***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: Because several studies have suggested that beta blockers are effective in the prophylaxis of first variceal bleeding in cirrhosis , screening for oesophageal varices might be appropriate . We prospect ively studied 84 cirrhotic patients without obvious evidence of large oesophageal varices and previous bleeding during a mean follow up of 16 months . At entry to the study 41 patients had no oesophageal varices and in 43 these were grade 1 . The subsequent percentages of patients without large oesophageal varices were 74 % at one year and 52 % at two years . Univariate analysis showed that a longer duration of cirrhosis ( p less than 0.05 ) and grade 1 oesophageal varices at entry ( p less than 0.001 ) were predictive factors for the occurrence of large oesophageal varices , whereas , multivariate analysis showed that the initial size of the oesophageal varices ( p less than 0.001 ) , a high initial Child-Pugh score , and a smaller improvement in Child-Pugh score during the study were independent risk factors . Among patients with grade s 0 and 1 oesophageal varices at the start of the study the proportions with large oesophageal varices at two years were 31 % and 70 % respectively . We have calculated that , accepting a maximum risk of first bleeding of 10 % without prophylactic treatment , a patient without oesophageal varices should be screened endoscopically every other year , while a patient with grade 1 disease should benefit from one annual upper gastrointestinal endoscopy BACKGROUND The current guidelines recommend the screening of all cirrhotic patients by endoscopy , but repeated endoscopic examinations are unpleasant for patients and have a high cost impact and burden on endoscopic units . The aim of this study is to evaluate the optimal liver lobe size/albumin ratio and to compare this ratio with spleen size , platelet count and platelet count/spleen diameter ratio as potential noninvasive predictors of oesophageal varices in hepatitis C virus (HCV)-related liver cirrhosis in Egyptian patients . METHODS This prospect i ve study included one hundred patients with HCV-related liver cirrhosis . All studied subjects underwent a detailed clinical examination , biochemical workup , upper gastrointestinal endoscopy and abdominal ultrasound . The platelet count/spleen diameter ratio and the right liver lobe/albumin concentration ratio for all patients were calculated . RESULTS The 4 predictors demonstrated a high statistically significant correlation with the presence and grade of oesophageal varices ( P values<0.001 ) . The platelet count/spleen diameter ratio had the highest accuracy , followed by the right liver lobe/albumin concentration ratio , spleen size and then platelet count . CONCLUSION The use of the studied noninvasive predictors , especially the platelet count/spleen diameter ratio and the right liver lobe/albumin concentration ratio , can help physicians by restricting the use of endoscopic screening only to patients presenting a high probability of oesophageal varices . This is especially useful in clinical setting s where re sources are limited and endoscopic facilities are not present in all areas . Such is the case in Egypt , where there is a large number of patients who require oesophageal screening for oesophageal varices Background Esophageal variceal hemorrhage is a devastating complication of portal hypertension that occurs in approximately one-third of cirrhotic patients . Objectives We assessed the value of the  platelet count/ bipolar spleen diameter ratio  as a noninvasive parameter for the prediction of esophageal varices ( EVs ) in Egyptian cirrhotic patients . Patients and Methods Laboratory and ultrasonographic and imaging variables were prospect ively evaluated in 175 patients with liver cirrhosis . All patients underwent upper gastrointestinal endoscopy . Patients with active gastrointestinal bleeding at the time of admission were excluded . Results The platelet count/ bipolar spleen diameter ratio in patients with EVs was significantly lower than in patients without EVs . In an analysis of the receiver operating characteristic curves ( ROCs ) , we calculated an optimal cutoff value of 939.7 for this ratio , which gave 100 % sensitivity and negative predictive values , 86.3 % specificity , a 95.6 % positive predictive value , and an area under the