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He R, Liu C, Grgurevic I, Guo Y, Xu H, Liu J, Liu Y, Wang X, Shi H, Madir A, Podrug K, Zhu Y, Hua Y, Wang K, Wen J, Su M, Zhang Q, Li J, Qi X. Validation of Baveno VII criteria for clinically significant portal hypertension by two-dimensional shear wave elastography. Hepatol Int 2024; 18:1020-1028. [PMID: 38740698 DOI: 10.1007/s12072-024-10657-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Accepted: 02/02/2024] [Indexed: 05/16/2024]
Abstract
BACKGROUND The Baveno VII consensus proposed criteria for the non-invasively diagnosis of clinically significant portal hypertension (CSPH) in patients with compensated advanced chronic liver disease (cACLD). The performance of Baveno VII criteria for assessing CSPH by two-dimensional shear wave elastography (2D-SWE) had not been well validated. We aimed to validate the performance of Baveno VII criteria for rule-in and rule-out CSPH by 2D-SWE. METHOD This is an international multicenter study including cACLD patients from China and Croatia with paired liver stiffness measurement (LSM), spleen stiffness measurement (SSM) by 2D-SWE, and hepatic venous pressure gradient (HVPG) were included. CSPH was defined as HVPG ≥ 10 mmHg. RESULT A total of 146 patients with cACLD were enrolled, and finally 118 patients were included in the analysis. Among them, CSPH was documented in 79 (66.9%) patients. Applying the Baveno VII criteria for rule-out CSPH by 2D-SWE, [LSM ≤ 15 kPa and platelet count ≥ 150 × 109/L] OR SSM < 21 kPa, could exclude CSPH with sensitivity > 90% (93.5 or 98.7%) but negative predictive value < 90% (74.1 or 85.7%). Using the Baveno VII criteria for rule-in CSPH by 2D-SWE, LSM ≥ 25 kPa OR SSM ≥ 50 kPa, could diagnose CSPH with 100% specificity and 100% positive predictive values. CONCLUSION Baveno VII criteria by 2D-SWE showed a good diagnostic performance for ruling in but not for ruling out CSPH, which might become an emerging non-invasive elastography tool to select the patients who needed non-selective beta blocker therapy.
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Affiliation(s)
- Ruiling He
- Department of Ultrasound, Donggang Branch of the First Hospital of Lanzhou University, Lanzhou, China
- The First Clinical Medical College of Lanzhou University, Lanzhou, China
| | - Chuan Liu
- Center of Portal Hypertension, Department of Radiology, Zhongda Hospital, Medical School, Southeast University, Nurturing Center of Jiangsu Province for State Laboratory of AI Imaging & Interventional Radiology (Southeast University), Nanjing, China
- Basic Medicine Research and Innovation Center of Ministry of Education, Zhongda Hospital, Southeast University; State Key Laboratory of Digital Medical Engineering, Nanjing, China
| | - Ivica Grgurevic
- Department of Gastroenterology, Hepatology and Clinical Nutrition, School of Medicine and Faculty of Pharmacy and Biochemistry, University Hospital Dubrava, University of Zagreb, Zagreb, Croatia
| | - Ying Guo
- Department of Hepatology, The Third People's Hospital of Taiyuan, Taiyuan, China
| | - Huixiong Xu
- Department of Ultrasound, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Jiacheng Liu
- Department of Infectious Diseases, Affiliated Hospital of Medical School, Nanjing Drum Tower Hospital, Nanjing University, Nanjing, China
| | - Yunfang Liu
- Department of Hepatology, The Third People's Hospital of Taiyuan, Taiyuan, China
| | - XiaoYan Wang
- Department of Hepatology, The Third People's Hospital of Taiyuan, Taiyuan, China
| | - Hongmei Shi
- Department of Ultrasound, The Third People's Hospital of Taiyuan, Taiyuan, China
| | - Anita Madir
- 4-University Hospital Dubrava, Zagreb, Croatia
| | - Kristian Podrug
- Department of Gastroenterology and Hepatology, University Hospital Center Split, Split, Croatia
| | - Yuli Zhu
- Department of Ultrasound, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Yongli Hua
- Department of Hepatology, The Third People's Hospital of Taiyuan, Taiyuan, China
| | - Kun Wang
- Department of Hepatology, The Third People's Hospital of Taiyuan, Taiyuan, China
| | - Jing Wen
- Department of Hepatology, The Third People's Hospital of Taiyuan, Taiyuan, China
| | - Meiqin Su
- Department of Ultrasound, The Third People's Hospital of Taiyuan, Taiyuan, China
| | - Qun Zhang
- Department of Infectious Disease, Zhongda Hospital, Medical School, Southeast University, Nanjing, China
| | - Jie Li
- Department of Infectious Diseases, Affiliated Hospital of Medical School, Nanjing Drum Tower Hospital, Nanjing University, Nanjing, China.
| | - Xiaolong Qi
- The First Clinical Medical College of Lanzhou University, Lanzhou, China.
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Celsa C, Veneziano M, Di Giorgio FM, Cannova S, Lombardo A, Errigo E, Landro G, Simone F, Sinagra E, Calvaruso V. Non-Invasive Diagnostic Tests for Portal Hypertension in Patients with HBV- and HCV-Related Cirrhosis: A Comprehensive Review. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:690. [PMID: 38792873 PMCID: PMC11123262 DOI: 10.3390/medicina60050690] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/18/2024] [Revised: 04/10/2024] [Accepted: 04/17/2024] [Indexed: 05/26/2024]
Abstract
Clinically significant portal hypertension (CSPH) in patients with compensated advanced chronic liver disease indicates an increased risk of decompensation and death. While invasive methods like hepatic venous-portal gradient measurement is considered the gold standard, non-invasive tests (NITs) have emerged as valuable tools for diagnosing and monitoring CSPH. This review comprehensively explores non-invasive diagnostic modalities for portal hypertension, focusing on NITs in the setting of hepatitis B and hepatitis C virus-related cirrhosis. Biochemical-based NITs can be represented by single serum biomarkers (e.g., platelet count) or by composite scores that combine different serum biomarkers with each other or with demographic characteristics (e.g., FIB-4). On the other hand, liver stiffness measurement and spleen stiffness measurement can be assessed using a variety of elastography techniques, and they can be used alone, in combination with, or as a second step after biochemical-based NITs. The incorporation of liver and spleen stiffness measurements, alone or combined with platelet count, into established and validated criteria, such as Baveno VI or Baveno VII criteria, provides useful tools for the prediction of CSPH and for ruling out high-risk varices, potentially avoiding invasive tests like upper endoscopy. Moreover, they have also been shown to be able to predict liver-related events (e.g., the occurrence of hepatic decompensation). When transient elastography is not available or not feasible, biochemical-based NITs (e.g., RESIST criteria, that are based on the combination of platelet count and albumin levels) are valid alternatives for predicting high-risk varices both in patients with untreated viral aetiology and after sustained virological response. Ongoing research should explore novel biomarkers and novel elastography techniques, but current evidence supports the utility of routine blood tests, LSM, and SSM as effective surrogates in diagnosing and staging portal hypertension and predicting patient outcomes.
