Independent predictors for EVs were identified by multivariate logistic regression analysis and then combined into an equation. The diagnostic performance with area under curve (AUC) was further evaluated by receiver operating characteristic curve analysis.


Overall, 363 patients were included, of whom 260 had EVs and 180 presented with AUGIB. In all patients, AUGIB, ascites, and platelets were the independent predictors for EVs. The equation (i.e., Liaoning score) was 0.466 + 1.088 × AUGIB (1 = yes; 0 = no) + 1.147 × ascites (1 = yes; 0 = no) − 0.012 × platelets, which had an AUC of 0.807 (p < 0.0001). In patients with AUGIB, ascites and platelets were the independent predictors for EVs. The equation was as follows: 1.205 + 1.557 × ascites (1 = yes; 0 = no) − 0.008 × platelets, which had an AUC of 0.782 (p < 0.0001). In patients without AUGIB, platelets was the only independent predictor for EVs, which had an AUC of 0.773 (p < 0.0001).


The Liaoning score is based on easy-to-access regular clinical and laboratory data and has a good diagnostic performance for non-invasive prediction of EVs in cirrhotic patients.

Trial Registration Identifier: NCT02593799.


Endoscopy Esophageal varices Gastrointestinal bleeding Liver cirrhosis Portal hypertension 



Area under curve


Acute upper gastrointestinal bleeding


Confidence interval


Esophageal varices


Odds ratio





We thank the participants of the study.


This study was partially supported by the Grant from the Natural Science Foundation of Liaoning Province (no. 201800050) for Dr. Xingshun Qi. The article processing charges were funded by the authors.


All named authors meet the International Committee of Medical Journal Editors (ICMJE) criteria for authorship for this article, take responsibility for the integrity of the work as a whole, and have given their approval for this version to be published.

Authorship Contributions

Xingshun Qi conceived the study, analyzed the data, performed the statistical analyses, and wrote the paper; Yiling Li, Ran Wang, Lianjie Lin, Jing Li, Lijun Wang, Shuang Zheng, Yonghong Sun, Lixin Zhao, Xiaolin Fu, Mengchun Wang, Xinping Qiu, Han Deng, Cen Hong, Qianqian Li, and Hongyu Li collected the data and analyzed the data; Xiaozhong Guo conceived and supervised the study. All authors read and approved the final manuscript. The authors Xingshun Qi, Yiling Li and Ran Wang are co-first authors and contributed to this work equally.


All authors, including Xingshun Qi, Yiling Li, Ran Wang, Lianjie Lin, Jing Li, Lijun Wang, Shuang Zheng, Yonghong Sun, Lixin Zhao, Xiaolin Fu, Mengchun Wang, Xinping Qiu, Han Deng, Cen Hong, Qianqian Li, Hongyu Li, and Xiaozhong Guo, declared no conflict of interest related to this work. The funding sponsor did not influence the results of this study.

Compliance with Ethics Guidelines

This cross-sectional study was carried out following the rules of the Declaration of Helsinki and approved by the Medical Ethical Committee of the General Hospital of Northern Theater Command (formerly General Hospital of Shenyang Military Area), which is the principal affiliation of this study. The approval number was k(2015)11. This study was registered ( ID: NCT02593799). Considering the nature of this observational study, the patients’ written informed consent was waived.

Data Availability

The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.

Supplementary material

12325_2019_967_MOESM1_ESM.jpg (263 kb)
Supplementary material 1 (JPEG 262 kb)


