Chronic liver disease (CLD) represents a major global health burden and is commonly associated with the development of portal hypertension, which plays a central role in the progression to life-threatening complications such as esophageal varices.¹ Variceal bleeding is one of the most severe consequences of portal hypertension and contributes significantly to morbidity and mortality among cirrhotic patients.

Esophageal varices develop in nearly half of patients with compensated cirrhosis and in up to 80% of those with decompensated disease, making timely detection vital to prevent first bleeding episodes.² Early identification allows clinicians to implement prophylactic therapies such as non-selective beta-blockers or endoscopic variceal ligation to reduce mortality risk. Upper gastrointestinal endoscopy is considered the gold standard for diagnosing and grading esophageal varices; however, it is invasive, resource-intensive, and often unacceptable to asymptomatic patients.³ In regions with limited access to endoscopic facilities, reliance on non-invasive predictors is crucial for early stratification of high-risk individuals.

Among the available surrogate markers, thrombocytopenia has shown strong association with portal hypertension due to splenic sequestration and reduced thrombopoietin synthesis.⁴ Simultaneously, splenomegaly corresponds to progressive congestion in the portal venous system, making splenic size a key reflection of disease severity. The platelet count/splenic diameter (PC/SD) ratio integrates these two pathophysiological consequences of portal hypertension into a single measurable parameter and has emerged as a promising, simple, and cost-effective non-invasive predictor; a low PC/SD ratio has been reported to correlate with the presence of esophageal varices and may help identify patients requiring urgent endoscopic screening.⁵

Using this ratio allows clinicians to prioritise high-risk individuals for endoscopic evaluation, particularly in resource-limited healthcare settings where routine endoscopy for all cirrhotic patients is impractical, thereby improving screening efficiency and reducing unnecessary invasive procedures.⁶ The PC/SD ratio is non-operator dependent, relies on basic laboratory testing and ultrasonography that are widely available, and avoids the complications associated with endoscopy, making it suitable for repeated follow-up assessments.⁷

Cirrhotic patients in peripheral and semi-urban regions such as Shivamogga often present late with complications due to limited awareness and access to specialised gastroenterology services; evaluating a non-invasive tool that can be widely implemented in general medicine departments is therefore particularly relevant in such settings.⁸ Determining the diagnostic value of the PC/SD ratio may provide evidence to incorporate it into routine screening protocols for cirrhosis patients.⁹ˌ¹⁰

This study was designed to evaluate the usefulness of the platelet count/splenic diameter ratio in predicting esophageal varices in cirrhosis patients and to determine its diagnostic potential as a non-invasive screening tool in the clinical setting of SUIMS, Shivamogga.

1.1 Objectives

• To assess the presence/absence of esophageal varices using the platelet count/splenic diameter ratio.
• To assess the predictive value of the platelet count/splenic diameter ratio in predicting esophageal varices in cirrhotic patients.

