Validation of the Baveno VI criteria to identify low risk cirrhotic patients not requiring endoscopic surveillance for varices

Development and Validation of a Noninvasive Model for the Detection of High-Risk Varices in Patients With Unresectable Hepatocellular Carcinoma

BACKGROUND & AIMS

Noninvasive variceal risk stratification systems have not been validated in patients with hepatocellular carcinoma (HCC), which presents logistical barriers for patients in the setting of systemic HCC therapy. We aimed to develop and validate a noninvasive algorithm for the prediction of varices in patients with unresectable HCC.

METHODS

We performed a retrospective cohort study in 21 centers in the United States including adult patients with unresectable HCC and Child-Pugh A5-B7 cirrhosis diagnosed between 2007 and 2019. We included patients who completed an esophagogastroduodonoscopy (EGD) within 12 months of index imaging but before HCC treatment. We divided the cohort into a 70:30 training set and validation set, with the goal of maximizing negative predictive value (NPV) to avoid EGD in low-risk patients.

RESULTS

We included 707 patients (median age, 64.6 years; 80.6% male; 74.0% White). Median time from HCC diagnosis to EGD was 47 (interquartile range, 114) days, with 25.0% of patients having high-risk varices. A model using clinical variables alone achieved an NPV of 86.3% in the validation cohort, whereas a model integrating clinical and imaging variables had an NPV 97.4% in validation. The clinical and imaging model would avoid EGDs in more than half of low-risk patients while misclassifying 7.7% of high-risk patients.

CONCLUSIONS

A model incorporating clinical and imaging data can accurately predict the absence of high-risk varices in patients with HCC and avoid EGD in many low-risk patients before the initiation of systemic therapy, thus expediting their care and avoiding treatment delays.

Prediction Modelling for Gastroesophageal Variceal Bleeding in Patients With Chronic Hepatitis B Using Four-dimensional Flow MRI

Background/Aims

In this study, we aim to develop a model for predicting gastroesophageal varices (GEV) bleeding in patients with chronic hepatitis B (CHB) by utilizing hemodynamic parameters obtained through four-dimensional flow MRI (4D flow MRI).

Methods

This study conducted a prospective enrollment of CHB patients suspected of GEV from October 2021 to May 2022. The severity of varices and bleeding risk were evaluated using clinical findings and upper gastrointestinal endoscopy, and patients were classified into high-risk and non-high-risk groups. The study utilized serological examination, ultrasonographic examination, and 4D flow MRI. Relevant parameters were selected through univariate and multivariate analyses, and a prediction model was established using binary logistic regression analysis. The model was combined with the Baveno Ⅵ/Ⅶ and Expanded Baveno Ⅵ/Ⅶ criteria to evaluate diagnostic efficacy and the risk of avoiding endoscopic examination.

Results

A total of 40 CHB patients were enrolled and categorized into the high-risk group (n = 15) and the non-high-risk group (n = 25). The spleen diameter and regurgitant fraction (R%) were independent predictors of variceal bleeding and a predictive model was established. The combination of this prediction model and the Baveno Ⅵ/Ⅶ criteria achieved high diagnostic efficiency, enabling 45.00% (18/40) of patients to be exempted from the unnecessary endoscopic procedure and the high-risk misclassification rate (0%) was less than 5%.

Conclusion

The prediction model generated by 4D flow MRI has the potential to assess the likelihood of varices and can be supplemented by the Baveno VI/VII criteria to improve diagnostic accuracy in CHB patients.

Noninvasive Assessment of portal Hypertension in Patients With Primary Biliary Cholangitis is Affected by Severity of Cholestasis

BACKGROUND & AIMS

Noninvasive tests (NITs) for ruling-out clinical significant portal hypertension (CSPH) and high-risk varices (HRVs) in patients with primary biliary cholangitis (PBC) and compensated advanced chronic liver disease (cACLD) are lacking. We evaluated NITs in these patients and the influence of cholestasis on their performance.

METHODS

Consecutive patients from the "Italian PBC registry" and 2 United Kingdom large-volume PBC referral centers with upper endoscopy within 6 months from biochemical evaluation and transient elastography were included. Rete Sicilia Selezione Terapia (RESIST), Baveno VI (BVI), and Expanded Baveno VI (EBVI) criteria for ruling out HRV were assessed according to alkaline phosphatase (ALP) levels (< or ≥1.5 × upper limit of normal). Decision curve analysis was performed. Prevalence of any sized esophageal varices among patients fitting Baveno VII (BVII) criteria was also calculated.

RESULTS

The final cohort consisted of 293 patients with cACLD. RESIST criteria were associated with the lowest rate of missed HRV (2.5% vs 9.8% for BVI and 8.9% for EBVI). In patients with ALP levels ≥1.5 × upper limit of normal, BVI and EBVI missed a higher rate of HRV (15.5% and 14.5%, respectively) than RESIST (3.1%). Decision curve analysis demonstrated the highest net benefit of RESIST criteria for ruling out HRV, regardless of ALP levels. Among 75 patients classified as low risk of CSPH according to BVII, 14 (18.7%) showed esophageal varices.

CONCLUSIONS

Biochemical-based RESIST criteria demonstrate the highest net benefit compared with elastography-based criteria for ruling out HRV. The severity of cholestasis affects NITs performance to rule out HRV and CSPH in patients with PBC and cACLD.

ICG-r15 predicts esophageal varices in compensated liver cirrhosis: a noninvasive approach

OBJECTIVE

The aim of our study was to evaluate the indocyanine green (ICG) retention test as a noninvasive marker of esophageal varices(EV).

METHODS

The clinical data of patients diagnosed with compensated liver cirrhosis in Tianjin Second People's Hospital between January 2018 and January 2021 were analysed with SPSS 23.0.

RESULT

A total of 144 patients (88 M/56 F, 51.7 ± 11.06 years) were enrolled. The ICG retention at 15 min(ICG-r15), PVD, TBIL, Cholinesterase(CHE), AST to ALT ratio(ARR), APRI, splenic area, Lok index, Park index and liver stiffness measurement in the absent or small EV group were lower than those in the medium or large EV group, while the ICG disappareance rate(ICG-K), Effective hepatic blood flow(EHBF), ALB, PLT, and Platelet to Spleen Diameter Ratio(PSDR) were higher, and the differences were significant (P < 0.05). ICG-r15, splenic area, APRI and PLT were independent predictors for medium or large esophageal varices (OR = 1.115, 1.025, 0.281, and 0.987, respectively,P < 0.05). The predictive value of ICG-r15 for medium or large varices was 17.95%, the specificity was 0.849, and the sensitivity was 0.662, the AUROC was 0.815. The cut-off value of PLT for M/L EV was 113.5, and the specificity and sensitivity were 0.616 and 0.887, the AUROC was 0.759. The AUROC of ICG-r15 combined with PLT was 0.866, which was more superior than others.

CONCLUSION

Although we are far from the replacement of endoscopy, ICG-r15 combined with PLT seems to be able to identify patients with medium or large EV in patients with compensated liver cirrhosis.

Non-invasive fibrosis markers are useful in predicting the presence of varices in compensated cirrhosis and variceal bleeding in decompensated cirrhosis

This study aims to investigate the effectiveness of non-invasive fibrosis markers in predicting varices in compensated advanced chronic liver disease patients and variceal bleeding in decompensated cirrhotic patients. Between 1 July 2020-2021, 137 newly diagnosed cirrhosis patients (67 females/70 males; mean age: 53.35) were included in the study. The diagnosis of cirrhosis was made based on clinical, laboratory, imaging, and, if available, biopsy findings. Laboratory and clinical parameters, including lysyl oxidase-like protein 2 (LOXL2), were recorded for all patients. Commonly used noninvasive fibrosis scores were calculated, and endoscopies were performed to assess varices. All patients were followed up for 12 months, and variceal bleeding events were recorded. Parameters that could predict the presence of varices and variceal bleeding were identified using appropriate statistical methods. Out of the 137 cirrhotic patients, 55 were in the compensated stage and 82 were in the decompensated stage. Varices were detected in 36 (65%) of the compensated cirrhotic patients. It was found that a variceal score derived from spleen size and the ELF score could be used to predict varices (AUC: 0.83). Variceal bleeding developed in 26 (31%) of the patients with decompensated cirrhosis. It was determined that a scoring system derived from albumin, spleen size, LOXL2 level, and the Lok index could be used to predict variceal bleeding in this patient group (AUC: 0.845). This study demonstrates that, besides device-dependent examinations, non-invasive fibrosis scores and various serum parameters can predict varices and variceal bleeding in cirrhotic patients.

Cost-Effectiveness of the Baveno VI Criteria Compared With Endoscopy for High-Risk Varices in Patients With Child-Pugh A Cirrhosis

BACKGROUND & AIMS

Although upper gastrointestinal endoscopy (EGD) remains the gold standard for detecting varices in cirrhosis, the Baveno VI criteria proposed a combination of transient elastography and platelet count that could rule out high-risk varices, therefore sparing the need for an endoscopy, with significant potential cost savings. We performed a cost-effectiveness analysis of the Baveno VI criteria compared with EGD in the diagnosis of high-risk varices in cirrhosis.

METHODS

We built an analytical decision model to estimate the cost and benefits of using the Baveno VI criteria compared with EGD in patients with Child-Pugh A cirrhosis. The analysis was performed from the UK National Health Service perspective, over 1, 5, and 20 years. A Markov model was populated with data from published evidence. Outcomes were measured in terms of quality-adjusted life years (QALYs) and avoided deaths. The analyses were repeated for Canada and Spain, using relevant cost inputs.

RESULTS

The Baveno VI criteria were cost effective compared with endoscopy in all analyses. For 1000 patients, they produced 0.16 additional QALYs at an incremental cost of £326 ($443.41) over 5 years, resulting in an incremental cost of £2081 ($2830) per additional QALY gained. The incremental net monetary benefit of Baveno VI compared with EGD was £2808 ($3819) over 5 years per patient. Baveno VI criteria also were cost effective in Canada and Spain. Deterministic and probabilistic sensitivity analysis supported these findings.

CONCLUSIONS

The findings demonstrate that the Baveno VI criteria are cost effective, suggesting that they should be considered for widespread implementation on the basis of safety, appropriateness, and economic grounds.