  1. 1.
    Garcia-Tsao G, Bosch J. Management of varices and variceal hemorrhage in cirrhosis. N Engl J Med. 2010;362:823–32.CrossRefGoogle Scholar
  2. 2.
    Biecker E. Portal hypertension and gastrointestinal bleeding: diagnosis, prevention and management. World J Gastroenterol. 2013;19:5035–50.CrossRefGoogle Scholar
  3. 3.
    Garcia-Tsao G, Sanyal AJ, Grace ND, Carey W. Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis. Hepatology. 2007;46:922–38.CrossRefGoogle Scholar
  4. 4.
    de Franchis R. Expanding consensus in portal hypertension: report of the Baveno VI Consensus Workshop: stratifying risk and individualizing care for portal hypertension. J Hepatol. 2015;63:743–52.CrossRefGoogle Scholar
  5. 5.
    de Franchis R, Dell'Era A. Invasive and noninvasive methods to diagnose portal hypertension and esophageal varices. Clin Liver Dis. 2014;18:293–302.CrossRefGoogle Scholar
  6. 6.
    Tripathi D, Stanley AJ, Hayes PC, et al. UK guidelines on the management of variceal haemorrhage in cirrhotic patients. Gut. 2015;64:1680–704.CrossRefGoogle Scholar
  7. 7.
    Marcellin P, Kutala BK. Liver diseases: a major, neglected global public health problem requiring urgent actions and large-scale screening. Liver Int. 2018;38(Suppl 1):2–6.CrossRefGoogle Scholar
  8. 8.
    Qi X, Guo X, Li H, Liu X, Deng H. Knowledge about non-invasive diagnostic tests for varices in liver cirrhosis: a questionnaire survey to the Gastroenterology Branch of the Liaoning Medical Association, China. Gastroenterol Rep (Oxf). 2016;4:141–7.CrossRefGoogle Scholar
  9. 9.
    Mokdad AA, Lopez AD, Shahraz S, et al. Liver cirrhosis mortality in 187 countries between 1980 and 2010: a systematic analysis. BMC Med. 2014;12:145.CrossRefGoogle Scholar
  10. 10.
    Lozano R, Naghavi M, Foreman K, et al. Global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet. 2012;380:2095–128.CrossRefGoogle Scholar
  11. 11.
    Laine L, Laursen SB, Zakko L, et al. Severity and outcomes of upper gastrointestinal bleeding with bloody vs coffee-grounds hematemesis. Am J Gastroenterol. 2018;113:358–66.CrossRefGoogle Scholar
  12. 12.
    Deng H, Qi X, Guo X. Diagnostic accuracy of APRI, AAR, FIB-4, FI, King, Lok, Forns, and FibroIndex scores in predicting the presence of esophageal varices in liver cirrhosis: a systematic review and meta-analysis. Medicine (Baltimore). 2015;94:e1795.CrossRefGoogle Scholar
  13. 13.
    Deng H, Qi X, Guo X. Computed tomography for the diagnosis of varices in liver cirrhosis: a systematic review and meta-analysis of observational studies. Postgrad Med. 2017;129:318–28.CrossRefGoogle Scholar
  14. 14.
    Deng H, Qi X, Zhang T, Yoshida EM, Guo X. Supersonic shear imaging for the diagnosis of liver fibrosis and portal hypertension in liver diseases: a meta-analysis. Expert Rev Gastroenterol Hepatol. 2018;12:91–8.CrossRefGoogle Scholar
  15. 15.
    Marot A, Trepo E, Doerig C, Schoepfer A, Moreno C, Deltenre P. Liver stiffness and platelet count for identifying patients with compensated liver disease at low risk of variceal bleeding. Liver Int. 2017;37:707–16.CrossRefGoogle Scholar
  16. 16.
    Chen R, Deng H, Ding X, Xie C, Wang W, Shen Q. Platelet count to spleen diameter ratio for the diagnosis of gastroesophageal varices in liver cirrhosis: a systematic review and meta-analysis. Gastroenterol Res Pract. 2017;2017:7407506.PubMedPubMedCentralGoogle Scholar
  17. 17.
    Chawla S, Katz A, Attar BM, Gupta A, Sandhu DS, Agarwal R. Platelet count/spleen diameter ratio to predict the presence of esophageal varices in patients with cirrhosis: a systematic review. Eur J Gastroenterol Hepatol. 2012;24:431–6.PubMedGoogle Scholar
  18. 18.
    Sami SS, Harman D, Ragunath K, Bohning D, Parkes J, Guha IN. Non-invasive tests for the detection of esophageal varices in compensated cirrhosis: systematic review and meta-analysis. United Eur Gastroenterol J. 2018;6:806–18.CrossRefGoogle Scholar
  19. 19.
    Manatsathit W, Samant H, Kapur S, et al. Accuracy of liver stiffness, spleen stiffness, and LS-spleen diameter to platelet ratio score in detection of esophageal varices: systemic review and meta-analysis. J Gastroenterol Hepatol. 2018;33:1696–706.CrossRefGoogle Scholar
  20. 20.
    Qi X, Zhu Q, Tian Y. Alternative diagnostic tests of gastroesophageal varices in liver cirrhosis: recent advance. In: Tsoulfas G, editor. Liver cirrhosis—update and current challenges. Rijeka: InTech; 2017.Google Scholar
  21. 21.
    Maurice JB, Brodkin E, Arnold F, et al. Validation of the Baveno VI criteria to identify low risk cirrhotic patients not requiring endoscopic surveillance for varices. J Hepatol. 2016;65:899–905.CrossRefGoogle Scholar
  22. 22.
    Spearman CW, Sonderup MW. Health disparities in liver disease in sub-Saharan Africa. Liver Int. 2015;35:2063–71.CrossRefGoogle Scholar
  23. 23.
    Ohta T, Sakaguchi K, Fujiwara A, et al. Simple surrogate index of the fibrosis stage in chronic hepatitis C patients using platelet count and serum albumin level. Acta Med Okayama. 2006;60:77–84.PubMedGoogle Scholar
  24. 24.
    Wai CT, Greenson JK, Fontana RJ, et al. A simple noninvasive index can predict both significant fibrosis and cirrhosis in patients with chronic hepatitis C. Hepatology. 2003;38:518–26.CrossRefGoogle Scholar
  25. 25.
    Giannini E, Risso D, Botta F, et al. Validity and clinical utility of the aspartate aminotransferase-alanine aminotransferase ratio in assessing disease severity and prognosis in patients with hepatitis C virus-related chronic liver disease. Arch Intern Med. 2003;163:218–24.CrossRefGoogle Scholar
  26. 26.
    Vallet-Pichard A, Mallet V, Nalpas B, et al. FIB-4: an inexpensive and accurate marker of fibrosis in HCV infection. Comparison with liver biopsy and fibrotest. Hepatology. 2007;46:32–36.CrossRefGoogle Scholar
  27. 27.
    Deng H, Qi X, Peng Y, et al. Diagnostic accuracy of APRI, AAR, FIB-4, FI, and king scores for diagnosis of esophageal varices in liver cirrhosis: a retrospective study. Med Sci Monit. 2015;21:3961–77.CrossRefGoogle Scholar
  28. 28.
    Sung JJ, Chiu PW, Chan FKL, et al. Asia-Pacific working group consensus on non-variceal upper gastrointestinal bleeding: an update 2018. Gut. 2018;67:1757–68.CrossRefGoogle Scholar

