PHTN and subsequently EVs varices are the main complications of liver cirrhosis. Once the EVs bleed, the hepatic reserve begins to decrease with each attack since the liver is dependent in such condition on the hepatic artery. Screening for EVs is needed to detect and eradicate them and so prevent variceal bleeding. Endoscopy is the gold standard for the diagnosis but it is invasive maneuver that a lot of patients are afraid to undergo it.
According to the Baveno VI consensus , patients with the following criteria can avoid screening endoscopy, namely, TE < 20 kPa and platelets > 150,000/mm3. These criteria though easily to be applied, depended mainly on the presence of FibroScan that is not available in all hospitals and primary care units. Another point that the FibroScan is costly regarding the machine price and the maintenance costs. As a result, we still need scores or models that depend on routine laboratory investigations.
Johnson et al.  in a large number international study assessed the liver function among patients with hepatocellular carcinoma and correlation with the survival after treatment. They developed the ALBI score that correlated with the liver dysfunction. In comparison with Child Pugh score (CTP), it is simple, non-objective, using two routine labs and being discriminatory for the liver dysfunction. It also correlated with survival. Various publications studied ALBI score in all the aspects of hepatocellular carcinoma from the diagnosis to treatment [16,17,18].
Roayaie et al. [12, 19] incorporated the platelet count into the ALBI score and called the new model PALBI score. They incorporated the liver function status and the PHTN indirectly. PALBI was divided it into 3 grades (PALBI 1 ≤ − 2.53, PALBI 2 − 2.53 to − 2.09, PALBI 3 >− 2.09). PALBI score was developed to stratify HCC patient and assessing the survival post-treatment. Liu et al.  reinforced the beneficial role of PALBI score.
ALBI and PALBI scores were initiated mainly for hepatocellular carcinoma patients but its success have encouraged researches to assess them in other liver diseases.
Chen et al.  found that ALBI score was superior to MELD and CTP score for predicting 1-, 2-, 3-year mortality in HBV-related cirrhosis patients. The lower the ALBI score the more the survival. Shao et al.  found that generally ALBI, CTP, and MELD score were comparable for assessing the in-hospital mortality in patients with cirrhosis. In subgroup analysis, CTP score and ALBI score were the best for HBV patients, meanwhile CTP score and MELD were the best for alcoholic hepatitis patients.
Chen and Lin  found that high admission ALBI score was a predictor of 3-month mortality in patients with HBV-related acute-on-chronic liver failure. Hou et al.  found that patients with hepatic encephalopathy had higher ammonia and ALBI grade, and their combination was useful for predicting advent of encephalopathy. ALBI score was prognostic in patients with primary biliary cholangitis . Both MELD and ALBI predicted the post transjugular intrahepatic portosystemic shunt (TIPS) creation mortality but the performance of MELD score was superior than ALBI score .
Xavier et al.  conducted a study on 111 patients with acute upper gastrointestinal hemorrhage. Compared to CTP score and MELD score, only ALBI could predict in hospital stay and 30 days mortality. All the three score were the same statistically for the 1 year mortality.
Zou et al.  found that ALBI score >− 1.492 had 100% sensitivity, 69.62% specificity, 7.4% PPV, and 100% NPV for predicting acute upper gastrointestinal hemorrhage-related in-hospital mortality of in liver cirrhosis. The etiology of cirrhosis was, HBV, HCV, alcohol, or mixed. Unfortunately, the AUC of ALBI score was statistically comparable to the CTP and MELD score, so it did not add benefit .
Recently, Chen et al.  developed new score (ALBI-PLT) to screen for high-risk esophageal varices (HRVs) in patients with HCC. He combined the ALBI grade (I–III) to platelets grade (I–II) so the sum ranged from 2 to 5. HRVs were common with ALBI grade II > I. ALBI-PLT score > 2 had 90% sensitivity, 27% specificity, 21% PPV, and 97% NPV for detecting HRVs. It is very simple score that also incorporated the dysfunction grade and PHTN indirectly. ABLI-PLT could discriminate patients with HRVs so it is a simple non-invasive screening tool and obviated unnecessary endoscopy.
In the current study, patients with EVs had more incidence of Schistosomiasis 21.8% against 10.6%. Schistosomiasis per se is a major cause of presinusoidal PHTN but it may augment the effect of HCV on the liver subsequently PHTN [29, 30]. The increased serum bilirubin, portal vein diameter and the decreased level of serum albumin, hemoglobin, WBCs and platelets reflect liver dysfunction, PHTN, and splenic sequestration or hypersplenism in patients with EVs.
In fact ALBI, PALBI, and ALBI-PT scores could reflect the degree of liver dysfunction and PHTN since higher values were seen in patients with EVs. Furthermore, they were of higher values in patients with large varices compared to small varices.
Despite the promising studies of GAR value in patients with HBV-related fibrosis [15, 20, 31], some studies did not find this advantage compared to other score in patients with HBV fibrosis [32, 33]. Shimakawa et al.  conducted the first study of GAR in patients with HCV fibrosis. GAR was comparable to APRI and Fib-4 score. In our study, it was useless for the diagnosis and discrimination of EVs though the number of patient with data was relatively low.
For EVs prediction, ALBI >− 2.43 had 81.28% sensitivity and 74.89% specificity. The ALBI-PLT score > 3 had 77.34% sensitivity and 72.93% specificity. The PALBI score >− 2.28 had 62.1% sensitivity and 76.4% specificity.
ALBI >− 1.88 (92.96% sensitivity, 60.61% specificity), ALBI-PLT score > 4 (39.44% sensitivity, 75% specificity), and PALBI score >− 2.12 (87.32% sensitivity, 64.39% specificity) could discriminate large from small varices. Again which one is the best? The ALBI-PLT score was less effective than ALBI and PALBI for EVs size discrimination.
The ROC analysis of the TE cutoff (> 20kPa) adopted by the Baveno VI consensus  in our study showed 83.64% sensitivity and 91.62% specificity. Thrombocytopenia < 150,000/mm3 was statistically associated with EVs but the percentage is not too high (55.9%).
On comparison of the different ROCs liver stiffness measured by FibroScan was better than all other scores, namely, ALBI, ALBI-PLT, and PALBI. In fact, ALBI was better than ALBI-PLT and PALBI. Both ALBI-PLT and PALBI were comparable.
Regarding the size of the varix, TE did not add benefit unlike the other scores where the ALBI and PALBI were the best for variceal size discrimination.
Positive indirect hemagglutination of schistosomiasis, portal vein diameter, splenic vein diameter, liver stiffness, ALBI score, ALBI-PLT score, and PALBI score were independent predictors of EVs existence. On multivariate analysis, portal vein diameter, TE, and ALBI score were statistically independent predictors for esophageal varices presence.
As aforementioned, three studies were conducted on relationship of ALBI and ALBI-PLT and portal hypertension reflected by variceal bleeding [27, 28] or the presence of HRVs . None of them assessed the PALBI score. We are the first study to assess PALBI score and the role of the three scores in screening for EVs in cirrhosis patients without hepatocellular carcinoma.
The cutoff of ALBI-PLT was lower than our study (2 vs. 4–5) . The possible explanations that the authors compared to us chose a cutoff value with high sensitivity (90% vs. 77.34%) and very low specificity (27% vs. 72.93%).
The limitations of the study are that it is single-center experience, did not assess the longitudinal follow-up mortality, and did not assess them in non-HCV liver diseases or patients with ascites nor HCC. Large number multi-centric studies are needed.