Prognostic indicators of risk for first variceal bleeding in cirrhosis: A multicenter study in 711 patients to validate and improve the North ItalianEndoscopic Club (NIEC) Index

OBJECTIVE: The best known indicator of risk for first bleeding in patients with cirrhosis without previous bleeding is the index devised by the North Italian Endoscopic Club for the Study and Treatment of Esophageal Varices ( NIEC index), which results from the combination of size of esophageal varic es, severity of red wale marks, and Child-Pugh class. Its efficiency is far from optimal, and validation studies have reported sensitivities and speci ficities markedly lower than those reported in the original study. In the p resent study we analyzed the efficiency of NIEC index in a large series of cirrhotic patients with varices without previous bleeding. In addition, we tried to improve the effectiveness of the index by modifying it, and to val idate the modifications in an independent group of patients. METHODS: A total of 627 patients were enrolled and followed until either a variceal bleeding or for a maximum of 2 yr. During this time, 117 experienc ed a first variceal bleeding. RESULTS: Using Cox's regression analysis, size of varices, severity of red wale marks, and Child-Pugh score were significant and independent predictor s of first bleeding, as already noted in the original report of the NIEC gr oup. However, coefficients and standard errors were markedly different, and the importance of size of esophageal varices in the regression was much la rger, whereas that of Child-Pugh score was much lower. According to these d ata, a revised index was developed (Rev-NIEC). Using receiver operating cha racteristic (ROC) curve analysis, the revised index showed a larger efficie ncy, and the area under the curve was significantly larger (0.80 +/- 0.02 v s 0.74 +/- 0.02; p < 0.01). In particular, the curve showed that for a spec ificity of 75%, the new index had a sensitivity of 72% compared to that of 55% of the NIEC index. Validation in an independent sample of 84 patients s howed good agreement between predicted and observed risk for bleeding. Vali dation with the bootstrap technique also showed adequate stability of the r esults. CONCLUSIONS: The revised index seems to be superior to the traditional inde x, and may turn out to be more useful in the selection of patients for diff erent therapeutic procedures and in the stratification of patients in clini cal trials. (Am J Gastroenterol 2000;95:2915-2920. (C) 2000 by Am. Coll. of Gastroenterology).