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Affiliation(s)
- Ciro Celsa
- Gastroenterology and Hepatology Unit, Department of Health Promotion, Mother & Child Care, Internal Medicine & Medical Specialties, University of Palermo, 90127 Palermo, Italy; (M.V.); (F.M.D.G.); (S.C.); (A.L.); (E.E.); (G.L.); (F.S.); (V.C.)
- Department of Surgery & Cancer, Imperial College London, Hammersmith Hospital, London W12 0NN, UK
| | - Marzia Veneziano
- Gastroenterology and Hepatology Unit, Department of Health Promotion, Mother & Child Care, Internal Medicine & Medical Specialties, University of Palermo, 90127 Palermo, Italy; (M.V.); (F.M.D.G.); (S.C.); (A.L.); (E.E.); (G.L.); (F.S.); (V.C.)
| | - Francesca Maria Di Giorgio
- Gastroenterology and Hepatology Unit, Department of Health Promotion, Mother & Child Care, Internal Medicine & Medical Specialties, University of Palermo, 90127 Palermo, Italy; (M.V.); (F.M.D.G.); (S.C.); (A.L.); (E.E.); (G.L.); (F.S.); (V.C.)
| | - Simona Cannova
- Gastroenterology and Hepatology Unit, Department of Health Promotion, Mother & Child Care, Internal Medicine & Medical Specialties, University of Palermo, 90127 Palermo, Italy; (M.V.); (F.M.D.G.); (S.C.); (A.L.); (E.E.); (G.L.); (F.S.); (V.C.)
| | - Antonino Lombardo
- Gastroenterology and Hepatology Unit, Department of Health Promotion, Mother & Child Care, Internal Medicine & Medical Specialties, University of Palermo, 90127 Palermo, Italy; (M.V.); (F.M.D.G.); (S.C.); (A.L.); (E.E.); (G.L.); (F.S.); (V.C.)
| | - Emanuele Errigo
- Gastroenterology and Hepatology Unit, Department of Health Promotion, Mother & Child Care, Internal Medicine & Medical Specialties, University of Palermo, 90127 Palermo, Italy; (M.V.); (F.M.D.G.); (S.C.); (A.L.); (E.E.); (G.L.); (F.S.); (V.C.)
| | - Giuseppe Landro
- Gastroenterology and Hepatology Unit, Department of Health Promotion, Mother & Child Care, Internal Medicine & Medical Specialties, University of Palermo, 90127 Palermo, Italy; (M.V.); (F.M.D.G.); (S.C.); (A.L.); (E.E.); (G.L.); (F.S.); (V.C.)
| | - Fabio Simone
- Gastroenterology and Hepatology Unit, Department of Health Promotion, Mother & Child Care, Internal Medicine & Medical Specialties, University of Palermo, 90127 Palermo, Italy; (M.V.); (F.M.D.G.); (S.C.); (A.L.); (E.E.); (G.L.); (F.S.); (V.C.)
| | - Emanuele Sinagra
- Gastroenterology and Endoscopy Unit, Fondazione Istituto G. Giglio, 90015 Cefalù, Italy;
| | - Vincenza Calvaruso
- Gastroenterology and Hepatology Unit, Department of Health Promotion, Mother & Child Care, Internal Medicine & Medical Specialties, University of Palermo, 90127 Palermo, Italy; (M.V.); (F.M.D.G.); (S.C.); (A.L.); (E.E.); (G.L.); (F.S.); (V.C.)
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Vanderschueren E, Armandi A, Kwanten W, Cassiman D, Francque S, Schattenberg JM, Laleman W. Spleen Stiffness-Based Algorithms Are Superior to Baveno VI Criteria to Rule Out Varices Needing Treatment in Patients With Advanced Chronic Liver Disease. Am J Gastroenterol 2024:00000434-990000000-01023. [PMID: 38502095 DOI: 10.14309/ajg.0000000000002708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Accepted: 01/23/2024] [Indexed: 03/20/2024]
Abstract
INTRODUCTION The Baveno VI criteria have set the stage for noninvasive assessment of compensated advanced chronic liver disease (ACLD). The algorithm combining liver stiffness measurement (LSM, <20 kPa) and platelet count (>150,000/μL) safely avoids screening endoscopy for varices needing treatment (VNT) but identifies only a relatively low number of patients. We aimed to evaluate the value of spleen stiffness measurement (SSM) using spleen-dedicated elastography in ruling out VNT. METHODS In this real-life multicenter retrospective derivation-validation cohort, all consecutive patients with ACLD (defined by LSM ≥10 kPa) with available upper endoscopy, laboratory results, spleen diameter, LSM, and SSM measured with spleen-dedicated transient elastography were included. VNT were defined as medium-to-large varices or small varices with red spots. RESULTS In the derivation cohort (n = 201, 11.9% VNT), SSM demonstrated excellent capability at identifying VNT (area under the receiver operating characteristic curve [AUROC] 0.88), outperforming LSM (AUROC 0.77, P = 0.03) and platelets (AUROC 0.73, P = 0.002). In comparison with Baveno VI criteria (33.8% spared endoscopies), the sequential Baveno VI plus SSM and a novel spleen size and stiffness model were able to increase the number of patients avoiding endoscopy (66.2% and 71.1%, respectively) without missing more than 5% of VNT. These findings were confirmed in an external validation cohort of patients with more advanced liver disease (n = 176, 34.7% VNT) in which the number of spared endoscopies tripled (27.3% and 31.3% for SSM-based algorithms) compared with Baveno VI criteria (8.5%). DISCUSSION Spleen stiffness-based algorithms are superior to Baveno VI criteria in ruling out VNT in patients with ACLD and double the number of patients avoiding screening endoscopy.