Copyright information

© Springer Healthcare Ltd., part of Springer Nature 2019

Authors and Affiliations

  • Xingshun Qi
    • 1
    Email author
  • Yiling Li
    • 2
  • Ran Wang
    • 1
  • Lianjie Lin
    • 3
  • Jing Li
    • 4
  • Lijun Wang
    • 5
  • Shuang Zheng
    • 6
  • Yonghong Sun
    • 7
  • Lixin Zhao
    • 8
  • Xiaolin Fu
    • 9
  • Mengchun Wang
    • 3
  • Xinping Qiu
    • 10
  • Han Deng
    • 1
  • Cen Hong
    • 1
  • Qianqian Li
    • 1
  • Hongyu Li
    • 1
  • Xiaozhong Guo
    • 1
    Email author
  1. 1.Liver Cirrhosis Study Group, Department of GastroenterologyGeneral Hospital of Northern Theater Command (Formerly General Hospital of Shenyang Military Area)ShenyangChina
  2. 2.Department of GastroenterologyThe First Hospital of China Medical UniversityShenyangChina
  3. 3.Department of GastroenterologyShengjing Hospital, China Medical UniversityShenyangChina
  4. 4.Department of GastroenterologyThe First Affiliated Hospital of Jinzhou Medical UniversityJinzhouChina
  5. 5.Department of GastroenterologyPanjin Central HospitalPanjinChina
  6. 6.The Sixth People’s Hospital of ShenyangShenyangChina
  7. 7.Department of GastroenterologyDalian Friendship Hospital of Dalian Medical UniversityDalianChina
  8. 8.Department of GastroenterologyGeneral Hospital of Liaohe Oilfield CompanyPanjinChina
  9. 9.Department of GastroenterologyAnsteel Group HospitalAnshanChina
  10. 10.Department of GastroenterologyGeneral Hospital of Fuxin Mining Industry Group of Liaoning Health Industry GroupFuxinChina

Personalised recommendations