Combining Spleen Diameter and the Baveno VI Criteria Assessed by 2-Dimensional Shear Wave Elastography to Rule Out High-Risk Varices

ABSTRACT

Patients with compensated advanced chronic liver disease (cACLD) can safely spared screening esophagogastroduodenoscopy (EGD) when they meet the Baveno VI criteria as assessed by transient elastography. Recently, the cutoff values of the Baveno VI criteria assessed by 2-dimensional shear wave elastography (2D-SWE) were proposed. We aimed to validate it to rule out high-risk varices (HRVs) in cACLD patients; combine spleen diameter (SPD) with the Baveno VI criteria and assess whether it can spare more screening EGD. A total of 173 cACLD patients with successful liver stiffness (LS) measurements and EGD examinations were included. We analyzed the risk factors that predicted HRVs and compared the performances of different models for ruling out HRVs. The platelet count, LS, and SPD were independent predictors of HRVs. The AUCs of platelet count, LS, spleen stiffness and SPD for diagnosing HRVs were 0.797, 0.757, 0.834, and 0.804, respectively. The Baveno VI criteria assessed by 2D-SWE spared 25.4% of EGD screenings and missed 2.4% of the HRV patients. Combining SPD ≤11.1 cm with the Baveno VI criteria could spare more EGD screenings than just applying the Baveno VI criteria (45.1% vs 25.4%, P < 0.001), and missed 4.9% of the HRV patients. The Baveno VI criteria assessed by 2D-SWE could be safely applied in cACLD patients to rule out HRV patients. The combined model Baveno VI/SPD could safely and significantly increase the rate of spared EGD.

Diagnostic accuracy of magnetically guided capsule endoscopy with a detachable string for detecting oesophagogastric varices in adults with cirrhosis: prospective multicentre study

OBJECTIVE

To evaluate the diagnostic accuracy and safety of using magnetically guided capsule endoscopy with a detachable string (ds-MCE) for detecting and grading oesophagogastric varices in adults with cirrhosis.

DESIGN

Prospective multicentre diagnostic accuracy study.

SETTING

14 medical centres in China.

PARTICIPANTS

607 adults (>18 years) with cirrhosis recruited between 7 January 2021 and 25 August 2022. Participants underwent ds-MCE (index test), followed by oesophagogastroduodenoscopy (OGD, reference test) within 48 hours. The participants were divided into development and validation cohorts in a ratio of 2:1.

MAIN OUTCOME MEASURES

The primary outcomes were the sensitivity and specificity of ds-MCE in detecting oesophagogastric varices compared with OGD. Secondary outcomes included the sensitivity and specificity of ds-MCE for detecting high risk oesophageal varices and the diagnostic accuracy of ds-MCE for detecting high risk oesophagogastric varices, oesophageal varices, and gastric varices.

RESULTS

ds-MCE and OGD examinations were completed in 582 (95.9%) of the 607 participants. Using OGD as the reference standard, ds-MCE had a sensitivity of 97.5% (95% confidence interval 95.5% to 98.7%) and specificity of 97.8% (94.4% to 99.1%) for detecting oesophagogastric varices (both P<0.001 compared with a prespecified 85% threshold). When using the optimal 18% threshold for luminal circumference of the oesophagus derived from the development cohort (n=393), the sensitivity and specificity of ds-MCE for detecting high risk oesophageal varices in the validation cohort (n=189) were 95.8% (89.7% to 98.4%) and 94.7% (88.2% to 97.7%), respectively. The diagnostic accuracy of ds-MCE for detecting high risk oesophagogastric varices, oesophageal varices, and gastric varices was 96.3% (92.6% to 98.2%), 96.9% (95.2% to 98.0%), and 96.7% (95.0% to 97.9%), respectively. Two serious adverse events occurred with OGD but none with ds-MCE.

CONCLUSION

The findings of this study suggest that ds-MCE is a highly accurate and safe diagnostic tool for detecting and grading oesophagogastric varices and is a promising alternative to OGD for screening and surveillance of oesophagogastric varices in patients with cirrhosis.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03748563.

Spleen stiffness: a new tool to predict high-risk varices in cirrhotic patients

INTRODUCTION

Cirrhosis is one of the major causes of morbidity and mortality worldwide. Portal hypertension is the major contributor of cirrhosis-related complications and is defined as a hepatic venous pressure gradient (HVPG) > 5 mmHg. Measurement of HVPG is an invasive, difficult, and costly procedure. Therefore, it is only performed in specialized centers. Liver stiffness measured with transient elastography is one of the most studied noninvasive markers of portal hypertension, and spleen elastography has recently emerged as an important adjuvant tool. The development of a new probe (100 Hz) that more reliably reflect the grade of portal hypertension evaluated by spleen stiffness measurement has improved the accuracy of this technique. The aim of this work was to evaluate the accuracy of spleen stiffness with the new dedicated probe to predict the presence of high-risk varices, as well as to determine the ideal cutoff to predict it.

METHODS

Prospective study of cirrhotic patients admitted to upper endoscopy that were also submitted to liver and spleen elastography with the 100-Hz probe by the same blinded operator in a tertiary center.

RESULTS

We included 209 cirrhotic patients, with mean age of 61.9 years (±9.9), 77.0% male. The most common etiology was alcoholic liver disease (72.7%). The median value of liver elastography was 25.3 [4.5-75] kPa, and the median value of spleen elastography was 42.4 [7.6-100] kPa. At the cutoff of 53.25 kPa, we obtained sensitivity of 100% and specificity of 72.6% to predict high-risk varices, and, according to this cutoff, 133/175 of esophagogastroduodenoscopy could have been spared (76.0%), while according to Baveno guidelines, only 51/175 would have been spared (29.1%).

CONCLUSION

In the era of noninvasive exams, spleen elastography with the 100-Hz probe emerges as an excellent tool for prediction of presence of high-risk varices. At the cutoff of 53.25 kPa, spleen elastography avoids upper endoscopy for screening for high-risk varices, promising to be become part of the hepatologists' daily routine.

Diagnosis of esophageal varices by liver stiffness and serum biomarkers in virus-related compensated advanced chronic liver disease

Background

Individuals infected with hepatitis B (HBV), hepatitis C (HCV), and human immunodeficiency (HIV) viruses can experience compensated advanced chronic liver disease (cACLD) leading to esophageal varices (EV). In patients at low risk of esophageal varices needing treatment (EVNT), non-invasive criteria based on liver stiffness measurement (LSM) with platelets, or fibrosis biomarkers, may avoid unnecessary screening esophagogastroduodenoscopies (EGD). These approaches have not been compared among people infected with HIV, HBV, and HCV patients.

Methods

Patients with a diagnosis of cACLD (LSM ≥10 kPa) and EGD availability were included from two cohorts. Baveno VI and expanded Baveno VI criteria (based on LSM and platelets), fibrosis biomarkers Fibrosis-4 Index (FIB-4), AST-to-Platelets Ratio Index (APRI), AST-to-ALT ratio (AAR), and RESIST criteria (based on platelets and albumin) were applied to determine the proportion of spared EGD and of missed EVNT.

Results

Three hundred fifty three patients (30.6% with HIV, 25.3% monoinfected with HBV, and 44.1% with HCV) were included. The prevalence of EVNT was 8.2%. Both Baveno VI and expanded Baveno VI criteria performed well in patients with virus-related cACLD, by sparing 26.1% and 51.6% EGD, respectively, while missing <2% EVNT. The proportion of spared EGD were 48.2%, 58%, and 24.3% by FIB-4 (<2.78), APRI (<1.1), and AAR (<0.75), respectively, while missing <3% EVNT. RESIST criteria spared 47.8% EGD while missing 1.9% EVNT.

Conclusions

Non-invasive criteria based on LSM can spare unnecessary EGD in virus-related cACLD. Simple fibrosis biomarkers can ameliorate resource utilization for EVNT screening in low resource settings.

Prediction of High-Risk Varices in Patients with Compensated Advanced Chronic Liver Disease in Saudi Arabia

Purpose

Liver stiffness and low platelet count can predict portal hypertension and high-risk varices (HRVs) in patients with cirrhosis. Thus, screening endoscopy may not be required for all patients with compensated advanced chronic liver disease (cACLD). However, data from Saudi Arabia are limited. This study aimed to validate the Baveno VI and expanded Baveno VI criteria for screening endoscopy and identify the risk factors associated with HRVs in patients with cACLD in Saudi Arabia.

Patients and Methods

We analyzed data from 215 patients with cACLD diagnosed on transient elastography (LSM > 10 kPa) and had paired platelet count and screening upper endoscopy performed within one year of diagnosis. HRVs or varices needing treatment (VNTs) were defined as medium-to-large esophageal varices (EVs), small EVs with red flags, or gastric varices. Sensitivity, specificity, and area under the receiver operating characteristic curve were calculated. Univariate and multivariate logistic regression analyses identified HRV risk factors.

Results

The Baveno VI criteria spared 50.7% of endoscopies, missing 3.7% of VNTs, while the expanded Baveno VI criteria spared 63.7% of endoscopies, missing 5.1% VNTs. An LSM <20 kPa and platelet count > 150,000/µL were associated with HRV in 8.1% and 8.3%, respectively. While an LSM <25 kPa and platelet count > 110,000/µL were associated with HRV in 9.7% and 9%, respectively. The Baveno VI criteria had sensitivity and specificity of 76% and 55%, while the expanded criteria had 67% and 69%, respectively. Baveno VI criteria performed better in hepatitis C virus patients than nonalcoholic fatty liver disease patients. Multivariate logistic regression analysis revealed platelet count and LSM as predictors of HRV.

Conclusion

The Baveno VI criteria effectively identified HRVs in cACLD patients from Saudi Arabia, reducing unnecessary endoscopies. Although the expanded criteria avoided more endoscopies, it led to a higher rate of missed HRVs.

Shear wave elastography measured liver stiffness-spleen size-to-platelet ratio for the prediction of high-risk oesophageal varices: a meta-analysis

OBJECTIVES

The potential predictive role of shear wave elastography (SWE) measured liver stiffness-spleen size-to-platelet ratio score (LSPS) for high-risk oesophageal varices (HREV) in patients with cirrhosis remains controversial. A systematic review and meta-analysis was performed to investigate the diagnostic efficacy of SWE-measured LSPS for HREV.

METHODS

Relevant studies were retrieved by searching PubMed, Embase, Web of Science, Wanfang, and CNKI databases. Only studies comparing the diagnostic efficacy of SWE-measured LSPS with oesophagogastroduodenoscopy for HREV in patients with cirrhosis were included. Pooled sensitivity and specificity were calculated with a random-effect model.

RESULTS

Overall, eight cohorts were included. Four of them used point SWE (pSWE) and the other four used 2D-SWE. Pooled results showed that a high LSPS measured by pSWE and 2D-SWE were both associated with satisfying diagnostic efficacy for endoscopic-evidenced HREV, with pooled sensitivity, specificity, diagnostic odds ratio, and pooled area under receiver operating characteristic curve of 0.86, 0.86, 39.36, and 0.92 for pSWE-derived LSPS, and 0.77, 0.86, 20.64, and 0.89 for 2D-SWE-derived LSPS. No significant difference was observed in the diagnostic efficacy between pSWE- and 2D-SWE-derived LSPS ( P all > 0.05). Significant heterogeneity was observed. However, further subgroup and meta-regression analysis failed to show that differences in study design, sex, diagnosis (compensated or overall cirrhosis), or LPSP cutoffs may lead to heterogeneity ( P for subgroup difference > 0.05).