ROC curve of 0.94 ± 0.02 , reflecting its overall diagnostic accuracy . These findings were extended to a subset analysis of compensated cirrhotic patients . Conclusions The platelet count/ bipolar spleen diameter ratio has excellent accuracy in the noninvasive assessment of EVs in patients with compensated or decompensated liver cirrhosis . It is easy to calculate and can lower the financial and sanitary burdens of endoscopy units , especially in developing countries BACKGROUND Current medical management dictates that all cirrhotic patients without a history of variceal hemorrhage undergo endoscopic screening to detect large varices . However , referral for endoscopic screening of only patients at highest risk for varices may be most cost-effective . The aim of this case-control study was to identify clinical , laboratory , and radiologic findings that predict the presence of varices in patients with cirrhosis . METHODS Three hundred patients without a history of variceal hemorrhage underwent upper endoscopy as part of an evaluation before liver transplantation . Cases defined as the presence of any varices and cases defined as the presence of large varices were used for examining the risks associated with finding varices on upper endoscopy . Logistic regression was performed to evaluate associations between the presence of varices and patient characteristics . RESULTS Platelet count and Child-Pugh class were independent risk factors for the presence of any varices and the presence of large varices . For the presence of any varices , a platelet count of 90 x 10(3)/microL or less ( odds ratio [ OR ] , 2.4 ; 95 % confidence interval [ CI ] , 1.4 - 4.0 ) and advanced Child-Pugh class ( OR , 3.0 ; 95 % CI , 1.6 - 5.6 ) were independent risk factors . For large varices , a platelet count of 80 x 10(3)/microL or less ( OR , 2.3 ; 95 % CI , 1.4 - 3.9 ) and advanced Child-Pugh class ( OR , 2.8 ; 95 % CI , 1.3 - 5.8 ) were independent risk factors associated with varices . CONCLUSIONS Low platelet count and advanced Child-Pugh class were associated with the presence of any varices and with large varices . These factors allow identification of a subgroup of cirrhotic patients who would benefit most from referral for endoscopic screening for varices This guidance provides a data -supported approach to risk stratification , diagnosis , and management of patients with cirrhosis and portal hypertension ( PH ) . A guidance document is different from a guideline . Guidelines are developed by a multidisciplinary panel of experts who rate the quality ( level ) of the evidence and the strength of each recommendation using the Grading of Recommendations Assessment , Development , and Evaluation system . A guidance document is developed by a panel of experts in the topic , and guidance statements , not recommendations , are put forward to help clinicians underst and and implement the most recent evidence . This guidance focuses on PH , varices , and variceal hemorrhage ( VH ) , and statements are based on the following : ( 1 ) review of the recent literature using PubMed , giving more weight to large , well- design ed , prospect i ve trials and well-performed meta-analyses ; ( 2 ) several consensus conferences among experts ; and ( 3 ) the authors ’ years of experience caring for patients with cirrhosis and varices . Management of ascites and encephalopathy is addressed in other documents BACKGROUND All patients with liver cirrhosis are recommended for evaluation of oesophagogastric varices ( EGV ) regularly . This prospect i ve study was design ed to develop a predictive model for EGV in cirrhotic patients . METHODS Ninety-two patients were recruited . From all patients studied , the size of palpable spleen , liver chemistry value , platelet count , prothrombin time , diameter of main portal vein and splenic length as assessed by ultrasonography were determined . Upper endoscopy was performed . Oesophageal varices ( EV ) and gastric varices ( GV ) were grade d ( EV , grade 1 - 4 ; GV , grade 1 - 3 ) . In the predictive model , the EGV was classified into two grade s ( low , grade 1 - 2 EV or grade 1 GV ; high , grade 3 - 4 EV or grade 2 - 3 GV ) . RESULTS There were 53 patients with EGV and 39 patients without EGV as determined by endoscopy . Patients with EGV had a significantly higher degree of ascites and hepatic encephalopathy , lower platelet count and longer