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Affiliation(s)
- Emma Vanderschueren
- Department of Gastroenterology and Hepatology, University Hospital Leuven, Leuven, Belgium
- Department of Chronic Diseases, Metabolism and Aging (CHROMETA), Catholic University of Leuven, Leuven, Belgium
| | - Angelo Armandi
- Metabolic Liver Disease Research Program, I Department of Internal Medicine, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
- Division of Gastroenterology and Hepatology, Department of Medical Sciences, University of Turin, Turin, Italy
| | - Wilhelmus Kwanten
- Laboratory of Experimental Medicine and Paediatrics (LEMP), University of Antwerp (UA), Antwerp, Belgium
- Department of Gastroenterology & Hepatology, University Hospital Antwerp, Antwerp, Belgium
| | - David Cassiman
- Department of Gastroenterology and Hepatology, University Hospital Leuven, Leuven, Belgium
- Department of Chronic Diseases, Metabolism and Aging (CHROMETA), Catholic University of Leuven, Leuven, Belgium
| | - Sven Francque
- Laboratory of Experimental Medicine and Paediatrics (LEMP), University of Antwerp (UA), Antwerp, Belgium
- Department of Gastroenterology & Hepatology, University Hospital Antwerp, Antwerp, Belgium
| | - Jörn M Schattenberg
- Department of Internal Medicine, Saarland University Medical Center, Homburg, Germany
| | - Wim Laleman
- Department of Gastroenterology and Hepatology, University Hospital Leuven, Leuven, Belgium
- Department of Chronic Diseases, Metabolism and Aging (CHROMETA), Catholic University of Leuven, Leuven, Belgium
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Liu J, Xu H, Liu W, Zu H, Ding H, Meng F, Zhang J. Spleen stiffness determined by spleen-dedicated device accurately predicted esophageal varices in cirrhosis patients. Ther Adv Chronic Dis 2023; 14:20406223231206223. [PMID: 37928628 PMCID: PMC10623997 DOI: 10.1177/20406223231206223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Accepted: 09/19/2023] [Indexed: 11/07/2023] Open
Abstract
Background The advantages of spleen stiffness in prediction of high-risk varices (HRV) in cirrhosis patients have been confirmed. Recently, a new device utilizing a 100 Hz probe dedicated to spleen stiffness measurement (SSM) was developed. Objectives To validate the clinical applicability of SSM@100 Hz in predicting HRV by comparing it with other non-invasive tests (NITs). Design A prospective cohort study. Methods A total of 171 cirrhosis patients who underwent esophagogastroduodenoscopy (EGD) examination were included in this study. SSM using a 100 Hz probe and liver stiffness measurement using a 50 Hz probe were performed. Additionally, 22 healthy controls underwent spleen stiffness evaluation using the 100 Hz probe. Results The failure rates of spleen stiffness examination in patients with cirrhosis and in healthy controls were 2.9% and 4.5%, respectively. The means of SSM values were 56.4 ± 21.6 and 13.8 ± 6.7 kPa in cirrhosis and controls. SSM increased proportionally with the severity of esophageal varices. The area under receiver operating characteristic (ROC) for spleen stiffness in predicting HRV was 0.881 (95% confidence interval 0.829-0.934), with a cutoff value of 43.4 kPa. The accuracy, false negative rate and EGD spare rate were 86.5%, 2.5% and 24.3%, respectively. For HRV prediction, SSM was comparable to expanded Baveno VI and VII and superior to other NITs. As to viral versus non-viral cirrhosis and compensated versus decompensated cirrhosis, the cut-off and performance of SSM were different. Conclusion SSM@100 Hz demonstrates high accuracy in predicting HRV with a low missed HRV rate. Our findings suggest that SSM@100 Hz can be used independently due to its simplicity and effectiveness. However, further studies are needed to determine appropriate cutoff values based on the cause of cirrhosis and liver function. Trail Registration ChiCTR2300070270.
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Affiliation(s)
- Jiqing Liu
- Beijing Youan Hospital, Capital Medical University, Beijing, China
- The Fourth People’s Hospital of Qinghai Province, Xining, Qinghai, China
| | - Hangfei Xu
- Beijing Youan Hospital, Capital Medical University, Beijing, China
- Beijing Institute of Hepatology, Beijing Youan Hospital, Capital Medical University, Beijing, China
| | - Weiyuan Liu
- Beijing Youan Hospital, Capital Medical University, Beijing, China
| | - Hongmei Zu
- The Fourth People’s Hospital of Qinghai Province, Xining, Qinghai, China
| | - Huiguo Ding
- Beijing Youan Hospital, Capital Medical University, Beijing, China
| | - Fankun Meng
- Beijing Youan Hospital, Capital Medical University, Beijing, China
| | - Jing Zhang
- Department of Hepatology, Beijing YouAn Hospital, Capital Medical University, No.8, Youanmenwai Street, Fengtai District, Beijing 100069, China
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Elbasiony M, Abed H, Alaskalany HM, Saleh A. Transient elastography and platelet count as noninvasive predictors of gastroesophageal varices in patients with compensated hepatitis C virus-related liver cirrhosis. Med J Armed Forces India 2023; 79:710-717. [PMID: 37981928 PMCID: PMC10654393 DOI: 10.1016/j.mjafi.2021.08.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2021] [Accepted: 08/15/2021] [Indexed: 11/20/2022] Open
Abstract
Background Early detection of esophageal varices (EV) before the first attack of bleeding is crucial for primary prophylaxis. The current work aims to investigate the use of a combination of FibroScan and platelet count as noninvasive means to identify EV in patients with compensated cirrhosis. Methods Sixty-two patients with compensated hepatitis C virus (HCV)-related cirrhosis were divided into two groups with and without EV. All patients were exposed to complete history, physical examination, laboratory, and endoscopic evaluation. FibroScan was performed for all patients, and the two groups were compared. Results A statistically significant higher mean liver stiffness measurement (LSM) (KPa), lower mean platelet count to splenic diameter ratio (PSR), and higher mean fibrosis-4 (FIB4) score were noticed in those with EV with P < 0.0005. A cutoff value of ≥23.1 for LSM, ≥3.71 for FIB4, and ≥130 mm for splenic diameter have a sensitivity of 94%, 97%, and 97% and a specificity of 81%, 81%, and 68%, respectively, in the detection of varices. Platelet count of ≥112,500 (×103/dl) and of ≥771.33 for PSR have a sensitivity of 84% and 77% and a specificity of 87% and 90%, respectively, to rule out the presence of varices. LSM, FIB4 score, and splenic diameter are predictors of the presence of varices where platelet count and PSR are negative predictors. Conclusion The combination of LSM by transient elastography (TE), PSR, or platelet count can be used to detect a relevant category of patients with compensated cirrhosis who have a very low possibility of EV where endoscopy can be avoided.
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Affiliation(s)
- Mohamed Elbasiony
- Department of Internal Medicine, Hepatology & Gastroenterology Unit, Faculty of Medicine, Mansoura University, Egypt
| | - Hassan Abed
- Nabaroh Central Hospital, Ministry of Health, Egypt
| | - Hassan M. Alaskalany
- Department of Internal Medicine, Hepatology & Gastroenterology Unit, Faculty of Medicine, Mansoura University, Egypt
| | - Ahmed Saleh
- Department of Internal Medicine, Hepatology & Gastroenterology Unit, Faculty of Medicine, Mansoura University, Egypt
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Gaspar R, Silva M, Cardoso P, Goncalves R, Andrade P, Macedo G. Spleen stiffness: a new tool to predict high-risk varices in cirrhotic patients. J Gastroenterol Hepatol 2023; 38:1840-1846. [PMID: 37655720 DOI: 10.1111/jgh.16344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Revised: 07/23/2023] [Accepted: 08/18/2023] [Indexed: 09/02/2023]
Abstract
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.