CONCLUSION

A high LSPS with liver stiffness measured by pSWE or 2D-SWE shows satisfying predictive accuracy for HREV in patients with cirrhosis.

PRO-C3 is a predictor of clinical outcomes in distinct cohorts of patients with advanced liver disease

Background & Aims

Fibroblast activity is a key feature of fibrosis progression and organ function loss, leading to liver-related complications and mortality. The fibrogenesis marker, PRO-C3, has been shown to have prognostic significance in relation to fibrosis progression and as a treatment efficacy marker. We investigated whether PRO-C3 was prognostic for clinical outcome and mortality in two distinct cohorts of compensated cirrhosis.

Methods

Cohort 1 was a rapid fibrosis progression cohort including 104 patients with HCV and biopsy-proven Ishak fibrosis stage ≥3 without prior clinical events. Cohort 2 was a prospective cohort including 172 patients with compensated cirrhosis of mixed aetiology. Patients were assessed for clinical outcomes. PRO-C3 was assessed in serum at baseline in cohorts 1 and 2, and compared with model for end-stage liver disease and albumin-bilirubin (ALBI) scores.

Results

In cohort 1, a 2-fold increase in PRO-C3 was associated with 2.7-fold increased hazard of liver-related events (95% CI 1.6-4.6), whereas a one unit increase in ALBI score was associated with a 6.5-fold increased hazard (95% CI 2.9-14.6). In cohort 2, a 2-fold increase in PRO-C3 was associated with a 2.7-fold increased hazard (95% CI 1.8-3.9), whereas a one unit increase in ALBI score was associated with a 6.3-fold increased hazard (95% CI 3.0-13.2). A multivariable Cox regression analysis identified PRO-C3 and ALBI as being independently associated with the hazard of liver-related outcomes.

Conclusions

PRO-C3 and ALBI were independent prognostic factors for predicting liver-related clinical outcomes. Understanding the dynamic range of PRO-C3 might enhance its use for both drug development and clinical practice.

Impact and Implications

We tested novel proteins of liver scarring (PRO-C3) in two groups of liver patients with advanced disease to see if they could predict clinical events. We found that this marker and an established test called ALBI were both independently associated with future liver-related clinical outcomes.

Spleen stiffness: a predictive factor of dismal prognosis in liver cirrhosis

Portal hypertension (PH) is a major complication of liver cirrhosis, as it predisposes to the development of serious clinical manifestations such as ascites, hepatic encephalopathy and variceal bleeding, aggravating the prognosis of patients. Hepatic vein pressure gradient (HVPG) is considered the reference method for the estimation of the presence and severity of PH, but this procedure is available only in specialized centers. Alternatively, many non-invasive methods have been proposed in order to substitute HVPG. Among them, liver stiffness measurement (LSM) has been widely used, as it has been shown to correlate well with HVPG, though this relationship seems to weaken in values of HVPG higher than 12 mmHg, the threshold of serious complications development. Several studies supported the use of spleen stiffness measurement (SSM) instead of LSM, anticipating to a more adequate assessment of this advanced stage of PH. The aim of this paper is to critically appraise and summarize the literature about the role of SSM as a predictive tool of liver decompensation and prognosis, highlighting the strengths and the potential limitations of the studies published so far. EXPERT'S OPINION: The utility of SSM in ruling out high risk for bleeding varices in cirrhotic patients has been demonstrated, driving the Baveno VII consensus to encompass SSM in its last recommendations, though its use in patients with non-viral cirrhosis remains to be validated. We believe that in the near future, SSM alone or combined with other tests, will being used not only for sparing upper endoscopies, but also for predicting decompensation and prognosis in advanced compensated cirrhotic patients, regardless of liver disease's etiology. Herein, we present the data that support this consideration, pointing out these issues that should further be investigated in order to elucidate and intensify the value of SSM in the management of patients with liver cirrhosis.

Development and validation of a machine learning-based model for varices screening in compensated cirrhosis (CHESS2001): an international multicenter study

BACKGROUND AND AIMS

The prevalence of high-risk varices (HRV) is low among compensated cirrhotic patients undergoing EGD. Our study aimed to identify a novel machine learning (ML)-based model, named ML EGD, for ruling out HRV and avoiding unnecessary EGDs in patients with compensated cirrhosis.

METHODS

An international cohort from 17 institutions from China, Singapore, and India were enrolled (CHESS2001). The variables with the top 3 importance scores (liver stiffness, platelet count, and total bilirubin) were selected by the Shapley additive explanation and input into a light gradient-boosting machine algorithm to develop ML EGD for identification of HRV. Furthermore, we built a web-based calculator for ML EGD, which is free with open access (http://www.pan-chess.cn/calculator/MLEGD_score). Unnecessary EGDs that were not performed and the rates of missed HRV were used to assess the efficacy and safety for varices screening.

RESULTS

Of 2794 enrolled patients, 1283 patients formed a real-world cohort from 1 university hospital in China used to develop and internally validate the performance of ML EGD for varices screening. They were randomly assigned into the training (n = 1154) and validation (n = 129) cohorts with a ratio of 9:1. In the training cohort, ML EGD spared 607 (52.6%) unnecessary EGDs with a missed HRV rate of 3.6%. In the validation cohort, ML EGD spared 75 (58.1%) EGDs with a missed HRV rate of 1.4%. To externally test the performance of ML EGD, 966 patients from 14 university hospitals in China (test cohort 1) and 545 from 2 hospitals in Singapore and India (test cohort 2) comprised the 2 test cohorts. In test cohort 1, ML EGD spared 506 (52.4%) EGDs with a missed HRV rate of 2.8%. In test cohort 2, ML EGD spared 224 (41.1%) EGDs with a missed HRV rate of 3.1%. When compared with the Baveno VI criteria, ML EGD spared more screening EGDs in all cohorts (training cohort, 52.6% vs 29.4%; validation cohort, 58.1% vs 44.2%; test cohort 1, 52.4% vs 26.5%; test cohort 2, 41.1% vs 21.1%, respectively; P < .001).

CONCLUSIONS

We identified a novel model based on liver stiffness, platelet count, and total bilirubin, named ML EGD, as a free web-based calculator. ML EGD could efficiently help rule out HRV and avoid unnecessary EGDs in patients with compensated cirrhosis. (Clinical trial registration number: NCT04307264.).

Spleen stiffness can predict liver decompensation and survival in patients with cirrhosis

BACKGROUND AND AIM

Liver stiffness measurement (LSM) has been predicting liver decompensation and survival in cirrhotics. The aim of our study was to investigate if spleen stiffness measurement (SSM) by 2D shear-wave elastography could predict better the probability of decompensation and mortality, compared with LSM and other parameters.

METHODS

Consecutive cirrhotic patients were recruited between 1/2017 and 12/2021. LSM and SSM were performed at baseline and epidemiological, clinical, and laboratory data were collected. Clinical events were recorded every 3 months.

RESULTS

Totally, 177 patients were followed for a mean period of 31 ± 18 months. In Cox regression analysis, only SSM was independently associated with the probability of decompensation (HR: 1.063, 95% CI: 1.009-1.120; P = 0.021), offering an AUROC of 0.710 (P = 0.003) for predicting 1-year liver decompensation (NPV: 81.1% for the cut-off point of 37 kPa). The occurrence of death/liver transplantation was independently associated only with higher SSM (HR: 1.043; 95% CI:1.003-1.084; P = 0.034). The AUROC of SSM for predicting 1-year death/liver transplantation was 0.72 (P = 0.006) (NPV: 95% for the cut-off of 38.8 kPa). The performance of SSM to predict the 1-year death/liver transplantation increased in high-risk patients (CTP: B/C plus MELD >10 plus LSM > 20 kPa), giving an AUROC of 0.80 (P < 0.001). Only 1/26 high-risk patients with SSM < 38.8 kPa died during the first year of follow-up (NPV: 96.4%).

CONCLUSIONS

SSM was the only factor independently associated with the probability of decompensation and occurrence of death, showing better diagnostic accuracy for the prediction of 1-year decompensation or death compared with LSM and MELD score.

Correlation between serum liver fibrosis markers and early gastroesophageal varices among patients with compensated liver cirrhosis: a cross-sectional analysis

BACKGROUND AND AIM

Portal hypertension is a common complication of chronic liver diseases responsible for most liver cirrhosis consequences. In patients with portal hypertension, oesophagogastric variceal bleeding is a leading cause of death. Most research has focused on high-risk gastroesophageal varices and bleeding, with only a few studies on early varices. However, early intervention of gastroesophageal varices was found to better improve the prognosis and reduce mortality, but there is still no relevant research. Ultrasonic endoscopy is a combination of endoscopy and ultrasonic imaging. It can gastroscopically detect varices around the oesophagus and stomach and detect oesophageal collateral veins and perforating veins earlier, which is helpful for the early diagnosis of varices. Therefore, this study aimed to explore the correlation between serum fibrosis markers and early gastroesophageal varices in compensated cirrhosis patients.

METHODS

This study included 791 patients with compensated cirrhosis. The selected patients were categorized into three groups. The early gastroesophageal varices group included patients with gastroesophageal varices found by endoscopic ultrasonography but not by gastroscopy. The no gastroesophageal varices group underwent endoscopic ultrasonography and gastroscopy without varices. In addition, gastroesophageal varices can be detected with both techniques. Multiple logistic regression analysis explored the association of serum fibrosis markers with early gastroesophageal varices.

RESULTS

Among the 791 compensated liver cirrhosis patients, 198 patients were without gastroesophageal varices, 279 patients had early gastroesophageal varices, 314 patients had gastroesophageal varices, and both techniques could detect varices. There was a positive correlation between serum fibrosis markers and early gastroesophageal varices. In univariate logistic regression analysis, the patients with early gastroesophageal varices had lower platelet counts (P = 0.034) and higher aspartate aminotransferase (P = 0.046), total bilirubin (P = 0.041), hyaluronic acid (P < 0.001), laminin (P < 0.001), type III procollagen (P = 0.005), type IV collagen (P = 0.002), liver stiffness measurement (P = 0.001), APRI (P = 0.019) and FIB-4 (P = 0.002). Multivariate analysis showed that laminin (OR 1.011; 95% CI 1.004-1.017, P = 0.001) was an independent risk factor for predicting early gastroesophageal varices in compensated cirrhosis patients.

CONCLUSION

Higher laminin was independently associated with early gastroesophageal varices in compensated cirrhosis patients.

Impact of COVID-19 on endoscopic follow-up of gastroesophageal varices

BACKGROUND

Portal hypertension is considered as a major complication of liver cirrhosis. Endoscopy plays a main role in managing of gastrointestinal complications of portal hypertension. Endoscopists are at increased risk for COVID-19 infection because upper gastrointestinal (GI) endoscopy is a high-risk aerosol-generating procedure and may be a potential route for COVID-19.