2.1 Study Design and Setting This cross-sectional observational study was conducted in the Department of General Medicine at Subbaiah Institute of Medical Sciences (SUIMS), Shivamogga, in the Medicine Outpatient Department and Inpatient Wards. Data collection was undertaken from 1 May 2024 to 31 December 2025. All data were obtained from patients attending the Medicine outpatient clinics and those admitted to the inpatient wards of SUIMS. 2.2 Study Population and Sample Size All consecutive patients who fulfilled the eligibility criteria and provided written informed consent were included. The sample size was calculated based on the previously reported proportion of cirrhosis patients with esophageal varices (77.41%) from an earlier publication on the PC/SD ratio as a predictor of esophageal varices. Using the standard formula for estimating a single proportion — n = Z²₁₋ₐ/₂ P(1−P) / d², where P is the expected proportion (77.41%), d is the absolute precision (8.5%), and Z₁₋ₐ/₂ is the standard normal deviate for a 95% confidence level — the minimum required sample size was 93, which was achieved. 2.3 Eligibility Criteria Inclusion criteria: (i) provision of written informed consent; (ii) diagnosis of cirrhosis of the liver. Exclusion criteria: (i) present or past history of portal hypertensive bleeding; (ii) hepatocellular carcinoma; (iii) portal vein thrombosis; (iv) Budd–Chiari syndrome. 2.4 Study Procedure Patients presenting with features of chronic liver disease to the Department of General Medicine were evaluated after obtaining written informed consent. Ethical clearance for the study was obtained from the Institutional Ethics Committee prior to data collection. A detailed clinical history was taken and a comprehensive clinical examination performed; demographic details, presenting symptoms, clinical signs, and relevant investigation findings were recorded in a structured case record form. All enrolled patients underwent complete blood count and liver function testing; abdominal and pelvic ultrasonography for assessment of splenic diameter and other relevant findings; and upper gastrointestinal endoscopy to determine the presence or absence of esophageal varices and to grade them where present. The PC/SD ratio was calculated for each patient using the platelet count obtained from the hemogram and the maximum bipolar splenic diameter measured on ultrasonography. All clinical and investigational data were systematically documented in a structured case record form. 2.5 Statistical Analysis Data were entered and analysed using appropriate statistical software. Continuous variables were summarised as median and interquartile range (IQR) and compared using the unpaired Student’s t-test (paired observations, where applicable, were analysed using the paired t-test). Categorical variables were expressed as frequencies and percentages, and associations were assessed using the Chi-square test or Fisher’s exact test as appropriate. The Kruskal–Wallis test was used to compare PC/SD ratio across variceal grades. Receiver operating characteristic (ROC) curve analysis was performed to determine the area under the curve (AUC), optimal cut-off value, sensitivity, specificity, and predictive values of the PC/SD ratio. A p-value < 0.05 was considered statistically significant throughout.

The study population comprised 93 cirrhosis patients, with a near-equal distribution between those without esophageal varices (n = 47) and those with varices (n = 46).

3.1 Baseline Demographic and Clinical Characteristics

The median age was comparable across both groups (52.0 vs 53.0 years; p = 0.488), and gender distribution was similar between groups (p = 0.6), indicating that neither age nor sex confounded the presence of varices (Table 1). The median duration of chronic liver disease was significantly longer in patients with varices (10 years, IQR 8–13) than in those without (8 years, IQR 6–11; p = 0.041) (Table 2). Alcohol use was significantly more common among patients with varices (78.3% vs 57.4%; p = 0.038) (Table 3), whereas smoking (49.5% overall; p = 1.0) (Table 4) and diabetes mellitus (19.4% overall; p = 0.832) (Table 5) showed no significant association with variceal presence. Systemic hypertension was significantly more prevalent among patients with varices (39.1% vs 10.6%; p = 0.002).

3.2 Platelet Count/Splenic Diameter (PC/SD) Ratio (Primary Objective)

The PC/SD ratio showed a marked and statistically significant difference between patients with and without esophageal varices. The overall median PC/SD ratio was 0.66 (IQR 0.44–0.91). Patients without varices had a significantly higher median ratio of 0.91 (IQR 0.79–1.00), whereas those with varices demonstrated a substantially lower median ratio of 0.39 (IQR 0.28–0.51; p < 0.001), indicating a strong inverse association between PC/SD ratio and the presence of esophageal varices (Table 1).

Table 1. Comparison of Platelet Count/Splenic Diameter (PC/SD) Ratio Between Varices Absent and Varices Present Groups

3.3Diagnostic Accuracy of the PC/SD Ratio

ROC curve analysis demonstrated excellent diagnostic accuracy of the PC/SD ratio in predicting esophageal varices, with an AUC of 0.92 (95% CI 0.86–0.97; p < 0.001) (Table 2). A cut-off value of ≤ 0.65 yielded a sensitivity of 89.1%, specificity of 87.2%, positive predictive value of 86.9%, and negative predictive value of 89.4% (Table 3), with an overall diagnostic accuracy of 88.2% (Table 4). The PC/SD ratio also showed a statistically significant progressive decline with increasing variceal grade (Grade 0: 0.91; Grade 2: 0.45; Grade 3: 0.31; p < 0.001, Kruskal–Wallis test), supporting its utility in predicting both the presence and severity of esophageal varices (Table 5).