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Affiliation(s)
- Rui Gaspar
- Gastroenterology Department, Centro Hospitalar São João, Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Marco Silva
- Gastroenterology Department, Centro Hospitalar São João, Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Pedro Cardoso
- Gastroenterology Department, Centro Hospitalar São João, Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Raquel Goncalves
- Gastroenterology Department, Centro Hospitalar São João, Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Patrícia Andrade
- Gastroenterology Department, Centro Hospitalar São João, Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Guilherme Macedo
- Gastroenterology Department, Centro Hospitalar São João, Faculty of Medicine of the University of Porto, Porto, Portugal
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Zhang X, Wang H, Xie X, Song J, Zhang Y, Zhou D, Wu Q, Tai J, Huang J, Cheng X, Li J, Gu Y, Chen J. Outstanding feasibility of spleen stiffness measurement by 100-Hz vibration-controlled transient elastography. JGH Open 2023; 7:387-392. [PMID: 37265926 PMCID: PMC10230108 DOI: 10.1002/jgh3.12904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Revised: 12/23/2022] [Accepted: 04/11/2023] [Indexed: 06/03/2023]
Abstract
This novel spleen-dedicated FibroScan has high success rate and is easy to operate. The spleen stiffness is correlated with liver stiffness, which reflects the liver fibrosis stage. However, whether SSM is able to reflect the severity of liver disease warrants further observation.
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Affiliation(s)
- Xiaofeng Zhang
- Hepatology Unit, Department of Infectious Diseases, Nanfang HospitalSouthern Medical UniversityGuangzhouChina
- Department of Hepatology, Zengcheng Branch, Nanfang HospitalSouthern Medical UniversityGuangzhouChina
| | - Haiyu Wang
- Hepatology Unit, Department of Infectious Diseases, Nanfang HospitalSouthern Medical UniversityGuangzhouChina
| | - Xinpeng Xie
- Hepatology Unit, Department of Infectious Diseases, Nanfang HospitalSouthern Medical UniversityGuangzhouChina
- Department of Equipment information, Zengcheng Branch, Nanfang HospitalSouthern Medical UniversityGuangzhouChina
| | - Jiankang Song
- Hepatology Unit, Department of Infectious Diseases, Nanfang HospitalSouthern Medical UniversityGuangzhouChina
| | - Yuanjian Zhang
- Hepatology Unit, Department of Infectious Diseases, Nanfang HospitalSouthern Medical UniversityGuangzhouChina
| | - Damei Zhou
- Hepatology Unit, Department of Infectious Diseases, Nanfang HospitalSouthern Medical UniversityGuangzhouChina
- Department of Hepatology, Zengcheng Branch, Nanfang HospitalSouthern Medical UniversityGuangzhouChina
| | - Qiaoping Wu
- Hepatology Unit, Department of Infectious Diseases, Nanfang HospitalSouthern Medical UniversityGuangzhouChina
| | - Jiaoyu Tai
- Hepatology Unit, Department of Infectious Diseases, Nanfang HospitalSouthern Medical UniversityGuangzhouChina
- Department of Hepatology, Zengcheng Branch, Nanfang HospitalSouthern Medical UniversityGuangzhouChina
| | - Jing Huang
- Hepatology Unit, Department of Infectious Diseases, Nanfang HospitalSouthern Medical UniversityGuangzhouChina
- Department of Hepatology, Zengcheng Branch, Nanfang HospitalSouthern Medical UniversityGuangzhouChina
| | - Xiao Cheng
- Hepatology Unit, Department of Infectious Diseases, Nanfang HospitalSouthern Medical UniversityGuangzhouChina
- Department of Hepatology, Zengcheng Branch, Nanfang HospitalSouthern Medical UniversityGuangzhouChina
| | - Junying Li
- Hepatology Unit, Department of Infectious Diseases, Nanfang HospitalSouthern Medical UniversityGuangzhouChina
- Department of Hepatology, Zengcheng Branch, Nanfang HospitalSouthern Medical UniversityGuangzhouChina
| | - Yixiu Gu
- Hepatology Unit, Department of Infectious Diseases, Nanfang HospitalSouthern Medical UniversityGuangzhouChina
| | - Jinjun Chen
- Hepatology Unit, Department of Infectious Diseases, Nanfang HospitalSouthern Medical UniversityGuangzhouChina
- Department of Hepatology, Zengcheng Branch, Nanfang HospitalSouthern Medical UniversityGuangzhouChina
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Odriozola A, Puente Á, Cuadrado A, Iruzubieta P, Arias-Loste MT, Redondo C, Rivas C, Fábrega E, Crespo J, Fortea JI. High accuracy of spleen stiffness measurement in diagnosing clinically significant portal hypertension in metabolic-associated fatty liver disease. Liver Int 2023. [PMID: 36912787 DOI: 10.1111/liv.15561] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2022] [Revised: 03/01/2023] [Accepted: 03/03/2023] [Indexed: 03/14/2023]
Abstract
BACKGROUND AND AIMS Spleen stiffness measurement (SSM) by vibration-controlled transient elastography (VCTE) has been tested in a limited number of studies versus hepatic venous pressure gradient (HVPG), especially with the 100 Hz spleen-specific module. The current study aims to evaluate the diagnostic performance of this novel module for detecting clinically significant portal hypertension (CSPH) in a cohort of compensated patients with metabolic-associated fatty liver disease (MAFLD) as the main aetiology and to improve the performance of the Baveno VII criteria for CSPH diagnosis by including SSM. METHODS This is a retrospective single-centre study including patients with available measurements of HVPG, Liver stiffness measurement (LSM) and SSM by VCTE with the 100 Hz module. Area under the receiver operating characteristic (AUROC) curve analysis was conducted to identify dual cut-offs (rule-out and rule-in) associated with the absence/presence of CSPH. The diagnostic algorithms were adequate if negative predictive value (NPV) and positive predictive values (PPV) were >90%. RESULTS A total of 85 patients were included, 60 MAFLD and 25 non-MAFLD. SSM showed a good correlation with HVPG (MAFLD: r = .74; p < .0001; non-MAFLD: r = .62; p < .0011). In MAFLD patients, SSM had a high accuracy in discarding/diagnosing CSPH (cut-off values of <40.9 and >49.9 kPa, AUC 0.95). The addition of these cut-offs in a sequential or combined approach to the Baveno VII criteria significantly reduced the grey zone (60% vs. 15%-20%), while maintaining adequate NPV and PPV. CONCLUSIONS Our findings support the utility of SSM for diagnosing CSPH in MAFLD patients and demonstrate that the addition of SSM to the Baveno VII criteria increases accuracy.
