Comparison of Different Non-invasive Indices in Predicting High-Risk Esophageal Varices in a Pakistani Population

Introduction Esophageal varices (EV) generally develop as a complication of portal hypertension, whereas high-risk esophageal varices (HRV) are associated with significant morbidity and mortality. Although endoscopic surveillance is widely recommended in recent guidelines, its invasiveness and cost are important concerns, particularly in resource-poor countries such as Pakistan. The aim of this study was to compare the diagnostic performance of the P²MS index ((platelet count (×10⁹/L))² / (monocyte fraction (%) × segmented neutrophil fraction (%)), the EVendo score, the international normalized ratio (INR) to platelet ratio (INPR), and splenic stiffness for predicting HRV in a Pakistani population. Study methodology After the approval from the Ethical Review Committee, Sindh Institute of Urology and Transplantation (ERC-SIUT) (approval-1141), this cross-sectional study was carried out at the Department of Hepatogastroenterology, Sindh Institute of Urology and Transplantation, Karachi, from April to September 2024. A total of 340 cirrhotic patients aged >18 years underwent laboratory tests, abdominal ultrasound, shear-wave elastography (SWE), and esophagogastroduodenoscopy assessment of HRV. Data were analyzed for the area under the receiver operating curve (AUROC) for each non-invasive index in predicting HRV, and at an optimal cutoff, sensitivity, specificity, and diagnostic accuracy of these indices were obtained. Results Among 340 patients, HRV was detected in 84 (24.7%). The EVendo score showed the highest AUROC of 0.92 (p ≤ 0.001) with a diagnostic accuracy of 86.56%, followed by the P²MS index, which had an AUROC of 0.859 and diagnostic accuracy of 81.71%, splenic stiffness with an AUROC of 0.838 and diagnostic accuracy of 66.47%, and INPR with an AUROC of 0.90 and diagnostic accuracy of 58.24%. EVendo score was associated with higher sensitivity, 92.94%, and specificity, 71.88%, for predicting HRV. Conclusion Non-invasive indices, mainly the EVendo score, showed a very good diagnostic performance for predicting HRV in resource-limited settings like Pakistan. These tools might have the potential to restrict indications for routine endoscopy, thus improving patient management and reducing the cost and economic burden. Future multicenter studies will be required for the validation of these results and to enhance their clinical applicability.