 Hello everyone, I am Dr. Deepanshu Sharma and I am going to present my paper on Predictive Role of Spinnick vs. Hepatic Stiffness in Diagnosis of Serotic Isopropyl Viruses. This paper is based on my research work that I have conducted in past 1.5 years in VEMC in Sabdajam Hospital, New Delhi under the indispensable guidance of my guide Dr. Yatish Garwal and my mentor Dr. Swarna Gupta Jain from Department of Rural Diagnosis and my co-guide Dr. Manisha Baish Thakur from Department of Medicine. So, let us move to the discussion. As we all know, serosis is the end state of any chronic liver disease and it constitutes swift leading cause of adult deaths. It ranks 8th in the economical cost among the major illnesses. Now whenever a patient is diagnosed with serosis, the most important thing that a clinician is always worried of is that patient might not develop portal hypertension. Why is it so? Because portal hypertension in a patient with serosis is a root cause of myriad of complications and amongst all these complications the most important complication is esophageal varices. Now if the patient develops esophageal varices and if they rupture in the later course of disease, patient can go through a life threatening episode. Therefore, every serotic patient is advised to have an upper GI endoscopy to determine the presence and the size of varices. However, upper GI endoscopy being an invasive and an expensive procedure also it is not free of risk. It requires significant amount of patient preparation. Therefore, there has been an ongoing research for non-invasive parameters to predict if not diagnose the presence of esophageal varices. So that if we could find a non-invasive parameter to predict the presence of varices, we could reduce the number of endoscopies that are performed significantly. Among these previously researched non-invasive parameters, liver stiffness and spleen stiffness have shown promising results. Now what exactly is liver stiffness and spleen stiffness? Liver stiffness and spleen stiffness are nothing but the altered elasticity of liver and spleen and they are measured by ultrasound elastography or magnetic resonance or MR elastography. Now important thing is that liver stiffness has already been largely accepted to reflect the degree of fibrosis and the presence of esophageal varices in CLD. However, in the last few years, the research emphasis has been plays on spleen stiffness measurement in predicting the varices. Why is it so? It is so because cirrhosis as a pathology, it directly affects liver. However, it does not affect directly spleen. So that if we measure liver stiffness, we are actually calculating the stiffness, which is a total of stiffness caused by cirrhosis and due to portal hypertension. However, spleen is only affected by the reverse pressure hemodynamics due to portal hypertension. That is why spleen stiffness is superior to the liver stiffness as being researched in past studies. However, very few studies have evaluated the role of spleen stiffness in doing so. That's why our study endeavors to compare the role of these two parameters in diagnosis and the presence of esophageal varices and also their severity. So as a part of methodology, every patient went through these stages of investigations. Firstly, patient had clinical evaluation, where patient was evaluated for the signs and symptoms of liver cirrhosis. We also took proper history. After this, patient had laboratory investigations where CBC, liver function test and viral markers were done. Thereafter, patient had abdominal ultrasonography, where we looked for the gray scale features of the cirrhosis, which is followed by ultrasound elastography, where we measured liver and spleen stiffness values in the form of Young's modulus. And lastly, we followed up the patient with the gold standard upper GI endoscopy to diagnose the presence of esophageal varices and the assessment of severity in terms of grade. Once all these investigations have been done, we acquired a data for 31 patients and we did the statistical analysis. As a part of statistical analysis, we made ROC curves. ROC curves are made to find out the cut-off values for the liver stiffness and spleen stiffness values in order to predict the presence of varices. Also, we correlated these values with the grading of the varices that we found on the upper GI endoscopy. Now let's look at the observation results. Regarding liver stiffness, as you can all see that this is a ROC curve, receiver operating curve, where you can clearly see that the area under the ROC curve has come down to be 0.936, which is very close to 1. Now it is statistically significant at the p-value less than 0.001 and the cut-off value of liver stiffness calculated to be 16.9. At this particular cut-off, the presence of varices is diagnosed with a sensitivity of 89% and 85%. Same for the spleen stiffness as we can all see that area under ROC curve came down to be 1, which is very, very significant. At a p-value of less than 0.01, it's an excellent diagnostic performance and the cut-off value that we have taken is 52 kPa. At this particular cut-off value, it is helpful in predicting the presence of varices at a sensitivity and specificity of 100%. In this particular ROC curve, we have merged all the non-resistant parameters that we evaluated and we can clearly see that among these, the straight line that goes at a slope of 45 degree is the spleen stiffness values, which are having excellent diagnostic performance and the area under ROC curve to be 1. Best parameter in terms of area under ROC curve came down to be spleen stiffness. In the next two slides, I will be dealing with the association of the varicelle grade with the liver stiffness and spleen stiffness values. This is a box and whisker plot as you can clearly see that with the increasing grade of varices, which is F1, F2 and F3, you can clearly see that liver stiffness values are increasing. Similarly, you can also see that spleen stiffness values are also increasing with the increasing grade of the varices and the increase is very, very significant. If you can clearly see that chi-square value for this particular difference is 23.457 at a p-value of less than 0.01. The same is in spleen also, which is 25.992. The same is for spleen also, which is 25.992 at a p-value of less than 0.001. So, spleen stiffness here also is better than liver stiffness in predicting the varicelle grade. So, this is one of 31 patients that we included in our study. He was a 56 year old male patient with cirrhosis CTP class C and F3 varicelle grade on upper GI endoscopy. In the first part of this image, you can clearly see the grayscale features of the cirrhosis where we have irregular nodular margins and you know, portal vein is dilated. So, patient had portal hypertension or ultrasonography. In the second part of the image, you can clearly see it is basically the ROI box that we kept to calculate the liver stiffness values via shear wave electrography and the values came down to be 40.34 plus minus 7.43 kPa. Same we evaluated for the spleen also, where the values came down to be 48.16 plus minus 17.81 kPa. Lastly, we did the upper GI endoscopy and we can clearly see the presence of esophageal varices as it is obliterating the complete lumen. So, it is F3 varicelle grade. The classification that we use is back to classification. Lastly, let's move to discussion. At a cutoff value of liver stiffness more than equal to 16.9 kPa, we could predict the presence of varices with sensitivity of 89% and 85%. Same values for spleen stiffness, you can clearly see that 52 kPa cutoff is helpful in predicting the presence of varices with a sensitivity of 100% and specificity of 100%. The value of the spleen stiffness and liver stiffness were also seen to increase with the increase in the grade of varices. So, with these two important things, we can clearly see that liver stiffness and spleen stiffness are very important non-invasive parameters in predicting the presence of varices. Also, they are important in predicting the severity of the varices and among these two parameters, the most important parameter that came down was spleen stiffness. So, we ranked the parameters in terms of area under ROC curve, sensitivity, specificity, positive predictive value, negative predictive value and diagnostic accuracy. And under all these grounds, spleen stiffness came to be superior over liver stiffness in predicting the presence of varices. Also, there has been statistically significant differences among the various varicelle grades and it has been seen that spleen stiffness tends to increase with the increase in the varicelle grade. So, what do we recommend? So, we recommend every CLD patient should be evaluated with a grayscale ultrasonography and also ultrasound elastography to predict the likelihood of the presence of esophageal varices before a pergeal endoscopy. Why is it so? It will shorten the number of endoscopies performed in day to day practice. So, it is also imperative to evaluate spleen stiffness along with liver stiffness during elastography of the patient. And changes in the spleen stiffness should be given priority over liver stiffness while predicting the likelihood of the presence of varices and their grade. And these are my differences. Thank you so much. This was my paper presentation. I would like to again thank the family of city bus in providing me a opportunity to present my paper on this big platform. Thank you.