OBJECTIVES

To compare the outcome between cirrhotic patients who underwent classic regular endoscopic variceal ligation after primary bleeding episode every 2-4 weeks, and those presented during the era of COVID-19 and their follow-up were postponed 2 months later.

METHODS

This retrospective study included cross-matched 238 cirrhotic patients with portal hypertension presented with upper GI bleeding, 112 cirrhotic patients presented during the era of COVID19 (group A) underwent endoscopic variceal ligation, another session after 2 weeks and their subsequent follow-up was postponed 2 months later, and 126 cirrhotic patients as control (group B) underwent regular endoscopic variceal band ligation after primary bleeding episode every 2-4 weeks.

RESULTS

Eradication of varices was achieved in 32% of cases in group A, and 46% in group was not any statistically significant (p > 0.05); also, there was no any statistical significant difference between both groups regarding occurrence of rebleeding, post endoscopic symptoms, and mortality rate (p > 0.05).

CONCLUSION

Band ligation and injection of esophageal and gastric vary every 2 months were as effective and safe as doing it every 2 to 4 weeks after primary bleeding episode for further studies and validation.

Nomogram based on spleen volume expansion rate predicts esophagogastric varices bleeding risk in patients with hepatitis B liver cirrhosis

BACKGROUND

We aimed to explore the risk factors for hemorrhage of esophagogastric varices (EGVs) in patients with hepatitis B cirrhosis and to construct a novel nomogram model based on the spleen volume expansion rate to predict the risk of esophagogastric varices bleeding.

METHODS

Univariate and multivariate logistic regression analysis was used to analyze the risk factors for EGVs bleeding. Nomograms were established based on the multivariate analysis results. The predictive accuracy of the nomograms was assessed using the area under the curve (AUC or C-index) of the receiver operating characteristic (ROC) and calibration curves. Decision curve analysis was used to determine the clinical benefit of the nomogram. We created a nomogram of the best predictive models.

RESULTS

A total of 142 patients' hepatitis B cirrhosis with esophagogastric varices were included in this study, of whom 85 (59.9%) had a history of EGVs bleeding and 57 (40.1%) had no EGVs bleeding. The spleen volume expansion rate, serum sodium levels (mmol/L), hemoglobin levels (g/L), and prothrombin time (s) were independent predictors for EGVs bleeding in patients with hepatitis B liver cirrhosis (P < 0.05). The above predictors were included in the nomogram prediction model. The area under the ROC curve (AUROC) of the nomogram was 0.781, the C-index obtained by internal validation was 0.757, and the calibration prediction curve fit well with the ideal curve. The AUROCs of the PLT-MELD and APRI were 0.648 and 0.548, respectively.

CONCLUSION

In this study, a novel nomogram for predicting the risk of EGVs bleeding in patients with hepatitis B cirrhosis was successfully constructed by combining the spleen volume expansion rate, serum sodium levels, hemoglobin levels, and prothrombin time. The predictive model can provide clinicians with a reference to help them make clinical decisions.

A strategy for varices screening based on acoustic radiation force impulse combined with platelet (CHESS2001): An alternative of Baveno VI criteria

Few studies have reported on acoustic radiation force impulse (ARFI) for varices screening. Our study aimed to identify a strategy based on liver stiffness measurement (LSM) and spleen stiffness measurement (SSM) by ARFI combined with platelet count (PLT), named the ARP strategy, for ruling out high-risk varices (HRV) and avoiding unnecessary esophagogastroduodenoscopy (EGD) in patients with compensated cirrhosis. We retrospectively reviewed patients who underwent ARFI from a previous cohort (NCT04307264). Of them, patients between 2017 and 2019 composed the training cohort to develop the ARP strategy. The validation cohort consisted of others between 2015 and 2016 to validate and compare it with Baveno VI criteria about the performance for varices screening. Primary outcomes were the rates of spared EGDs and HRV missed. A total of 741 consecutive patients were included in the final analysis. Of them, 576 patients were included in the training cohort and 165 patients in the validation cohort. In the training cohort, ARP strategy was defined as LSM < 1.805 m/s or SSM < 2.445 m/s and PLT > 110 × 109 /L. ARP strategy could spare 234 (40.6%) EGDs with a missed HRV rate of 3.4% (8 of 234). In the validation cohort, compared with Baveno VI criteria, the ARP strategy improved the proportion of avoided EGDs (49.7% vs. 34.5%; p < 0.001) and lowered the rate of misclassified HRV (1.2% vs. 3.5%; p < 0.001). Conclusion: The ARP strategy was an efficient and safe tool for varices screening in compensated cirrhosis, and it might be an auxiliary or even alternative to Baveno VI criteria.

RESIST-HCV Criteria to Monitor Progression of Low-Risk Esophageal Varices in Patients With Compensated Cirrhosis After HCV Eradication: The SIMPLE Study: SIMPLE: Scoring Index to Monitor Progression of Low-risk Esophageal varices

INTRODUCTION

Noninvasive criteria to predict the progression of low-risk esophageal varices (EV) in patients with compensated hepatitis C virus (HCV) cirrhosis after sustained virological response (SVR) by direct-acting antivirals (DAAs) are lacking. Our aim was to assess the diagnostic performance of Rete Sicilia Selezione Terapia-HCV (RESIST-HCV) criteria for EV progression compared with elastography-based criteria (Baveno VI, Expanded Baveno VI, and Baveno VII-HCV criteria).

METHODS

All consecutive patients observed at 3 referral centers with compensated HCV cirrhosis with or without F1 EV who achieved sustained virological response by DAAs were classified at last esophagogastroduodenoscopy (EGDS) as RESIST-HCV low risk (i.e., low probability of high-risk varices [HRV]) if platelets were >120 × 10 9 /L and serum albumin >3.6 g/dL or RESIST-HCV high risk (i.e., high probability of HRV) if platelets were <120 × 10 9 /L or serum albumin <3.6 g/dL. The primary outcome was the progression to HRV. The area under the receiver operating characteristic curve and decision curve analysis of noninvasive criteria were calculated.

RESULTS

The cohort consisted of 353 patients in Child-Pugh class A (mean age 67.2 years, 53.8% males). During a mean follow-up of 44.2 months, 34 patients (9.6%, 95% CI 6.7%-13.5%) developed HRV. At the last EGDS, 178 patients (50.4%) were RESIST-low risk, and 175 (49.6%) were RESIST-high risk. RESIST-HCV criteria showed the highest area under the receiver operating characteristic curve (0.70, 95% confidence interval 0.65-0.75), correctly sparing the highest number of EGDS (54.3%), with the lowest false-positive rate (45.7%), compared with elastography-based criteria. Decision curve analysis showed that RESIST-HCV had higher clinical utility than elastography-based criteria.

DISCUSSION

Biochemical-based RESIST-HCV criteria are useful to easily predict HRV development after HCV eradication by DAAs in patients with compensated cirrhosis and low-risk EV.

Endoscopic diagnosis and management of esophagogastric variceal hemorrhage: European Society of Gastrointestinal Endoscopy (ESGE) Guideline

1: ESGE recommends that patients with compensated advanced chronic liver disease (ACLD; due to viruses, alcohol, and/or nonobese [BMI < 30 kg/m2] nonalcoholic steatohepatitis) and clinically significant portal hypertension (hepatic venous pressure gradient [HVPG] > 10 mmHg and/or liver stiffness by transient elastography > 25 kPa) should receive, if no contraindications, nonselective beta blocker (NSBB) therapy (preferably carvedilol) to prevent the development of variceal bleeding.Strong recommendation, moderate quality evidence. 2: ESGE recommends that in those patients unable to receive NSBB therapy with a screening upper gastrointestinal (GI) endoscopy that demonstrates high risk esophageal varices, endoscopic band ligation (EBL) is the endoscopic prophylactic treatment of choice. EBL should be repeated every 2-4 weeks until variceal eradication is achieved. Thereafter, surveillance EGD should be performed every 3-6 months in the first year following eradication.Strong recommendation, moderate quality evidence. 3: ESGE recommends, in hemodynamically stable patients with acute upper GI hemorrhage (UGIH) and no history of cardiovascular disease, a restrictive red blood cell (RBC) transfusion strategy, with a hemoglobin threshold of ≤ 70 g/L prompting RBC transfusion. A post-transfusion target hemoglobin of 70-90 g/L is desired.Strong recommendation, moderate quality evidence. 4 : ESGE recommends that patients with ACLD presenting with suspected acute variceal bleeding be risk stratified according to the Child-Pugh score and MELD score, and by documentation of active/inactive bleeding at the time of upper GI endoscopy.Strong recommendation, high quality of evidence. 5 : ESGE recommends the vasoactive agents terlipressin, octreotide, or somatostatin be initiated at the time of presentation in patients with suspected acute variceal bleeding and be continued for a duration of up to 5 days.Strong recommendation, high quality evidence. 6 : ESGE recommends antibiotic prophylaxis using ceftriaxone 1 g/day for up to 7 days for all patients with ACLD presenting with acute variceal hemorrhage, or in accordance with local antibiotic resistance and patient allergies.Strong recommendation, high quality evidence. 7 : ESGE recommends, in the absence of contraindications, intravenous erythromycin 250 mg be given 30-120 minutes prior to upper GI endoscopy in patients with suspected acute variceal hemorrhage.Strong recommendation, high quality evidence. 8 : ESGE recommends that, in patients with suspected variceal hemorrhage, endoscopic evaluation should take place within 12 hours from the time of patient presentation provided the patient has been hemodynamically resuscitated.Strong recommendation, moderate quality evidence. 9 : ESGE recommends EBL for the treatment of acute esophageal variceal hemorrhage (EVH).Strong recommendation, high quality evidence. 10 : ESGE recommends that, in patients at high risk for recurrent esophageal variceal bleeding following successful endoscopic hemostasis (Child-Pugh C  ≤ 13 or Child-Pugh B > 7 with active EVH at the time of endoscopy despite vasoactive agents, or HVPG > 20 mmHg), pre-emptive transjugular intrahepatic portosystemic shunt (TIPS) within 72 hours (preferably within 24 hours) must be considered.Strong recommendation, high quality evidence. 11 : ESGE recommends that, for persistent esophageal variceal bleeding despite vasoactive pharmacological and endoscopic hemostasis therapy, urgent rescue TIPS should be considered (where available).Strong recommendation, moderate quality evidence. 12 : ESGE recommends endoscopic cyanoacrylate injection for acute gastric (cardiofundal) variceal (GOV2, IGV1) hemorrhage.Strong recommendation, high quality evidence. 13: ESGE recommends endoscopic cyanoacrylate injection or EBL in patients with GOV1-specific bleeding.Strong recommendations, moderate quality evidence. 14: ESGE suggests urgent rescue TIPS or balloon-occluded retrograde transvenous obliteration (BRTO) for gastric variceal bleeding when there is a failure of endoscopic hemostasis or early recurrent bleeding.Weak recommendation, low quality evidence. 15: ESGE recommends that patients who have undergone EBL for acute EVH should be scheduled for follow-up EBLs at 1- to 4-weekly intervals to eradicate esophageal varices (secondary prophylaxis).Strong recommendation, moderate quality evidence. 16: ESGE recommends the use of NSBBs (propranolol or carvedilol) in combination with endoscopic therapy for secondary prophylaxis in EVH in patients with ACLD.Strong recommendation, high quality evidence.