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Affiliation(s)
- Aitor Odriozola
- Gastroenterology and Hepatology Department, Clinical and Translational Research in Digestive Diseases, Valdecilla Research Institute (IDIVAL), Marqués de Valdecilla University Hospital, Santander, Spain
| | - Ángela Puente
- Gastroenterology and Hepatology Department, Clinical and Translational Research in Digestive Diseases, Valdecilla Research Institute (IDIVAL), Marqués de Valdecilla University Hospital, Santander, Spain
| | - Antonio Cuadrado
- Gastroenterology and Hepatology Department, Clinical and Translational Research in Digestive Diseases, Valdecilla Research Institute (IDIVAL), Marqués de Valdecilla University Hospital, Santander, Spain
| | - Paula Iruzubieta
- Gastroenterology and Hepatology Department, Clinical and Translational Research in Digestive Diseases, Valdecilla Research Institute (IDIVAL), Marqués de Valdecilla University Hospital, Santander, Spain
| | - María T Arias-Loste
- Gastroenterology and Hepatology Department, Clinical and Translational Research in Digestive Diseases, Valdecilla Research Institute (IDIVAL), Marqués de Valdecilla University Hospital, Santander, Spain
| | - Carlos Redondo
- Statistical and Bioinformatic Unit, Valdecilla Research Institute (IDIVAL), Santander, Spain
| | - Coral Rivas
- Gastroenterology and Hepatology Department, Clinical and Translational Research in Digestive Diseases, Valdecilla Research Institute (IDIVAL), Marqués de Valdecilla University Hospital, Santander, Spain
| | - Emilio Fábrega
- Gastroenterology and Hepatology Department, Clinical and Translational Research in Digestive Diseases, Valdecilla Research Institute (IDIVAL), Marqués de Valdecilla University Hospital, Santander, Spain
| | - Javier Crespo
- Gastroenterology and Hepatology Department, Clinical and Translational Research in Digestive Diseases, Valdecilla Research Institute (IDIVAL), Marqués de Valdecilla University Hospital, Santander, Spain
| | - José I Fortea
- Gastroenterology and Hepatology Department, Clinical and Translational Research in Digestive Diseases, Valdecilla Research Institute (IDIVAL), Marqués de Valdecilla University Hospital, Santander, Spain
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9
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Segna D, Mendoza YP, Lange NF, Rodrigues SG, Berzigotti A. Non-invasive tools for compensated advanced chronic liver disease and portal hypertension after Baveno VII - an update. Dig Liver Dis 2023; 55:326-335. [PMID: 36369196 DOI: 10.1016/j.dld.2022.10.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Revised: 10/12/2022] [Accepted: 10/13/2022] [Indexed: 11/10/2022]
Abstract
Non-invasive tests (NITs) and liver stiffness measurement (LSM) in particular, have entered clinical practice over 20 years ago as point-of-care tests to diagnose liver fibrosis in patients with compensated chronic liver disease. Since then, NITs use has evolved thanks to a large number of studies in all major etiologies of liver disease, and they have become important tools to stratify the risk of portal hypertension and liver-related events. The Baveno VII consensus workshop provided several novel recommendations regarding the use of well-established and novel NITs in the specific setting of portal hypertension screening, diagnosis and follow-up. The Baveno VII expert panels paid special attention to summarizing the existing data into simple clinical rules able to guide clinicians in their practice. The "rule of five" for LSM is a tool to stratify the risk of liver-related events, and LSM alone or in combination with platelet count, can be used now to rule-in and rule-out compensated advanced chronic liver disease (cACLD) and clinically significant portal hypertension, as well as to rule-out high-risk varices. Use of NITs in obese subjects with non-alcoholic fatty liver disease (NAFLD) and patients with viral hepatitis C that has been successfully treated, require specific knowledge. This review will update the reader on these aspects.
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Affiliation(s)
- Daniel Segna
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, BHH D115, Bern 3010, Switzerland
| | - Yuly P Mendoza
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, BHH D115, Bern 3010, Switzerland
| | - Naomi F Lange
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, BHH D115, Bern 3010, Switzerland; Graduate School for Health Sciences (GHS), University of Bern, Switzerland
| | - Susana G Rodrigues
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, BHH D115, Bern 3010, Switzerland
| | - Annalisa Berzigotti
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, BHH D115, Bern 3010, Switzerland.
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10
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Thabut D, Weil D, Bouzbib C, Rudler M, Cassinotto C, Castéra L, Serste T, Oberti F, Ganne-Carrié N, de Lédinghen V, Bourlière M, Bureau C. Non-invasive diagnosis and follow-up of portal hypertension. Clin Res Hepatol Gastroenterol 2022; 46:101767. [PMID: 34332128 DOI: 10.1016/j.clinre.2021.101767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2021] [Accepted: 07/23/2021] [Indexed: 02/04/2023]
Abstract
Compensated advanced chronic liver disease (cACLD) describes the spectrum of advanced fibrosis/cirrhosis in asymptomatic patients at risk of developing clinically significant portal hypertension (CSPH, defined by a hepatic venous pressure gradient (HVPG) ≥10 mmHg). Patients with cACLD are at high risk of liver-related morbidity and mortality. In patients at risk of chronic liver disease, cACLD is strongly suggested by a liver stiffness (LSM) value >15 kPa or clinical/biological/radiological signs of portal hypertension, and ruled out by LSM <10 kPa, or Fibrotest® ≤0.58, or Fibrometer® ≤0.786. Patients with chronic liver disease (excluding vascular diseases) with a LSM <10 kPa are at low risk of developing portal hypertension complications. The presence of CSPH can be strongly suspected when LSM is ≥20 kPa. In a patient without clinical, endoscopic or radiological features of portal hypertension, measurement of the HVPG is recommended before major liver or intra-abdominal surgery, before extra-hepatic transplantation and in patients with unexplained ascites. Endoscopic screening for oesophageal varices can be avoided in patients with LSM <20 kPa and a platelet count >150 G/L (favourable Baveno VI criteria) at the time of diagnosis. There is no non-invasive method alternative for oeso-gastroduodenal endoscopy in patients with unfavourable Baveno criteria (liver stiffness ≥20 kPa or platelet count ≤50 G/l). Platelet count and liver stiffness measurements must be performed once a year in patients with cACLD with favourable Baveno VI criteria at the time of diagnosis. A screening oeso-gastroduodenal endoscopy is recommended if Baveno VI criteria become unfavourable.
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Affiliation(s)
- Dominique Thabut
- Service d'hépato-gastroentérologie, Hôpital Pitié- Salpêtrière, Sorbonne Université, APHP, 47-83 boulevard de l'Hôpital, 75013 Paris, France.