Table 2. ROC Curve Analysis of PC/SD Ratio for Predicting Esophageal Varices

Table 3. Optimal Cut-off Value of PC/SD Ratio for Predicting Esophageal Varices

Table 4. Diagnostic Accuracy of PC/SD Ratio

Table 5. Correlation of PC/SD Ratio With Variceal Grade (Kruskal–Wallis test)

This study evaluated the platelet count/splenic diameter ratio as a non-invasive predictor of esophageal varices in patients with cirrhosis attending a tertiary care centre, and assessed its correlation with clinical, hematological, ultrasonographic, biochemical, and endoscopic parameters of portal hypertension. Endoscopy, although the gold standard, is invasive, resource-intensive, and often not feasible for universal screening in resource-limited settings; by validating the PC/SD ratio against endoscopic findings and disease severity indicators, this study highlights its potential role as a practical screening and risk-stratification tool. The findings emphasise that demographic factors, clinical symptoms, and routine laboratory tests are insufficient for predicting variceal presence, whereas portal hypertension–specific markers offer superior diagnostic value. 4.1 Baseline Demographic and Clinical Characteristics Age and sex were not significant determinants of variceal presence in this cohort (p = 0.488 and p = 0.6, respectively), consistent with previous reports by González-Ojeda et al.,¹¹ Shenoy et al.,¹² and Reddy,¹⁵ all of whom found no significant demographic differences between variceal and non-variceal groups. Duration of chronic liver disease was significantly longer in patients with varices (p = 0.041); however, comparable studies by Shenoy et al.¹² and Lamichhane et al.¹⁶ similarly noted that disease duration correlated weakly with variceal presence relative to portal hemodynamic markers, suggesting that varices are primarily driven by the degree of portal pressure elevation rather than disease chronology alone. Alcohol use was significantly associated with variceal presence (78.3% vs 57.4%; p = 0.038), while Okon et al.¹⁹ and Reddy¹⁵ reported that variceal presence correlated more strongly with platelet count and spleen diameter than with underlying etiology, indicating that etiology-specific screening strategies are unlikely to add discriminatory value once cirrhosis is established. Smoking (p = 1.0) and diabetes mellitus (p = 0.832) showed no significant association with variceal presence, in line with findings from Shenoy et al.,¹² Reddy,¹⁵ and Lamichhane et al.¹⁶ Systemic hypertension, by contrast, was significantly more prevalent among patients with varices (39.1% vs 10.6%; p = 0.002), which may reflect shared vascular and hemodynamic alterations — arterial stiffness, endothelial dysfunction, and neurohormonal activation — in advanced cirrhosis, consistent with the association between higher Child–Pugh class and variceal presence reported by González-Ojeda et al.¹¹ and Okon et al.¹⁹ Collectively, these findings indicate that demographic and lifestyle variables have limited discriminatory value for variceal risk stratification, reinforcing the need for objective, portal hypertension–specific markers such as the PC/SD ratio. 4.2 PC/SD Ratio as a Non-Invasive Predictor of Esophageal Varices The primary finding of this study was a marked and statistically significant difference in PC/SD ratio between patients with and without varices (0.39 vs 0.91; p < 0.001), reflecting an inverse relationship that is pathophysiologically well founded: portal hypertension leads to splenic congestion and hypersplenism-related thrombocytopenia, both of which the PC/SD ratio captures in a single composite index. These findings are consistent with González-Ojeda et al., who reported a cut-off of ≤ 884.3 achieving 84% sensitivity and 70% specificity,¹¹ and with Shenoy et al., who reported excellent diagnostic accuracy (cut-off 967; sensitivity 92%; specificity 91%; AUC 0.969) in an Indian cohort.¹² Reddy demonstrated a strong correlation between lower PC/SD ratios and higher variceal grades using a cut-off of ≤ 1014 (sensitivity and specificity of 92.77% each),¹⁵ while Lamichhane et al. reported a cut-off of 1150 with 89.7% sensitivity and 83.3% specificity in a resource-limited Nepalese setting.¹⁶ Although absolute cut-off values vary across studies — in part due to differences in the units and scales used to express the ratio, and in part due to population-specific differences, as emphasised by El-Sherbiny et al.¹³ — the consistent trend of lower PC/SD ratios among patients with varices strongly supports the ratio’s cross-population validity. Importantly, in the present study this association remained independent of demographic factors, etiology, metabolic comorbidities, and clinical presentation. 4.3 Hematological, Ultrasonographic, and Biochemical Correlates Platelet count was significantly lower and splenic diameter and portal vein diameter significantly higher in patients with varices (all p < 0.001), while hemoglobin and liver size did not differ significantly, consistent with Okon et al.¹⁹ and Mathew et al.,¹⁸ who similarly demonstrated progressive reduction in PC/SD ratio with worsening splenoportal parameters. Biochemical severity indices — bilirubin, INR, AST, ALT, and MELD score — were significantly higher, and albumin significantly lower, in the varices-present group (all p < 0.001), and Child–Pugh classification showed complete segregation, with all varices-absent patients in class A and all varices-present patients in class B or C (p < 0.001). This pattern mirrors the findings of Mattos et al., who identified Child–Pugh score as an independent correlate of variceal presence on multivariate analysis,¹⁴ and of Reddy, who linked lower PC/SD ratios to higher Child–Pugh class and variceal grade.