Development and validation of a nomogram for esophagogastric variceal bleeding in liver cirrhosis: A cohort study in 1099 cases

OBJECTIVES

Esophagogastric variceal bleeding (EVB) is a catastrophic complication of decompensated liver cirrhosis. We aimed to establish a nomogram based on noninvasive clinical and imaging variables to predict the risk of EVB.

METHODS

The cut-off value of each variable was determined through univariate regression analysis. The least absolute shrinkage and selection operator (LASSO) regression and multivariate logistic regression analyses were used to determine the risk factors and establish predictive models. The nomogram was established and validated using the calibration discrimination across different groups.

RESULTS

Six indicators, including platelet count, hemoglobin, albumin to globulin ratio, fasting blood glucose, serum chloride, and computed tomography portal vein diameter (CTPD), were found to be related to the risk of EVB. Two models, with or without CTPD, were established and compared. Model 1 with CTPD had better discrimination than model 2 with C-index of 0.893 (95% confidence interval [CI] 0.872-0.915) and 0.862 (95% CI 0.837-0.887) in the primary cohort, respectively (Z = 2.027, P = 0.043). While the C-index of the two models in the validation cohort was 0.878 (95% CI 0.838-0.919) and 0.810 (95% CI 0.757-0.863). Moreover, the clinical decision analysis curve and clinical impact curve showed that these models might confer a significant net benefit on patients and provide a reference threshold for clinicians.

CONCLUSION

A nomogram using routine clinical indicators was established to predict the risk of EVB in patients with liver cirrhosis, which was verified in an independent cohort and demonstrated a great consistency.

VariScreen secures the screening of high-risk varices in patients with hepatitis B virus-related cirrhosis beyond Baveno VI criteria

We aimed to validate the performance of the ratio of the platelet count (PLT) to liver stiffness measurement (LSM) in excluding high-risk varices (HRVs) in patients with hepatitis B virus (HBV)-related compensated cirrhosis beyond Baveno VI criteria. A total of 310 patients were assessed. The performances of the PLT:LSM ratio (PLER), PLER adjusted for the international normalized ratio, etiology, age, and sex (PLEASE), and the sequential algorithm for HRV screening (VariScreen) in excluding HRVs were evaluated and compared with those of expanded Baveno VI criteria (LSM &lt;25 kPa and PLT &gt;110×109/L, EB6C); PLT &gt;150×109/L and model for end-stage liver disease score = 6 (P150M6 criterion); PLT &gt;120×109/L and albumin &gt;36 g/L (P120A36 criterion); and albumin-bilirubin (ALBI) grade and PLT score (ALBI-PLT score). Among the enrolled patients, 43 (13.9%) had HRVs. The area under the receiver operating characteristic curve of PLER for predicting HRVs (0.771, 95% confidence interval, 0.720–0.817) was significantly higher than that for PLT and LSM (p &lt; 0.01). PLER was an independent risk factor for HRVs. VariScreen, PLEASE, and PLER could spare 20 (6.5%), 91 (29.4%), and 60 (19.4%) endoscopies, with 0, 3 (3.3%), and 1 (1.7%) HRVs missed, respectively. The EB6C and P120A36 criteria could spare 45 (14.5%) and 36 (11.6%) endoscopies, with 1 (2.2%) and 1 (2.8%) HRVs missed, respectively. The P150M6 criterion and ALBI-PLT score missed 6.8% and 10.3% of HRVs, respectively. We found that PLER performed better than other non-invasive tests. VariScreen secured the screening of HRVs in patients with HBV-related cirrhosis beyond Baveno VI criteria.

Current treatment of non-alcoholic fatty liver disease

Non-alcoholic fatty liver disease (NAFLD) comprises a wide spectrum of pathologies ranging from non-alcoholic fatty liver (NAFL), characterized by simple steatosis without inflammation, to non-alcoholic steatohepatitis (NASH), characterized by steatosis of the liver accompanied by inflammation and hepatocyte ballooning, which can lead to advanced fibrosis, cirrhosis and hepatocellular carcinoma. Apart from lifestyle modifications such as weight loss, a Mediterranean diet and physical activity, only a few NAFLD-specific pharmacological treatment options such as Vitamin E and Pioglitazone are considered by current international guidelines. However, recently randomized controlled trials with GLP-1 agonists, FXR and PPAR ligands as well as other agents have been published and may expand the therapeutic armamentarium for NAFLD in the near future. Finally, knowledge about treating complications of end-stage liver disease due to NASH becomes an increasingly important cornerstone in the treatment of the broad disease spectrum of NAFLD. In this review, we summarize currently available and future treatment options for patients with NAFLD that may help internal medicine specialists treat the complete clinical spectrum of this highly prevalent liver disease.

Quality standards for the management of non-alcoholic fatty liver disease (NAFLD): consensus recommendations from the British Association for the Study of the Liver and British Society of Gastroenterology NAFLD Special Interest Group

Non-alcoholic fatty liver disease (NAFLD) is common, affecting approximately 25% of the general population. The evidence base for the investigation and management of NAFLD is large and growing, but there is currently little practical guidance to support development of services and delivery of care. To address this, we produced a series of evidence-based quality standard recommendations for the management of NAFLD, with the aim of improving patient care. A multidisciplinary group of experts from the British Association for the Study of the Liver and British Society of Gastroenterology NAFLD Special Interest Group produced the recommendations, which cover: management of people with, or at risk of, NAFLD before the gastroenterology or liver clinic; assessment and investigations in secondary care; and management in secondary care. The quality of evidence for each recommendation was evaluated by the Grading of Recommendation Assessment, Development and Evaluation tool. An anonymous modified Delphi voting process was conducted individually by each member of the group to assess the level of agreement with each statement. Statements were included when agreement was 80% or greater. From the final list of statements, a smaller number of auditable key performance indicators were selected to allow services to benchmark their practice. It is hoped that services will review their practice against our recommendations and key performance indicators and institute service development where needed to improve the care of patients with NAFLD.

Modified and alternative Baveno VI criteria based on age for ruling out high-risk varices in patients with compensated cirrhosis

Background

The Baveno VI criteria (B6C) have been recommended to screen high-risk varices (HRV) in patients with liver cirrhosis to avoid the use of esophagogastroduodenoscopy (EGD). Due to conservative nature of B6C and the general unavailability of transient elastography in the medical institutions, clinical application of B6C is restricted. We aimed to optimize B6C and attempted to replace the liver stiffness (LS) score with other parameters that could help patients avoid EGD.

Methods

A total of 1,188 patients with compensated cirrhosis were analyzed and divided into the training cohort (TC) and validating cohort (VC) by the split-sample method. Variables were selected to develop new criteria in the TC before verification in the VC.

Results

The parameters of age ≥ 50 years, LS, platelet count (PLT), and spleen area (SA) were independently associated with HRV. The risk of HRV was 2.39 times greater in patients over 50 years, hence alternative B6C (AB6C) and modified B6C (MB6C) criteria were built based on age. MB6C was built by adjusting the cut-off value of LS and PLT (patients aged < 50 years with PLT > 100 × 10⁹/L and LS < 30 kPa; patients aged ≥ 50 years with a combined PLT > 125 × 10⁹/L and LS < 20 kPa). MB6C helped avoid EGD in 310 (51.2%) patients, whereas 7 (2.3%) cases of HRV were missed. The predicting performance HRV showed no statistical difference between PLT, SA, or LS. SA was selected to replace LS and in the built AB6C (patients aged < 50 years with PLT > 100 × 10⁹/L and SA < 55 cm²; patients aged ≥ 50 years with a combined PLT > 125 × 10⁹/L and SA < 44 cm²). Using AB6C avoided 297 (49.1%) EGDs with a total of 8 (2.7%) cases of HRV that were missed.

Conclusions

Our novel MB6C and AB6C were stratified by age and provided excellent performance for ruling out HRV, which performed better than B6C and EB6C (expanded B6C) in helping to avoid EGD screening.

Clinical trial registration number

ChiCTR-DDD-17013845.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12072-022-10359-y.

Noninvasive Prediction of Outcomes in Autoimmune Hepatitis-Related Cirrhosis

The value of noninvasive tools in the diagnosis of autoimmune hepatitis (AIH)-related cirrhosis and the prediction of clinical outcomes is largely unknown. We sought to evaluate (1) the utility of liver stiffness measurement (LSM) in the diagnosis of cirrhosis and (2) the performance of the Sixth Baveno Consensus on Portal Hypertension (Baveno VI), expanded Baveno VI, and the ANTICIPATE models in predicting the absence of varices needing treatment (VNT). A multicenter cohort of 132 patients with AIH-related cirrhosis was retrospectively analyzed. LSM and endoscopies performed at the time of cirrhosis diagnosis were recorded. Most of the patients were female (66%), with a median age of 54 years. Only 33%-49% of patients had a LSM above the cutoff points described for the diagnosis of AIH-related cirrhosis (12.5, 14, and 16 kPa). Patients with portal hypertension (PHT) had significantly higher LSM than those without PHT (15.7 vs. 11.7 kPa; P = 0.001), but 39%-52% of patients with PHT still had LSM below these limits. The time since AIH diagnosis negatively correlated with LSM, with longer time being significantly associated with a lower proportion of patients with LSM above these cutoffs. VNT was present in 12 endoscopies. The use of the Baveno VI, expanded Baveno VI criteria, and the ANTICIPATE model would have saved 46%-63% of endoscopies, but the latter underpredicted the risk of VNT. Conclusions: LSM cutoff points do not have a good discriminative capacity for the diagnosis of AIH-related cirrhosis, especially long-term after treatment initiation. Noninvasive tools are helpful to triage patients for endoscopy.

Assessment of clinically significant portal hypertension by two-dimensional shear wave elastography

BACKGROUND AND AIMS

To evaluate two-dimensional shear wave elastography (2DSWE) in parallel with transient elastography (TE) for diagnosing clinically significant portal hypertension (CSPH) and high-risk varices (HRV) in patients with chronic liver disease.