| | - Delphine Weil
- Service d'hépatologie, CHRU Besançon, Besançon, France
| | - Charlotte Bouzbib
- Service d'hépato-gastroentérologie, Hôpital Pitié- Salpêtrière, Sorbonne Université, APHP, 47-83 boulevard de l'Hôpital, 75013 Paris, France
| | - Marika Rudler
- Service d'hépato-gastroentérologie, Hôpital Pitié- Salpêtrière, Sorbonne Université, APHP, 47-83 boulevard de l'Hôpital, 75013 Paris, France
| | - Christophe Cassinotto
- Radiologie diagnostique et interventionnelle Saint Eloi, CHU Montpellier, Montpellier, France
| | - Laurent Castéra
- Service d'Hépatologie, Hôpital Beaujon, Université de Paris, APHP, Paris, France
| | - Thomas Serste
- Service d'hépato-gastroentérologie, CHU Saint-Pierre, Bruxelles, France
| | - Frédéric Oberti
- Service d'hépato-gastroentérologie et oncologie digestive, CHU Angers, Angers, France
| | - Nathalie Ganne-Carrié
- Service d'hépatologie, Hôpital Avicenne, APHP, Université Sorbonne Paris Nord, Bobigny & INSERM UMR 1138, Centre de Recherche des Cordeliers, Université de Paris, France
| | - Victor de Lédinghen
- Service d'hépato-gastroentérologie et d'oncologie digestive, Hôpital Haut-Lévêque, CHU Bordeaux, Pessac & INSERM U1053, Université de Bordeaux, Bordeaux, France
| | - Marc Bourlière
- Service d'hépato-gastroentérologie, Hôpital Saint Joseph & INSERM UMR 1252 IRD SESSTIM Aix Marseille Université, Marseille, France
| | - Christophe Bureau
- Service d'hépatologie, Hôpital Rangueil, CHU Toulouse, Toulouse, France
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11
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Rigamonti C, Cittone MG, Manfredi GF, Sorge A, Moia R, Patriarca A, Donato MF, Gaidano G, Pirisi M, Fraquelli M. High reproducibility of spleen stiffness measurement by vibration-controlled transient elastography with a spleen-dedicated module. Hepatol Commun 2022; 6:3006-3014. [PMID: 36082990 PMCID: PMC9592765 DOI: 10.1002/hep4.2070] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Revised: 07/29/2022] [Accepted: 08/02/2022] [Indexed: 02/06/2023] Open
Abstract
Spleen stiffness measurement (SSM) by vibration-controlled transient elastography (VCTE) is a noninvasive technique for estimating portal hypertension in patients with chronic liver disease (CLD), with its reproducibility yet to be established and its feasibility still unknown beyond CLD. We have studied 420 participants from two tertiary referral centers for liver diseases (Novara, Milan): 297 patients with CLD (32% with cirrhosis) of different etiology (Group A), 63 Philadelphia-negative myeloproliferative neoplasms (Group B), and 60 heathy volunteers (Group C). All underwent SSM by VCTE with a spleen-dedicated module (SSM@100 Hz) and liver stiffness measurement (LSM), blindly performed by 2 different operators. In total, 1680 VCTE examinations for SSM were performed (1000 in Novara, 680 in Milan), with an overall 3.2% failure rate. Median SSM was 26.5 kPa (interquartile range [IQR] 20.0-42.3) in Group A, 26.3 kPa (IQR 22.3-33.6) in Group B, and 16.1 kPa (IQR 14.6-18.7) in Group C. In Group A, the median LSM was 6.8 kPa (IQR 4.9-11.3) in Novara and 8.3 kPa (IQR 7.1-10.8) in Milan, the proportion of patients with cirrhosis being 34% in Novara and 31% in Milan. The Group A interobserver agreement ICC was 0.90 (0.88-0.92), significantly lower in the absence of splenomegaly (ICC 0.87 vs. 0.91) and in absence of cirrhosis (ICC 0.84 vs. 0.90); overweight slightly, but not significantly reduced the interobserveragreement. The intra-observer agreement ICC ranged from 0.91 to 0.96 for the four operators. The Group B interobserver agreement ICC was 0.90 (0.83-0.94). In conclusion, SSM measured by the new spleen-dedicated VCTE module is a feasible, reliable, and highly reproducible tool in patients with CLD and hematological disorders, and in healthy volunteers.
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Affiliation(s)
- Cristina Rigamonti
- Department of Translational MedicineUniversità del Piemonte Orientale and Division of Internal Medicine, Azienda Ospedaliero‐Universitaria Maggiore della CaritàNovaraItaly
| | - Micol Giulia Cittone
- Department of Translational MedicineUniversità del Piemonte Orientale and Division of Internal Medicine, Azienda Ospedaliero‐Universitaria Maggiore della CaritàNovaraItaly
| | - Giulia Francesca Manfredi
- Department of Translational MedicineUniversità del Piemonte Orientale and Division of Internal Medicine, Azienda Ospedaliero‐Universitaria Maggiore della CaritàNovaraItaly
| | - Andrea Sorge
- Gastroenterology and Endoscopy UnitFondazione IRCCS Ca' Granda–Ospedale Maggiore PoliclinicoMilanItaly
| | - Riccardo Moia
- Division of Hematology, Department of Translational MedicineUniversità del Piemonte Orientale and Azienda Ospedaliero–Universitaria Maggiore della CaritàNovaraItaly
| | - Andrea Patriarca
- Division of Hematology, Department of Translational MedicineUniversità del Piemonte Orientale and Azienda Ospedaliero–Universitaria Maggiore della CaritàNovaraItaly
| | - Maria Francesca Donato
- Gastroenterology and Hepatology UnitFondazione IRCCS Ca' Granda–Ospedale Maggiore PoliclinicoMilanItaly
| | - Gianluca Gaidano
- Division of Hematology, Department of Translational MedicineUniversità del Piemonte Orientale and Azienda Ospedaliero–Universitaria Maggiore della CaritàNovaraItaly
| | - Mario Pirisi
- Department of Translational MedicineUniversità del Piemonte Orientale and Division of Internal Medicine, Azienda Ospedaliero‐Universitaria Maggiore della CaritàNovaraItaly
| | - Mirella Fraquelli
- Gastroenterology and Endoscopy UnitFondazione IRCCS Ca' Granda–Ospedale Maggiore PoliclinicoMilanItaly
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12
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Llop E, Perelló C, Fontanilla T, de la Revilla J, Conde MH, López M, Minaya J, Ferre C, Abad J, Carrillo CF, Martínez JL, Puga NF, Trapero M, Hajra IE, Santos E, Calleja JL. Spleen Transient Elastography and Damping Index Identify a Subgroup of Patients Without an Acute or Chronic Response to Beta-Blockers. Front Med (Lausanne) 2022; 9:900073. [PMID: 35814751 PMCID: PMC9258685 DOI: 10.3389/fmed.2022.900073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2022] [Accepted: 05/30/2022] [Indexed: 11/18/2022] Open
Abstract
Background and Aims Monitoring of acute or chronic response to beta-blockers in patients with liver cirrhosis is based on the measurement of the HVPG. Our aim was to evaluate the response to beta-blockers with non-invasive techniques. Patients and Methods This is a prospective observational study. Consecutive patients with an indication of primary or secondary prophylaxis of variceal bleeding who did not meet exclusion criteria were included. Acute response and chronic response were evaluated. Baseline and after acute and chronic response hepatosplenic measurements of TE and ARFI were obtained. Contrast-enhanced Doppler ultrasound was performed before and after acute and chronic responses. Results From June 2015 to May 2018, 55 patients (14 with exclusion criteria) were included. We analyzed 41 patients, mean age 57 (SD: 8), 82.9% men, alcohol 43.9%, children A/B/C 78%/17.1%/4.9%, and 87.8% on primary prophylaxis. In all, the acute response was performed and was positive in 68.3% (CI 95: 55–85%). The chronic response was performed in 30 (73.2%) and was positive in 36.7% (CI 95: 18–55%). Basal measurements significantly related to acute response were spleen TE [responders 58.4 (SD: 23.0) KPa vs. non-responders 75 (SD: 0) KPa; p = 0.02] and damping index [non-responders 0.96 (0.8) vs. responders 0.44 (0.4), p = 0.01], and with chronic response, the spleen TE [responders 58.1 (SD: 21.4) KPa vs. non-responders 73.2 (SD: 5.5) KPa; p = 0.02], and damping index [non-chronic responders 0.8 (0.7) vs. chronic responders 0.4 (0.4), p = 0.04]. A spleen TE ≥ 74 KPa had a high sensitivity of 100% and specificity of 60% and a high NPV100% for predicting poor acute response to beta-blockers. The damping index > 0.6 showed moderate sensitivity of 67% and specificity of 69% with a high NPV of 82% for predicting poor acute response to beta-blockers. The combination of both measurements for predicting poor acute response to beta-blockers had an AUC of 0.8 (CI 95: 0.5–0.9). A spleen TE ≥ 74 KPa had a high sensitivity of 87% and specificity of 71% with a high NPV of 71% for predicting poor chronic response to beta-blockers. A damping index > 0.6 had moderate sensitivity of 60%, specificity of 82%, and NPV of 56% for predicting poor chronic response to beta-blockers. The combination of both measurements for predicting poor chronic response to beta-blockers had an AUC of 0.8 (CI 95: 0.7–0.9). Conclusion Spleen TE and damping index can identify a subgroup of patients with poor acute or chronic response to beta-blockers.
