Prospective Study
Copyright ©The Author(s) 2020. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastrointest Pharmacol Ther. Aug 8, 2020; 11(3): 59-68
Published online Aug 8, 2020. doi: 10.4292/wjgpt.v11.i3.59
Tongue thickness in health vs cirrhosis of the liver: Prospective observational study
Manish Tandon, Harshita Singh, Nishant Singla, Priyanka Jain, Chandra Kant Pandey
Manish Tandon, Harshita Singh, Chandra Kant Pandey, Formerly at Department of Anesthesia, Institute of Liver and Biliary Sciences, New Delhi 110070, India
Nishant Singla, Formerly at Department of Intervention Radiology, Institute of Liver and Biliary Sciences, New Delhi 110070, India
Priyanka Jain, Formerly at Department of Research, Institute of Liver and Biliary Sciences, New Delhi 110070, India
Author contributions: Tandon M conceived and wrote the manuscript and performed the literature search and review; Sigh H collected and compiled data and reviewed the literature; Singla N collected L3 skeletal muscle index data, trained others on ultrasonography measurements, and supervised ultrasonography measurements; Jain P performed statistical analysis of the data; Pandey CK reviewed the manuscript, and provided intellectual input.
Institutional review board statement: The study was reviewed and approved by the Review Board of the Institution of Liver and Biliary Sciences, New Delhi, India.
Clinical trial registration statement: The study titled “Study of thickness of tongue by ultrasound and its relation with severity of disease in patients with cirrhosis of liver: Prospective Study”, is registered with clinical trials registry of India vide No. CTRI/2017/10/010103.
Informed consent statement: All study participants or their legal guardian provided informed written consent regarding personal and medical data collection prior to study enrolment.
Conflict-of-interest statement: No conflict of interest to declare.
Data sharing statement: There are no additional data available.
CONSORT 2010 statement: The authors have read the CONSORT 2010 Statement, and the manuscript was prepared and revised according to the CONSORT 2010 Statement.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Corresponding author: Manish Tandon, MD, Doctor, Ex Additional Professor Anaesthesia, Department of Anaesthesiology, Institute of Liver and Biliary Sciences, D-1, Vasant Kunj, New Delhi 110070, India. manishtandon25@rediffmail.com
Received: December 29, 2019
Peer-review started: December 29, 2019
First decision: March 27, 2020
Revised: May 17, 2020
Accepted: May 21, 2020
Article in press: May 21, 2020
Published online: August 8, 2020
Abstract
BACKGROUND

Malnutrition affects 40%-90% of patients with cirrhosis of the liver. L3 skeletal muscle index (L3SMI) is presently accepted as the most objective and quantitative measure available for sarcopenia, a surrogate marker of malnutrition. L3SMI application is, however, limited by non-availability of computed tomography scanning in remote areas, cost, need for extensive training, and the risk of exposure to radiation. Therefore, an alternative dependable measure with wider availability is needed. Malnutrition causes sarcopenia not only in skeletal muscles but also in other muscular structures such as the psoas muscle, diaphragm and tongue. We therefore hypothesised that the tongue, being easily accessible for inspection and for measurement of thickness using ultrasonography, may be used to document sarcopenia.

AIM

To measure and compare tongue thickness in healthy individuals and in patients with cirrhosis of the liver and to study its correlation with conventional prognostic scores for patients with cirrhosis of the liver.

METHODS

Tongue thickness was measured using ultrasonography. One hundred twenty subjects of either gender aged 18 to 65 years were studied, with 30 subjects in each group. The tongue thickness was compared between groups based on “Child Turcotte Pugh” (CTP) scores. The correlations between measured tongue thickness and “Model for end stage liver disease” (MELD) score and between age and measured tongue thickness were also assessed.

RESULTS

Mean tongue thickness (mean ± SD) in patients with CTP class A, B and C was 4.39 ± 0.39 cm, 4.19 ± 0.53 cm, and 3.87 ± 0.42, respectively, and was 4.33 ± 0.49 cm in normal healthy individuals. Significant differences were seen in tongue thickness between patients with CTP class C and those with CTP class A and B (P < 0.05). Patients with CTP class C also had a significantly reduced tongue thickness than normal individuals (P < 0.05). However, no significant difference was seen in tongue thickness between patients with CTP class A and B and normal individuals. A statistically significant, negative correlation was found between MELD score and tongue thickness (r = -0.331) (P < 0.001). No correlation was observed between L3SMI and MELD score (r = 0.074, P = 0.424). L3SMI (mean ± SD) in healthy subjects was 39.66 ± 6.8 and was 38.26 ± 8.88 in patients with CTP class C, and the difference was not significant. No significant correlation was found between age of the patients and tongue thickness. Intra-class correlation coefficient was used to determine the reliability of the tongue thickness measurements. The intra-class correlation coefficient was 0.984 (95%CI: 0.979-0.989) and was indicative of good reliability.

CONCLUSION

Tongue thickness measured by ultrasonography, correlates significantly with the severity of liver disease, as assessed by CTP and MELD scores. The patients with a CTP score ≥ 10 have significantly reduced tongue thickness as compared to normal individuals and those with less severe liver disease and CTP scores of 5-9. No significant difference in tongue thickness was found between healthy individuals and CTP class A and B patients.

Keywords: Sarcopenia, Malnutrition, Cirrhosis of the liver, Child Turcotte Pugh class, Model for end stage liver disease score, Ultrasonography

Core tip: Sarcopenia has implications for the management and outcome of patients with cirrhosis of the liver and is therefore included in prognostication. However, the only objective and reproducible measure for sarcopenia using computed tomography (CT) scanning which measures skeletal muscle thickness, is the L3 skeletal muscle index (L3SMI). However, the application of L3SMI is restricted by the need for CT scanning. Compared with CT scan measured L3SMI, tongue thickness can easily be measured in a reproducible manner and accurately with minimal training using ultrasonography and as suggested by this study, is a more sensitive indicator of sarcopenia. Further studies are required to validate these findings and propose tongue thickness as a tool to diagnose sarcopenia.