PATIENTS AND METHODS

Consecutive patients with suspicion of compensated advanced chronic liver disease (cACLD) [liver stiffness measurement (LSM) ≥ 10 kPa by TE, or morphological signs suggestive of cACLD on imaging], with no history of liver decompensation, underwent hepatic venous pressure gradient (HVPG) measurement, transjugular liver biopsy and esophagogastroduodenoscopy, which served as the reference methods for diagnosing CSPH, cACLD and HRV. All patients underwent LSM and spleen stiffness measurements (SSM) by 2DSWE and TE.

RESULTS

Seventy-six (76) patients were included (78% men, mean age 62 years, body mass index 28.3 kg/m2 , 36.8% alcoholic, 30.3% non-alcoholic fatty liver disease, 14.5% viral hepatitis). Of them, 80.3%, 69.7%, 52.6% and 22.4% had cACLD, cirrhosis, CSPH and HRV respectively. LSM performed better than SSM in diagnosing CSPH and HRV. For CSPH, AUROCs (0.926 vs. 0.866), optimal cut-offs (20.1 vs. 20.2 kPa) and sensitivity/specificity (80.5%/94.3% vs. 77.5% /86.1%) were comparable for 2DSWE and TE. Ruling-out of CSPH by 2DSWE (LSM at cut-off with ≥90% sensitivity (13.5 kPa) and platelets ≥ 150 x 109 /L) performed comparably to TE, with 1/24 cases falsely classified as negative. For HRV, AUROCs were similar (0.875 2DSWE, 0.851 TE) with similar optimal LSM cut-offs enabling 100% sensitivity and ruling-out HRV.

CONCLUSION

Liver stiffness measurement by 2DSWE appears to perform equally well as TE for diagnosing CSPH and ruling-out HRV in compensated chronic liver disease.

Application of Supersonic Shear Imaging to the Baveno VI Criteria and a Combination Model with Spleen Stiffness Measurement to Rule Out High-Risk Varices in Compensated Advanced Chronic Liver Disease

PURPOSE

Recently, Colecchia et al. reported that by adding a spleen stiffness (SS) criterion sequentially to the Baveno VI criteria, screening endoscopy could be safely avoided. We aimed to compare the Baveno VI criteria, SS values and a sequential combination of the Baveno VI and SS values, measured by supersonic shear imaging (SSI), as approaches for safely avoiding screening endoscopy for high-risk varices (HRV).

MATERIALS AND METHODS

Between April 2017 and July 2018, we enrolled 274 compensated advanced chronic liver disease patients who had successfully undergone liver stiffness (LS) and SS measurements with SSI and esophagogastroduodenoscopy (EGD). 52 HRV patients were included, and we analyzed risk factors for HRV and compared proportions of patients who were spared EGD when Baveno VI criteria, SS cut-off and the combination of the two approaches were used.

RESULTS

The AUROC values for estimating HRV by platelet count, LS and SS were 0.701, 0.757 and 0.844, respectively, and all three measures were found to be independent predictors of HRV. The SS cut-off value for excluding HRV was ≤ 27.3 kPa. The percentages of patients spared EGD were 18.6 % for Baveno VI, 28.8 % for SS cut-off and 36.1 % for the sequential combination of Baveno VI and SS cut-off. Less than 2 % of HRV patients were missed when using all of the criteria.

CONCLUSION

The Baveno VI criteria can be applied to LS measurement by SSI. SS measurement by SSI is an excellent predictor of HRV. Screening endoscopy can be safely avoided when Baveno VI criteria and SS cut-off are applied together.

Validation of Baveno VI and Expanded-Baveno VI Criteria for predicting gastroesophageal varices in patients with alcoholic and non-alcoholic fatty liver disease

Background and aims: Baveno VI and Expanded-Baveno VI Criteria were validated to rule out high-risk esophageal varices (HRV) and to prevent unneeded endoscopies in compensated advanced chronic liver disease (cACLD) mainly related to viral hepatitis. We aim to assess these criteria to rule out low- and high- risk varices in patients with cACLD secondary to alcoholic liver disease (ALD) and non- alcoholic fatty liver disease (NAFLD). Methods: Data were collected retrospectively from 2016 to 2020. Inclusion criteria were: NAFLD and /or ALD related cACLD, a liver stiffness measurement (LSM) ≥ 10 kPa and an esophagogastroduodenoscopy (EGD) within 12 months. Exclusion criteria were: use of non cardioselective β-blockers, hepatic decompensation, previous variceal bleeding, portal thrombosis, liver cancer, or liver transplant. Results: One hundred and ninety-four patients were included in this study. Eighty-one patients (42%) met Baveno VI criteria and 103 (53%) met Expanded-Baveno VI criteria. Baveno VI criteria yielded a high negative predictive value (NPV ≥ 95%) for detecting HRV and varices of any size. Expanded-Baveno VI criteria yielded a high NPV ≥ 95% only for detecting HRV: the miss rate for varices of any size was 8%. Expanded-Baveno VI criteria could avoid more endoscopies than the original Baveno VI criteria to rule out HRV (53% versus 42%). Conclusion: In this study, both criteria showed high NPV to rule out HRV but only original Baveno VI criteria yielded a satisfactory high NPV to rule out varices of any size. Expanded-Baveno VI criteria could avoid more endoscopies to exclude HRV.

Screening and surveillance of oesophageal varices in patients with HCV-positive liver cirrhosis successfully treated by direct-acting antiviral agents

BACKGROUND & AIMS

limited evidence is available to guide hepatologists regarding endoscopic surveillance of oesophageal varices (EV) in Hepatitis C Virus (HCV)-positive cirrhotic patients achieving a sustained virologic response. To address these issues, we conducted a long-term prospective study on 427 HCV-positive cirrhotic patients successfully treated by Direct Antiviral Agents (DAAs).

METHODS

Patients were divided into two groups according to their baseline Baveno VI status: Group 1 (92, 21.5%, favourable Baveno VI status) and Group 2 (335, 78.5%, unfavourable Baveno VI status). Each patient underwent baseline endoscopy and was endoscopically monitored for a median follow-up of 65.2 months according to Baveno VI recommendations.

RESULTS

About 4.3% of Group 1 patients showed baseline EV compared with 30.1% of Group 2 patients (p < .0001). No patients belonging to Group 1 without baseline EV developed EV at follow-up endoscopy compared with 6.5% in Group 2 patients (p = .02); 69/107 (64.5%) patients with baseline EV showed small varices. During the endoscopic follow-up, EV disappeared/improved in 36 (33.6%), were stable in 39 (36.4%) and worsened in 32 (29.9%) patients, all belonging to Group 2 (p = .001). Improvement in Baveno VI status was observed in 118/335 (35.2%, p < .0001) of Group 2 patients and among those without pre-therapy EV, none developed EV throughout the follow-up.

CONCLUSIONS

HCV-positive cirrhotic patients cured by DAAs showing baseline favourable Baveno VI status and no worsening during follow-up can safely avoid endoscopic screening and surveillance. Patients having unfavourable Baveno VI status without baseline EV who improve their status may suspend further endoscopic surveillance.

Noninvasive assessment oesophageal varices: impact of the Baveno VI criteria

PURPOSE OF REVIEW

In 2015, as a consequence of the high development in noninvasive tests, Baveno VI consensus recommended for the first time the use of a prediction rule (liver stiffness <20kPa and platelet count > 150000) to identify patients at low risk of having varices and that could circumvent endoscopy. These became known as the Baveno VI criteria. We review here the data validating Baveno VI criteria and we discuss the attempts of expanding these criteria.

RECENT FINDINGS

We report 28 studies assessing the performance of Baveno VI criteria showing a pooled 99% negative predictive value for ruling out high-risk varices. Performance is not affected by the cause of cirrhosis. Different attempts at expanding these criteria show suboptimal performance. Nonelastography-based criteria require further validation.

SUMMARY

Baveno VI criteria can be safely used to avoid endoscopy in a substantial proportion of patients with compensated cirrhosis. The progressive change in approach to the management of compensated cirrhosis, progressively focusing on treating portal hypertension with beta-blockers independently of the presence of varices, might render these criteria less relevant.

Egyptian revalidation of non-invasive parameters for predicting esophageal varices in cirrhotic patients: A retrospective study

BACKGROUND AND STUDY AIMS

In resource-limited countries, non-invasive tests for assessing liver fibrosis are a potential alternative to costly endoscopic screening for esophageal varices. We aimed to validate several non-invasive parameters for predicting the presence of varices.

PATIENTS AND METHODS

Between September 2006 and August 2017, a total of 46,014 patients who underwent upper gastrointestinal endoscopy as one of the perquisites for receiving hepatitis C virus (HCV) therapy were enrolled and divided into group I (without varices) and group II (with varices). Non-invasive parameters of fibrosis, namely Lok index, Bonacini score, liver stiffness, FIB-4, Baveno, and extended Baveno criteria, were validated.

RESULTS

Lok index, Bonacini score, liver stiffness, and FIB-4 had areas under the receiver operating characteristic curve (AUCs) of >0.6 (all P < 0.01 for the null hypothesis that the AUC was 0.5) for determination of the presence/absence of varices, with cutoff values of 0.80, 6.5, 21.9 kPa, and 2.94, and sensitivities of 74%, 74%, 66%, and 83%, respectively. The expanded Baveno VI criteria performed better than the Baveno VI criteria (spared endoscopy rate 81% versus 63%).

CONCLUSION

The use of non-invasive methods is of limited value in predicting esophageal varices. The limited accuracy of ≤60% may delay the use of appropriate primary prophylaxis against variceal bleeding in a large proportion of cirrhotic patients.

Application of Noninvasive Tools to Decide the Need for Beta-Blockers for Variceal Bleeding Prophylaxis in Compensated Advanced Liver Disease: A Decision Curve Analysis

Background and aims

Noninvasive tools (NITs) reliably categorise patients with compensated advanced chronic liver disease (cACLD) into high-risk and low-risk group for harbouring varices needing treatment. Here, we assess the ability of these NITs to predict the need for nonselective beta-blockers at baseline based on risk of variceal bleeding (VB) on follow-up.

Methods

This was a retrospective multicentre analysis of patients with cACLD categorised at baseline into different risk groups by NITs (Baveno-VI, expanded Baveno-VI, platelet-albumin, platelet-model for end-stage liver disease (MELD) and anticipate study platelet criteria) and by endoscopy (high risk vs low risk/no varices). VB event rates on follow-up were estimated in different risk strata. Decision curve analysis (DCA) was used to estimate the benefit of administering nonselective beta-blockers (NSBB) using NITs over endoscopic classification at different threshold probabilities of VB event rates and estimating the number needed to treat (NNT) to identify one additional bleeder over endoscopy.