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Affiliation(s)
- Elba Llop
- Department of Gastroenterology and Hepatology, Hospital Universitario Puerta de Hierro Majadahonda, Madrid, Spain
- Instituto de Investigación Sanitaria Puerta Hierro-Segovia Arana (IDIPHISA), Madrid, Spain
- CIBERHD, Madrid, Spain
| | - Christie Perelló
- Department of Gastroenterology and Hepatology, Hospital Universitario Puerta de Hierro Majadahonda, Madrid, Spain
- Instituto de Investigación Sanitaria Puerta Hierro-Segovia Arana (IDIPHISA), Madrid, Spain
- CIBERHD, Madrid, Spain
| | - Teresa Fontanilla
- Instituto de Investigación Sanitaria Puerta Hierro-Segovia Arana (IDIPHISA), Madrid, Spain
- Department of Radiology, Hospital Universitario Puerta de Hierro Majadahonda, Madrid, Spain
| | - Juan de la Revilla
- Department of Gastroenterology and Hepatology, Hospital Universitario Puerta de Hierro Majadahonda, Madrid, Spain
| | - Marta Hernández Conde
- Department of Gastroenterology and Hepatology, Hospital Universitario Puerta de Hierro Majadahonda, Madrid, Spain
- Instituto de Investigación Sanitaria Puerta Hierro-Segovia Arana (IDIPHISA), Madrid, Spain
- CIBERHD, Madrid, Spain
| | - Marta López
- Department of Gastroenterology and Hepatology, Hospital Universitario Puerta de Hierro Majadahonda, Madrid, Spain
- Instituto de Investigación Sanitaria Puerta Hierro-Segovia Arana (IDIPHISA), Madrid, Spain
- CIBERHD, Madrid, Spain
| | - Javier Minaya
- Instituto de Investigación Sanitaria Puerta Hierro-Segovia Arana (IDIPHISA), Madrid, Spain
- Department of Radiology, Hospital Universitario Puerta de Hierro Majadahonda, Madrid, Spain
| | - Carlos Ferre
- Department of Gastroenterology and Hepatology, Hospital Universitario Puerta de Hierro Majadahonda, Madrid, Spain
- Instituto de Investigación Sanitaria Puerta Hierro-Segovia Arana (IDIPHISA), Madrid, Spain
- CIBERHD, Madrid, Spain
| | - Javier Abad
- Department of Gastroenterology and Hepatology, Hospital Universitario Puerta de Hierro Majadahonda, Madrid, Spain
- Instituto de Investigación Sanitaria Puerta Hierro-Segovia Arana (IDIPHISA), Madrid, Spain
- CIBERHD, Madrid, Spain
| | - Carlos Fernández Carrillo
- Department of Gastroenterology and Hepatology, Hospital Universitario Puerta de Hierro Majadahonda, Madrid, Spain
- Instituto de Investigación Sanitaria Puerta Hierro-Segovia Arana (IDIPHISA), Madrid, Spain
- CIBERHD, Madrid, Spain
| | - José Luís Martínez
- Department of Gastroenterology and Hepatology, Hospital Universitario Puerta de Hierro Majadahonda, Madrid, Spain
- Instituto de Investigación Sanitaria Puerta Hierro-Segovia Arana (IDIPHISA), Madrid, Spain
- CIBERHD, Madrid, Spain
| | - Natalia Fernández Puga
- Department of Gastroenterology and Hepatology, Hospital Universitario Puerta de Hierro Majadahonda, Madrid, Spain
- Instituto de Investigación Sanitaria Puerta Hierro-Segovia Arana (IDIPHISA), Madrid, Spain
- CIBERHD, Madrid, Spain
| | - María Trapero
- Department of Gastroenterology and Hepatology, Hospital Universitario Puerta de Hierro Majadahonda, Madrid, Spain
- Instituto de Investigación Sanitaria Puerta Hierro-Segovia Arana (IDIPHISA), Madrid, Spain
- CIBERHD, Madrid, Spain
| | - Ismael El Hajra
- Department of Gastroenterology and Hepatology, Hospital Universitario Puerta de Hierro Majadahonda, Madrid, Spain
| | - Elena Santos
- Department of Gastroenterology and Hepatology, Hospital Universitario Puerta de Hierro Majadahonda, Madrid, Spain
| | - José Luis Calleja
- Department of Gastroenterology and Hepatology, Hospital Universitario Puerta de Hierro Majadahonda, Madrid, Spain
- Instituto de Investigación Sanitaria Puerta Hierro-Segovia Arana (IDIPHISA), Madrid, Spain
- CIBERHD, Madrid, Spain
- *Correspondence: José Luis Calleja,
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13
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Comparison between spleen and liver stiffness measurements by sound touch elastography for diagnosing cirrhosis at different aminotransferase levels: a prospective multicenter study. Eur Radiol 2022; 32:4980-4990. [PMID: 35229196 DOI: 10.1007/s00330-022-08569-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2021] [Revised: 01/04/2022] [Accepted: 01/05/2022] [Indexed: 11/04/2022]
Abstract
OBJECTIVES To compare the performance of spleen stiffness measurement (SSM) and liver stiffness measurement (LSM) by sound touch elastography (STE) for the diagnosis of cirrhosis at different alanine aminotransferase (ALT) levels, and to compare the applicability and repeatability of SSM with LSM performed by STE, a new two-dimensional shear wave elastography technology. METHODS This prospective multicenter study included 25 centers and recruited chronic hepatitis B (CHB) patients with liver biopsy between May 2018 and November 2019. All patients underwent LSM and SSM by STE. Success and reliability rates were calculated and compared. Intra-observer agreement was assessed using intraclass correlation coefficients (ICCs). Differences between areas under the receiver operating characteristic curves (AUCs) of LSMs and SSMs at different ALT levels were compared using the Delong test. RESULTS Among 603 CHB patients, the success and reliability rates of SSM were 94.53% (570/603) and 85.74% (517/603), respectively, which were similar to those of LSM (p > 0.05), respectively. The ICC for intra-observer agreements of SSM was 0.964 (p < 0.001). In the total cohort, ALT ≤ 2 × upper limit of normal (ULN) group, and A0-1 group, the AUCs of SSMs were significantly lower than those of LSMs for the diagnosis of cirrhosis (p < 0.001). In the ALT > 2 × ULN group and A2-3 group, the AUC of SSM improved and was not significantly different from that of LSM (p = 0.342, p = 0.510, respectively). CONCLUSIONS SSM by STE achieved applicability and repeatability equivalent to those of LSM. SSM might be a good substitute to LSM in patients with high ALT levels. KEY POINTS • Spleen stiffness measurement performed by sound touch elastography was proven to have similar applicability and repeatability to liver stiffness measurement in this prospective multicenter study. • Spleen stiffness measurement demonstrated a poorer diagnostic performance for cirrhosis compared with liver stiffness measurement in the total cohort and low ALT level group, yet it showed a similar diagnostic performance to liver stiffness measurement in patients with high ALT levels.