splenic length than those without EGV . Low platelet count and presence of ascites were the significant independent predictors for high- grade EGV ( concordance rate 0.83 ) . The optimal critical value for the platelet count was 150 x 10(9)/L. Of patients without thrombocytopenia and ascites , 37 % had low- grade EGV but none had high- grade EGV , whereas 38 and 35 % of patients with thrombocytopenia or ascites had low and high- grade EGV , respectively . Therefore , this predictive model for high- grade varices had a positive and negative predictive value of 35 and 100 % , respectively . CONCLUSION Endoscopic screening for EGV was not necessary until thrombocytopenia or ascites occurred Background and aims : Risk factors for mortality and re-bleeding following acute variceal haemorrhage ( AVH ) are incompletely understood . The aim of this study was to determine risk factors for 6-week mortality , and re-bleeding within 5 days in patients with cirrhosis and AVH . Methods : Kaplan – Meier and Cox proportional hazards regression analyses were used to determine risk factors among 256 patients with AVH entered into a r and omised , prospect i ve trial . Results : Thirty-five patients ( 14 % ) died within 6 weeks of AVH ; 14 deaths ( 40 % ) occurred within 5 days . Only the Model for End-stage Liver Disease ( MELD ) score and units of packed red blood cells ( PRBCs ) transfused in the first 24 h were associated with 6-week mortality univariately ( HR 1.11 , p<0.001 ; HR 1.22 , p<0.001 ) and bivariately ( HR MELD = 1.10 , p<0.001 ; HR per unit of PRBCs transfused = 1.15 , p = 0.005 ) . Re-bleeding within 5 days occurred in 37 patients ( 15 % ) ; MELD score ( p = 0.01 ) and a clot on a varix ( p = 0.05 ) predicted re-bleeding . Patients with a MELD score ⩾18 ; both MELD score ⩾18 and ⩾4 units of PRBCs transfused ; both MELD score ⩾18 and active bleeding at index endoscopy ; and variceal re-bleeding had increased risk of death 6 weeks post-AVH ( HR = 7.4 , p<0.001 ; 11.3 , p<0.001 ; 9.9 , p<0.001 ; 10.2 , p<0.001 respectively ) . Conclusions : Patients with AVH and MELD score ⩾18 , requiring ⩾4 units of PRBCs within the first 24 h or with active bleeding at endoscopy are at increased risk of dying within 6 weeks . MELD score ⩾18 is also a strong predictor of variceal re-bleeding within the first 5 days BACKGROUND AND AIMS : Noninvasive assessment of esophageal varices ( EV ) may improve the management of patients with cirrhosis and decrease both the medical and financial burden related to screening . In this multicenter , international study , our aim was to prospect ively vali date the use of the platelet count/spleen diameter ratio for the noninvasive diagnosis of EV . METHODS : A total of 218 cirrhotic patients underwent screening endoscopy for EV .  Platelet count/spleen diameter ratio ( (N/mm3)/mm ) was assessed in all patients and its diagnostic accuracy was calculated . On the basis of previous results , a platelet count/spleen diameter ratio cutoff of 909 was applied to this population . The diagnostic accuracy of the platelet count/spleen diameter ratio was further evaluated for both severity and etiology of disease subgroups . RESULTS : Prevalence of EV was 54.1 % . The platelet count/spleen diameter ratio had 86.0 % ( 95 % CI , 80.7–90.4 % ) diagnostic accuracy for EV , which was significantly greater as compared with either accuracy of platelet count alone ( 83.6 % , 95 % CI 78.0–88.3 % , P = 0.038 ) or spleen diameter alone ( 80.2 % , 95 % CI 74.3–85.3 % , P = 0.018 ) . The 909 cutoff had 91.5 % sensitivity ( 95 % CI 85.0–95.9 % ) , 67.0 % specificity ( 95 % CI 56.9–76.1 % ) , 76.6 % positive predictive value , 87.0 % negative predictive value , 2.77 positive likelihood ratio , and 0.13 negative likelihood ratio for the diagnosis of EV 
    Output:
    
Platelet count-to-spleen length ratio could be used to stratify the risk of oesophageal varices .
This test can be used as a triage test before endoscopy , thus ruling out adults without varices .
In the case of a ratio > 909 (n/mm3)/mm , the presence of oesophageal varices of any size can be excluded and only 7 % of adults with varices of any size would be missed , allowing investigators to spare the number of oesophago-gastro-duodenoscopy examinations .
This test is not accurate enough for identification of oesophageal varices at high risk of bleeding that require primary prophylaxis .