Results

A total of 1284 patients (mean age: 44.7 ± 13.5 years, 72.4% males) of hepatitis B (29.2%), nonalcoholic fatty liver disease (24.9%), hepatitis C (20.1%), and alcohol (17.5%)-related cACLD were included with 323 (25.2%) having high-risk varices. Ninety-eight (7.6%) patients developed VB over a median follow-up of 20 (9-35) months. The 1-year and 3-year rate of VB with all NITs was 5.7-7.4% and 13.2-16.4% among high-risk and 0-2.3% and 0-5% among low-risk subgroups, respectively (P < 0.001) in both viral and nonviral aetiologies. Among patients classified as low risk on Baveno-VI criteria, none developed VB on follow-up. At thresholds of <3% event rate of VB, Baveno-VI (NNT-176), platelet-albumin (NNT-576) and anticipate platelet (NNT-233) criteria were superior, whereas endoscopic stratification was superior above this event rate on DCA.

Conclusions

The use of both elastography and blood-based NITs at baseline can accurately identify the need for NSBB for VB prophylaxis in patients of cACLD on follow-up.

Baveno VI criteria as a prognostic factor for clinical complications in patients with compensated cirrhosis

BACKGROUND

Combination of liver stiffness measurement and platelets count is a tool to safely rule out varices needing treatment (VNT) in patients with compensated advanced chronic liver disease (cACLD).

AIMS

to evaluate 4-year liver-related complications and survival in low-risk patients according to Baveno VI criteria.

METHODS

we conducted a monocentric retrospective analysis of prospectively collected data of all consecutive patients, with cirrhosis (LSM≥12.5 kPa) and without previous complication, evaluated between 2012 and 2015. Liver-related complications and survival were compared between 2 groups of patients: favourable (LSM< 20 kPa and platelet count>150.000/mm3) and unfavourable Baveno VI status patients (LSM ≥ 20 kPa or platelet count ≤150.000/mm3).

RESULTS

455 patients with cACLD were analysed. Two hundred patients had favourable Baveno VI criteria, 3.6% with VNT. The 4-year probability of being free of acute decompensation was higher in low-risk patients (94.4 ± 1.8% vs. 85.7%±2.6%, p = 0.018). Unfavourable Baveno status was independently associated with acute decompensation. The probability of being free of HCC was significantly higher in low-risk patients (94.2 ± 1.8% vs. 87.6 ± 2.4%, p = 0.048). Liver-related mortality was not different between the 2 groups (p = 0.56).

CONCLUSION

The Baveno VI criteria could predict clinical outcome in cACLD.

Establishment of a non-invasive prediction model for the risk of oesophageal variceal bleeding using radiomics based on CT

AIM

To establish a non-invasive prediction model for the risk of oesophageal variceal bleeding (OVB) using radiomics based on computed tomography (CT).

MATERIALS AND METHODS

The study included 317 patients, 69 of whom were OVB-positive and 248 were OVB-negative. The OVB was caused by cirrhosis associated with hepatitis B. All patients underwent both oesophagogastroduodenoscopy (OGD) and triple-phase contrast-enhanced CT with spectral imaging mode within 14 days before OGD. The patients were divided chronologically into training (n=222) and validation (n=95) cohorts at a ratio of 7:3. The clinical and CT features were collected from a picture archiving and communication system, and radiomics features were extracted from the portal venous phase CT. Spearman's correlation, least absolute shrinkage, and selection operator regression analyses were used to select the most correlated features. Models were built using the selected features. The predictive performance of the models was evaluated using the area under the receiver operating characteristic curve (AUC).

RESULTS

One clinical feature, five CT features, and three radiomics features were selected, and three non-invasive models were built. Integration of the radiomics, CT, and clinical features model showed a better performance in predicting the risk of OVB, with an AUC of 0.89 (95% confidence interval [CI], 0.84-0.94) in the training dataset and 0.78 (95% CI, 0.68-0.87) in the validation dataset.

CONCLUSION

The combination of radiomics, CT, and clinical features may have added value in the non-invasive prediction of OVB, enabling early prevention and treatment.

Validation of the EVendo score for the prediction of varices in cirrhotic patients

BACKGROUND

Screening endoscopy for varices may be deferred when the calculated EVendo score is ≤3.90. This novel score has not been validated in an external cohort. This study aimed to assess the performance of the EVendo score and compare it with the Baveno VI criteria.

METHODS

We identified and calculated this score in all cirrhotic patients who underwent screening endoscopy for the first time with laboratory tests and liver stiffness measurements within 6 months of the endoscopy date.

RESULTS

In total, 103 patients were included. An EVendo score of ≤3.90 identified patients with no gastroesophageal varices (GEV) and varices needing treatment (VNT) with sensitivities of 82% and 83% and specificities of 57% and 34%, respectively. The negative predictive value for VNT was 94%. A comparison with the Baveno VI criteria in Child-Turcotte-Pugh-A patients showed spared endoscopy and missed VNT rates with EVendo score cutoffs of ≤3.9 and ≤4.5 and the Baveno VI criteria of 25%, 33%, and 16.6% and 1.7%, 1.7%, and 0%, respectively.

CONCLUSIONS

EVendo score is reliable in clinical practice for predicting GEV and VNT. The number of spared endoscopies was higher than that with the Baveno VI criteria; however, there were more missed VNT cases.

Derivation of "Egyptian varices prediction (EVP) index": A novel noninvasive index for diagnosing esophageal varices in HCV Patients

•

Esophageal Varices is one complication of chronic liver disease that leads to deaths globally due to hemorrhage.

•

The prediction of presence the Esophageal Varices is essential to avoid bleeding for patients.

•

Now the only diagnostic method for Esophageal Varices by the upper gastrointestinal endoscopy but it has many disadvantages.

•

Only ten variables are the most significant for diagnosing the varices: PLT, Stiffness, PC, liver texture, spleen, HCV-RNA, Albumin, gender, Total bilirubin, and PV diameter.

•

We Evaluated the effectiveness of several noninvasive markers for predicting Varices.

•

We Introduced a novel (EVP) index with acceptable performance for diagnosing Varices and compared with the exist, it could save operating the upper endoscopic by nearly 46.5%.

Introduction

Esophageal Varices (EVs) is one of the major dangerous complications of liver fibrosis. Upper Gastrointestinal (UGI) Endoscopy is necessary for its diagnosis. Repeated examinations for EVs screening severely burden endoscopic units in terms of cost and other side implications; moreover, the lack of public health resources in rural areas and primary hospitals should be considered, particularly in developing countries. So, an accurate noninvasive marker for EV is highly needed for liver disease patients.

Objectives

This study sought to evaluate the values of several indices to determine how adequate are they in predicting EV and build a novel accurate prediction index.

Methods

Five thousand and thirteen patients were enrolled. The laboratory tests, abdominal ultrasonography, liver stiffness measurement using Fibro-scan, and UGI endoscopy were performed. Ten common indices: Fib-4 score, AST-to-platelet ratio index, Fibrosis index, AST/ALT ratio Varices Prediction Rule, Baveno VI, APRI-Fib4 Combo, King score, “Model for End-Stage Liver Disease”, and Lok Score were calculated. The significant predictors for EVs were identified by using “P-value Correlation-based Filter Selection” method, where a novel Egyptian Varices Prediction (EVP) index was developed using binary logistic regression. The diagnostic performance was evaluated by some parameters and the Area Under Curve (AUC).

Results

EVP Index was correlated to EVs at 0.5; it achieved higher performance (AUC 0.788, accuracy 73.3%, and sensitivity 78%) than the other indices at a cutoff point of 0.423.

Conclusion

EVP Index was a good noninvasive predictor. It had an acceptable performance for diagnosing EVs and it was only required regular laboratory tests and imaging data. It can provide a tool for classifying or arranging the patients according to the degree pre-emptive for selective endoscopy and the degree of severity. Also, it will enable clinicians to concentrate on one marker instead of a wide set of parameters.

Quantification of liver extracellular volume using dual-energy CT for ruling out high-risk varices in cirrhosis

PURPOSE

To determine the performance of quantification of liver extracellular volume fraction (fECV) using dual-energy CT (DECT) compared with CT imaging for ruling out high-riskesophageal varices(HRV) in cirrhotic patients.

METHODS

We retrospectively analyzed 229 cirrhotic patients (training [n = 159] and internal validation cohorts [n = 70]) who underwent dual-source DECT, serum marker assessment, and esophagogastroduodenoscopy (EGD) from 2017 to 2020. The fECV score was measured using iodine maps from 3-minute delayed, equilibrium-phase images at 100/140 Sn kVp. The association of CT parameters and serum markers with HRV was investigated. Criteria combining the fECV score (≤ 25.1%) or CT imaging with platelet count (> 150,000/mm³) were created and compared to rule out HRV.

RESULTS

In the training cohort, the fECV score (odds ratio (OR), 1.20; 95% confidence interval (CI), 1.09, 1.32) and CT imaging (OR, 28.21; 95% CI, 9.31, 85.93) were independent predictors of HRV, along with platelet count (OR, 0.85 and 0.78). Criteria combining the fECV score with platelet count showed significantly better performance than those combining CT imaging with platelet count in ruling out HRV (p < 0.001). Applying the criteria could have safely avoided an additional 10.7% and 8.6% of EGDs in the training and validation cohorts, respectively, achieving a final value of 36.5% and 35.7% spared EGDs (0 HRV missed) compared to CT imaging with platelet count.

CONCLUSIONS

The combined DECT-based fECV score with platelet count is useful for ruling out HRV and can safely avoid more EGDs than CT imaging with platelet count.

Non-invasive diagnosis and follow-up of autoimmune hepatitis

Autoimmune hepatitis (AIH) is a liver disease characterised by necrotico-inflammatory lesions of hepatocytes, the presence of specific autoantibodies and response to corticosteroid treatment. AIH must be considered in any patient with acute or chronic liver disease. As there is no pathognomonic sign of AIH, the diagnosis is based on a combination of clinical, biological, immunological and histological findings, after excluding other causes of liver disease. The clinical and biological presentation of AIH is variable and AIH can be associated with an autoimmune biliary disease, primary biliary cholangitis or primary sclerosing cholangitis in an overlap syndrome. For these reasons, diagnosis of AIH can be challenging. Even if liver histology remains essential in the diagnosis of AIH, non-invasive tests can be used at different steps of the management of AIH: diagnosis of AIH, notably diagnosis of an overlap syndrome, assessment of severity of AIH, searching for extra-hepatic disease frequently associated to AIH, evaluation of response to therapy, decision of treatment withdrawal. This review aims to provide practical guidelines for the use of non-invasive tests for the diagnosis and the follow-up of AIH.

Baveno criteria perform better than expanded Baveno and Rete Sicilia Selezione Terapia-Hepatitis C virus criteria for predicting varices needing treatment

BACKGROUND AND AIMS

Endoscopy is the gold standard for the detection and staging of varices. Baveno, expanded Baveno, and Rete Sicilia Selezione Terapia-hepatitis C virus (RESIST-HCV) criteria predict varices non-invasively in patients with cirrhosis. We assessed the performance of these criteria for predicting varices needing treatment (VNT).

