DOI: https://doi.org/10.53350/pjmhs22165259 ORIGINAL ARTICLE P J M H S Vol. 16, No. 05, May 2022 259 Elevation of AST/ALT Ratio in Association with Severity of Esophageal Varices in Patients with Hepatic Cirrhosis IMRAN KHAN 1 , MUKHTAR AHMAD 2 , FAHAD AMAN KHAN 3 , MUHAMMAD KASHIF 4 , TASHIA MALIK 5 , ANIQA ANSER TUFAIL KHAN 6 1,2,3 Assistant Professor, Allama Iqbal Medical College/Jinnah Hospital Lahore 4 Assistant Professor, University College of Medicine and Dentistry, University of Lahore, Lahore 5 Senior Registrar, Jinnah Hospital Lahore 6 Assistant Professor, Azra Naheed Medical College, Lahore Correspondence to: Dr Fahad Aman Khan, Cell: 03334344400, Email: dr.fahadamankhan@gmail.com ABSTRACT Objective: To determine the elevation of AST/ALT ratio in association with severity of esophageal varices in patients with hepatic cirrhosis. Study Design: Cross sectional survey Place and Duration of Study: Medical Unit II, Jinnah Hospital Lahore from November 2018 to April 2019 Methodology: One hundred and ten subjects were enrolled. The complete history, physical examination and appropriate investigations were done like liver functions test to see the ratio of AST/ALT and upper GI Endoscopy to confirm the presence or absence of esophageal varices. Results: The mean age of the patients was 45.6±5.2 years with 77.27% males and 22.73% females. Paquet grading system showed that esophageal varices were presented in 20.9% grade II. Within the 65 cases of esophageal varices 30 patients of liver cirrhosis were having a 27% high risk of esophageal varices. ALT and AST were significantly higher in high risk esophageal varices. Conclusion: The elevated level of ALT and AST are significantly associated with the severity of esophageal varices in hepatic cirrhosispatients. Key words: Elevation, AST/ALT ratio, Association, Esophageal varices, Hepatic cirrhosis INTRODUCTION Recent estimates show that more than 185 million people around the world have been infected with HCVand this virus has significant mortality rate as 350,000 die each year. 1 The burden of HCV in South Asia is around 3.4% and estimated >50 million people are affected. 2 In Pakistan situation is very alarming as more than 10 million population is reported to be affected. 3 Most people infected with the virus are unaware of their infection as this Virus remains asymptomatic in the body for years and for many who havebeen diagnosed, treatment remains unavailable. 4 Portal hypertension has been clearly associated with esophageal varices in hepatic cirrhosis patients. Hemorrhage caused as a consequence of esophageal varices is a major mortality causer and has a prevalence of bleeding as 10-20% with unfortunately survival ratio up to a year in only 63% of cases. Advancement in hepatic cirrhosis and red signs are the major factors related with esophageal varices. 5,6 Recent diagnostic protocol involves endoscopic findings of red signs and is considered as gold standard. 7,8 The recommended time for EGD is within a follow-up of one to three years dependent on varices size. On the other hand EGD is an invasive and costly procedure and might not be recommended. Lower cost non-invasive procedures can be relied on in such conditions. 5 There are various noninvasive methods to assess the presence of esophageal varices and presence of chronic liver disease .i.e. APRI ratio, AAT ratio, FIB-4 index. 9,10 Severity of thrombocytopenia as predictor of presence of esophageal varices was studied as a non invasive parameter. 8 A study conducted in Sindh showed that those cirrhotic patients that have esophageal varices also have advanced biochemical and radiological changes. 9 AST/ALT ratio (AAT ratio ) is considered to be one of the most important non invasive markers for prediction of liver cirrhosis. 5 AST/ALT ratio was found to be high in patients who were at more risk of bleeding. 6 Pakistan is a country with limited resources. Endoscopic facility is not available in many remote areas and even in some tertiary care hospitals. The rationale of this study is to establish a reliable easy and cheap method as compared to Endoscopy to screen the presence of EV in cirrhotic patients. MATERIAL AND METHOD This cross-sectional survey was conducted at Medical Unit II, Jinnah Hospital Lahore from November 2018 to April 2019 and 110 patients were enrolled. Patients age 18-70 years, either genders or liver cirrhosis were included. Patients of non-cirrhotic portal hypertension were excluded.After an informed consent a detailed demographic profile of each case was taken. Baseline medical history examination as well as clinical assessments was detailed. Laboratory assessments including CBC testing and liver functioning test were conducted. Ultrasonographical imaging comprising on liver scan was performed for proper assessment of liver cirrhosis. The lab test in addition to USG reports and clinical evaluation were collectively used for diagnosing hepatic cirrhosis. The cause of liver cirrhosis was evaluated through ultrasound imaging and laboratory assessment. Enzyme linked immune sorbent assay was used for detecting hepatitis C within enrolled patients. Complete history, physical examination and appropriate investigations were done like liver functions test to see the ratio of AST/ALT and upper GI endoscopy to confirm the presence or absence of esophageal varices. The variceal size was graded from grade I-IV by the method of Paquet grading system. Red sign was evaluated. Those patients having large varices and under grade III or IV or those with small varices and red signs were at high alert of their disease status. The data was entered and analyzed through SPSS-26. The Chi square test was applied and p value<0.05 considered significant. RESULTS The mean age of the patients was 45.6±5.2 years with 77.27% males and 22.73% females. The Paquet grading system showed that esophageal varices were presented in 20.6% grade II while in 19.2% patients as grade I. There were 40.6% those patients who were not having esophageal varices present in them (Table 1). Table 1: Age, gender and Paquet Grading System for esophageal varices (n=110) Characteristics No. % Age (years) 45.6±5.2 Gender Male 85 77.27 Female 25 22.73 Varices Grading Grad I 21 19.2 Grade II 23 20.6 Grade III 11 10.0 Grade IV 10 9.6 Without Varices 45 40.6