¹⁵ Together, these findings indicate that esophageal varices are predominantly a feature of decompensated, advanced-stage cirrhosis. 4.4 Clinical and Endoscopic Correlates Ascites was confined exclusively to the varices-present group (p < 0.001), consistent with the shared hemodynamic pathway of splanchnic vasodilatation underlying both ascites and variceal formation, as noted by Lamichhane et al.¹⁶ and Okon et al.¹⁹ By contrast, chief presenting complaints (p = 0.689), pallor (p = 0.375), and icterus (p = 0.814) showed no significant association with variceal status — findings that echo Shenoy et al.¹² and Reddy,¹⁵ who similarly reported that clinical symptoms and bedside signs are poor discriminators of variceal presence, since varices often remain clinically silent until bleeding occurs. Red colour signs, gastric varices, and portal hypertensive gastropathy were each observed exclusively in the varices-present group (all p < 0.001), and variceal grading showed a predominance of Grade 2 and Grade 3 varices among affected patients, findings that parallel those of Reddy¹⁵ and Mathew et al.,¹⁸ who reported progressively lower PC/SD ratio cut-offs corresponding to higher variceal grades. Vital parameters and routine laboratory values (pulse, blood pressure, temperature, respiratory rate, oxygen saturation, white cell count, and blood sugar) did not differ significantly between groups, in agreement with Okon et al.,¹⁹ reinforcing that esophageal varices are a manifestation of chronic portal hypertension rather than acute physiological derangement. 4.5 Diagnostic Accuracy and Comparison with Prior Literature ROC analysis in the present study demonstrated excellent discriminatory accuracy (AUC 0.92, 95% CI 0.86–0.97; p < 0.001), with a cut-off of ≤ 0.65 achieving 89.1% sensitivity and 87.2% specificity (overall accuracy 88.2%). These findings closely parallel those of Shenoy et al., who documented an AUC of 0.969 with 92% sensitivity and 91% specificity,¹² and Lamichhane et al., who reported 89.5% diagnostic accuracy with 89.7% sensitivity and 83.3% specificity.¹⁶ The variation in cut-off values across studies is attributable to population and measurement-scale differences, as emphasised by El-Sherbiny et al.¹³ Mattos et al. evaluated an alternative composite index (platelet count squared/spleen diameter–AST ratio) and found high sensitivity but low specificity (95.8% and 22.7%, respectively);¹⁴ by comparison, the PC/SD ratio in the present study offered a more balanced diagnostic profile, with both high sensitivity and high specificity. A statistically significant progressive decline in PC/SD ratio was also observed with increasing variceal grade (p < 0.001), consistent with Reddy¹⁵ and Shenoy et al.,¹² confirming that the ratio reflects not only the presence but also the severity of esophageal varices. 4.6 Strengths This study benefited from a near-equal distribution of patients with and without esophageal varices, minimising selection bias and enabling robust comparative analysis. Comprehensive evaluation integrating clinical, hematological, ultrasonographic, biochemical, and endoscopic parameters provided a holistic assessment of portal hypertension. Objective, reproducible measurements (platelet count, splenic diameter, portal vein diameter) reduced subjectivity, and the inclusion of detailed endoscopic findings — variceal grading, red colour signs, gastric varices, and portal hypertensive gastropathy — strengthened the clinical applicability of the results. The study population reflects real-world cirrhosis patients commonly encountered in tertiary care centres, supporting external validity in similar healthcare settings. 4.7 Clinical Implications and Recommendations The strong association between a low PC/SD ratio and the presence of esophageal varices suggests that this index can be used to identify high-risk cirrhosis patients and prioritise them for early endoscopy and prophylactic therapy, potentially reducing the burden of universal endoscopic screening. Routine calculation of the PC/SD ratio is recommended for all patients with diagnosed cirrhosis at initial and follow-up evaluation, with standardised ultrasonographic measurement of splenic diameter and adequate training of clinicians and sonographers to improve reproducibility. The ratio should be used as a screening and triaging tool rather than a replacement for endoscopy, particularly in patients with advanced liver disease. From a public health perspective, incorporating the PC/SD ratio into routine cirrhosis assessment protocols may improve resource allocation, reduce healthcare costs, and optimise endoscopy services, especially in resource-limited settings. 4.8 Limitations and Future Directions As a single-centre study, the findings may have limited generalisability to populations with different etiological and demographic profiles. The cross-sectional design precludes assessment of temporal changes in the PC/SD ratio and does not allow causal inference. Inter-observer variability in ultrasonographic measurement of splenic diameter, although minimised, cannot be entirely excluded, and hepatic venous pressure gradient measurement — the reference standard for portal hypertension — was not performed. Future multicentre, longitudinal studies with larger sample sizes are needed to validate and refine cut-off values across diverse populations, assess the utility of serial PC/SD ratio measurement in monitoring disease progression, and explore composite risk scores combining clinical, laboratory, and imaging markers, including elastography, to further improve prediction of variceal bleeding risk.