METHODS

Consecutive patients with compensated cirrhosis due to viral etiologies evaluated between January 2014 and May 2017 were included in this retrospective analysis of a prospectively maintained database. VNTs were defined as either large varies or small varices with red color signs on endoscopy. Performance characteristics to predict VNTs were estimated for the three criteria and spared endoscopy rate (SER) and missed VNT rates were determined.

RESULTS

Two hundred and ninety-five treatment-naïve cirrhosis patients, etiology hepatitis B (n = 154) or hepatitis C (n = 141), mean age 43.1 ± 13.2 years, 127 (43.1%) males were included. The median liver stiffness measurement (LSM) and platelet counts were 19.7 (interquartile range [IQR]: 14.8-28.8) kPa and 119 (IQR: 80-160) × 103/mm3, respectively. The SER and missed VNT rates were as follows-for Baveno criteria: 18.3% and 6.2%; expanded Baveno: 35.3% and 29.2%; and for RESIST-HCV criteria: 37.3% and 22.9%. The sensitivity, specificity, positive predictive value, and negative predictive value were 93.7%, 21.9%, 18.9%, and 94.7% for Baveno criteria; 70.8%, 42.3%, 19.3%, and 88.1% for expanded Baveno; and 77.1%, 44.5%, 21.3%, and 90.9% for RESIST-HCV criteria, respectively.

CONCLUSION

Baveno criteria are useful to avoid screening endoscopies in patients with cirrhosis of viral etiologies. In contrast, although expanded Baveno criteria and RESIST-HCV criteria spare more endoscopies, a high missed VNT rate limits their applicability.

Novel albumin, bilirubin and platelet criteria for the exclusion of high-risk varices in compensated advanced chronic liver disease: A validation study

BACKGROUND AND AIMS

Availability of transient elastography (TE) limits the application of Baveno-VI criteria. In a derivation study, the ABP criteria (Albumin >40 g/l, Bilirubin <22 μmol/l and Platelet >114,000/μl) had been shown to perform well in identifying compensated advanced chronic liver disease (cACLD) patients without high-risk varices (HRV). We aim to externally validate this novel ABP criteria for the exclusion of HRVs among cACLD patients.

METHODS

Data was retrospectively collected from consecutive cACLD patients with paired TE and esophagogastroduodenoscopy (EGD) performed between 2011 and 2017 in Changi General Hospital, Singapore. We estimate the discriminative ability of ABP criteria in validation cohort using AUROC and calibration-in-the-large. We subsequently compare the performance between ABP and Baveno-VI criteria in the validation cohort.

RESULTS

Among 314 patients included in our validation cohort, 32 (10.2%) had HRV on screening EGD. Application of ABP criteria within this validation cohort has increased discriminative ability than the derivation cohort. The AUROC of validation and derivation cohort were 0.68 (0.60-0.76) and 0.66 (0.60-0.76), respectively. The mean and standard error for calibration-in-the-large and calibration slope were -0.08 (0.22) and 0.93 (0.26) respectively. The ABP criteria had excellent performance in excluding HRV and will spare more screening EGDs than the Baveno-VI criteria (39.2% vs 27.4%, p < 0.001), without missing more HRVs.

CONCLUSION

We validated the performance of ABP criteria for the exclusion of HRVs in cACLD patients. ABP criteria is superior to Baveno-VI criteria by sparing more screening EGD without the need of TE.

Dual-energy computed tomography for non-invasive prediction of the risk of oesophageal variceal bleeding with hepatitis B cirrhosis

OBJECTIVE

Oesophageal variceal bleeding (OVB) is a fatal complication of cirrhosis and/or portal hypertension. We aimed to develop a non-invasive prediction model for the risk of OVB using dual-energy computed tomography (CT).

METHODS

317 oesophageal varices (OV) patients with hepatitis B virus-related cirrhosis were retrospectively assessed from January 2018 to December 2018. All patients underwent dual-energy CT scans within 14 days before endoscopy. 222 of 317 patients (174 OVB-negative patients and 48 OVB-positive patients) were included in the training cohort and 95 patients (74 OVB-negative patients and 21 OVB-positive patients) were included in the validation cohort chronologically. A model with the selected conventional CT features and a model with the conventional CT and dual-energy CT features were developed. The prediction accuracy was evaluated using the receiver operating characteristic (ROC) curve. The accuracy and reproducibility of the models for OVB risk prediction of cirrhosis were validated by the validation cohort. The areas under the curve (AUC) of the two models were compared with Delong test.

RESULTS

Diameter of oesophageal vein (OV(mm)), diameter of splenic vein (SPV(mm)), ascites (AS), iodine concentration in short gastric vein (SGV(HU)), iodine concentration in spleen (SP(HU)) were independent predictors of OVB risk (P < 0.05). Then, we developed a model with the selected conventional CT features [OV(mm), SPV(mm), AS] and a model with the conventional CT and dual-energy CT features [OV(mm), SPV(mm), AS, SGV(HU), SP(HU)]. The AUCs of the model built with the conventional CT and dual-energy CT features were higher than the model built only with the conventional CT features in the training (0.839 vs 0.809) and validation cohorts (0.798 vs 0.738).

CONCLUSION

The non-invasive prediction model developed with the conventional CT and dual-energy CT features may have added value in noninvasively predicting OVB than the model built only with the conventional CT features and may have significant clinical implications on early prevention and treatment of OVB.

ADVANCES IN KNOWLEDGE

Combination of dual-energy CT with conventional CT may have added value for non-invasive prediction of OVB compared to conventional CT.

Development and validation of a nomogram for predicting varices needing treatment in compensated advanced chronic liver disease: A multicenter study

BACKGROUND

Only a small proportion of patients with compensated advanced chronic liver disease (cACLD) had varices needing treatment (VNT) after recommended esophagogastroduodenoscopy (EGD) screening. We aimed to create a non-invasive nomogram based on routine tests to detect VNT in cACLD patients.

METHODS

The training cohort included 162 cACLD patients undergoing EGD in a university hospital, between January 2014 and September 2019. A nomogram was developed based on the independent predictors of VNT, selected using a multivariate logistic regression analysis. Thirty-three patients from eight university hospitals were prospectively enrolled as validation cohort between December 2018 and December 2019.

RESULTS

The prevalence of VNT was 32.7% (53/162) and 39.4% (13/33) in training and validation cohorts, respectively. The univariate analysis identified six risk factors for VNT. On the multivariate analysis, four of them, i.e., gallbladder wall thickness (odds ratio [OR]: 1.23; 95% confidence interval [CI]: 0.98-1.56), spleen diameter (OR: 1.02; 95% CI: 1.00-1.04), platelet count (OR: 0.98; 95% CI: 0.97-0.99), and international normalized ratio (OR: 0.58; 95% CI: 0.06-5.84) were independently associated with VNT. Thus, a nomogram based on the four above - mentioned variables was developed, and showed a favorable performance for detecting VNT, with an area under receiver operating characteristic curve of 0.848 (95% CI: 0.769-0.927) in training cohort. By applying a cut-off value of 105 in validation cohort, 31.0% of EGD were safely spared with 3.4% of missed VNT.

CONCLUSION

A nomogram based on routine clinical parameters was developed for detecting VNT and avoiding unnecessary EGD in cACLD patients.

Accuracy of non-invasive methods/models for predicting esophageal varices in patients with compensated advanced chronic liver disease secondary to nonalcoholic fatty liver disease

INTRODUCTION

Nonalcoholic fatty liver disease (NAFLD) patients can progress to cirrhosis. In these, there is a compensated stage in which esophageal varices can exist. However, no more than 20% of these patients have varices needing treatment (VNT).

OBJECTIVE

Evaluate the accuracy of non-invasive models to predict esophageal varices, as well as their performance to avoid esophagogastroduodenoscopy (EGD) with a risk of missing VNT of less than 5%, in Brazilian patients with compensated advanced chronic liver disease (cACLD) secondary to NAFLD.

METHODS

Twenty-one patients with biopsy-proven cACLD secondary to NAFLD were submitted to liver stiffness measurement (LSM) by transient elastography (TE), and data were collected to measure platelet count/spleen diameter ratio (PSR), LSM-spleen diameter to platelet ratio score (LSPS), varices risk score (VRS), Baveno VI, Expanded Baveno VI and NAFLD cirrhosis criteria.

RESULTS

The mean age was 61 (±6.6) years, and 81% were female; 14% presented VNT. For detection of VNT, LSPS and VRS performed excellently, with an area under receiver operating characteristic (AUROC) of 0.961 for both. LSM presented an AUROC of 0.889 and a cutoff point of 21.8 kPa. LSPS and VRS enabled sparing 75-80% of EGDs for VNT, with no risk of missing varices. Expanded Baveno VI enabled sparing 71% of EGDs, with 4.8% risk of missing VNT.

CONCLUSION

LSPS and VRS performed excellently in both predicting VNT and sparing EGD, and Expanded Baveno VI showed good performance in sparing EGDs, with acceptable risk of missing VNT. An LSM cutoff point was established and had good performance.

Development of a machine learning model to predict bleed in esophageal varices in compensated advanced chronic liver disease: A proof of concept

BACKGROUND AND AIM

Risk stratification beyond the endoscopic classification of esophageal varices (EVs) to predict first episode of variceal bleeding (VB) is currently limited in patients with compensated advanced chronic liver disease (cACLD). We aimed to assess if machine learning (ML) could be used for predicting future VB more accurately.

METHODS

In this retrospective analysis, data from patients of cACLD with EVs, laboratory parameters and liver stiffness measurement (LSM) were used to generate an extreme-gradient boosting (XGBoost) algorithm to predict the risk of VB. The performance characteristics of ML and endoscopic classification were compared in internal and external validation cohorts. Bleeding rates were estimated in subgroups identified upon risk stratification with combination of model and endoscopic classification.

RESULTS

Eight hundred twenty-eight patients of cACLD with EVs, predominantly related to non-alcoholic fatty liver disease (28.6%), alcohol (23.7%) and hepatitis B (23.1%) were included, with 455 (55%) having the high-risk varices. Over a median follow-up of 24 (12-43) months, 163 patients developed VB. The accuracy of machine learning (ML) based model to predict future VB was 98.7 (97.4-99.5)%, 93.7 (88.8-97.2)%, and 85.7 (82.1-90.5)% in derivation (n = 497), internal validation (n = 149), and external validation (n = 182) cohorts, respectively, which was better than endoscopic classification [58.9 (55.5-62.3)%] alone. Patients stratified high risk on both endoscopy and model had 1-year and 3-year bleeding rates of 31-43% and 64-85%, respectively, whereas those stratified as low risk on both had 1-year and 3-year bleeding rates of 0-1.6% and 0-3.4%, respectively. Endoscopic classification and LSM were the major determinants of model's performance.

CONCLUSION

Application of ML model improved the performance of endoscopic stratification to predict VB in patients with cACLD with EVs.