This study demonstrates that the platelet count/splenic diameter ratio is a robust, reliable, and clinically meaningful non-invasive predictor of esophageal varices in patients with cirrhosis. Esophageal varices were predominantly associated with markers of portal hypertension — lower platelet count, larger splenic and portal vein diameter, worse biochemical and Child–Pugh severity indices, ascites, red colour signs, gastric varices, and portal hypertensive gastropathy — rather than with demographic characteristics, disease duration, lifestyle factors, or non-specific clinical symptoms. The PC/SD ratio showed a clear, statistically significant separation between variceal and non-variceal groups (AUC 0.92), and a cut-off of ≤ 0.65 provided high sensitivity (89.1%) and specificity (87.2%) for predicting esophageal varices, with a progressive decline in ratio corresponding to increasing variceal grade. Given its simplicity, reproducibility, and reliance on routinely available investigations, the PC/SD ratio should be regarded as an essential adjunct in the routine evaluation of cirrhosis patients, supporting targeted, evidence-based screening that reduces unnecessary endoscopy while ensuring timely identification of patients at risk of variceal bleeding.

Declarations

Ethical approval: Obtained from the Institutional Ethics Committee, Subbaiah Institute of Medical Sciences, Shivamogga , prior to data collection.

Informed consent: Written informed consent was obtained from all individual participants included in the study.

Conflict of interest: Nil

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