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14
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Hirooka M, Tanaka T, Koizumi Y, Yano R, Sunago K, Watanabe T, Yoshida O, Tokumoto Y, Abe M, Hiasa Y. Measurement of multiple spleen lengths is not necessary for non-invasive prediction of high-risk esophagogastric varices. Hepatol Res 2022; 52:187-198. [PMID: 34570948 DOI: 10.1111/hepr.13716] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Revised: 09/03/2021] [Accepted: 09/21/2021] [Indexed: 12/27/2022]
Abstract
AIM To validate an appropriate spleen size measurement technique for the prediction of high-risk esophagogastric varices. METHODS This retrospective cross-sectional study included 369 patients who underwent ultrasonography and computed tomography (CT) of the spleen and esophagogastroduodenoscopy between January 2018 and December 2020. Maximum spleen length, width, and craniocaudal length were measured in a longitudinal view. The two-dimensional (2D) spleen index (maximum length × maximum width in the longitudinal view) was calculated. A three-dimensional (3D) spleen index was then defined as follows: 2D spleen index × maximum length in the transverse view. The similarity in spleen volume measured by CT and ultrasonography (spleen index) was assessed by the correlation coefficient. The diagnostic accuracies of the spleen index, platelet/spleen length, and platelet/spleen index were calculated to determine the overall diagnostic accuracy. RESULTS Compared to the other spleen indices, our 3D spleen index was significantly better correlated with spleen volume on CT (r = 0.91, 95% confidence interval 0.89-0.92, p < 0.001). Receiver-operating characteristic curve analyses revealed no significant difference between the 3D and 2D indices (p = 0.228) but did show a significant difference between the 3D and one-dimensional indices (p = 0.020). Although the area under the curve for the platelet count combined with the spleen index or length was higher than that for our 3D index, there was no significant difference between platelet count and spleen index or length (p = 0.078). CONCLUSIONS Platelet/spleen length has a reasonable ability to predict high-risk esophagogastric varices, even though measurement of two or three factors can be correlated with spleen volume.
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Affiliation(s)
- Masashi Hirooka
- Department of Gastroenterology and Metabology, Ehime University Graduate School of Medicine, Touon, Ehime, Japan
| | - Takaaki Tanaka
- Department of Gastroenterology and Metabology, Ehime University Graduate School of Medicine, Touon, Ehime, Japan
| | - Yohei Koizumi
- Department of Gastroenterology and Metabology, Ehime University Graduate School of Medicine, Touon, Ehime, Japan
| | - Ryo Yano
- Department of Gastroenterology and Metabology, Ehime University Graduate School of Medicine, Touon, Ehime, Japan
| | - Kotarou Sunago
- Department of Gastroenterology and Metabology, Ehime University Graduate School of Medicine, Touon, Ehime, Japan
| | - Takao Watanabe
- Department of Gastroenterology and Metabology, Ehime University Graduate School of Medicine, Touon, Ehime, Japan
| | - Osamu Yoshida
- Department of Gastroenterology and Metabology, Ehime University Graduate School of Medicine, Touon, Ehime, Japan
| | - Yoshio Tokumoto
- Department of Gastroenterology and Metabology, Ehime University Graduate School of Medicine, Touon, Ehime, Japan
| | - Masanori Abe
- Department of Gastroenterology and Metabology, Ehime University Graduate School of Medicine, Touon, Ehime, Japan
| | - Yoichi Hiasa
- Department of Gastroenterology and Metabology, Ehime University Graduate School of Medicine, Touon, Ehime, Japan
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15
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Cerrito L, Ainora ME, Nicoletti A, Garcovich M, Riccardi L, Pompili M, Gasbarrini A, Zocco MA. Elastography as a predictor of liver cirrhosis complications after hepatitis C virus eradication in the era of direct-acting antivirals. World J Hepatol 2021; 13:1663-1676. [PMID: 34904036 PMCID: PMC8637667 DOI: 10.4254/wjh.v13.i11.1663] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 07/08/2021] [Accepted: 08/17/2021] [Indexed: 02/06/2023] Open
Abstract
Chronic inflammation due to hepatitis C virus (HCV) infection leads to liver fibrosis and rearrangement of liver tissue, which is responsible for the development of portal hypertension (PH) and hepatocellular carcinoma (HCC). The advent of direct-acting antiviral drugs has revolutionized the natural history of HCV infection, providing an overall eradication rate of over 90%. Despite a significant decrease after sustained virological response (SVR), the rate of HCC and liver-related complications is not completely eliminated in patients with advanced liver disease. Although the reasons are still unclear, cirrhosis itself has a residual risk for the development of HCC and other PH-related complications. Ultrasound elastography is a recently developed non-invasive technique for the assessment of liver fibrosis. Following the achievement of SVR, liver stiffness (LS) usually decreases, as a consequence of reduced inflammation and, possibly, fibrosis. Recent studies emphasized the application of LS assessment in the management of patients with SVR in order to define the risk for developing the complications of chronic liver disease (functional decompensation, gastrointestinal bleeding, HCC) and to optimize long-term prognostic outcomes in clinical practice.
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Affiliation(s)
- Lucia Cerrito
- CEMAD Digestive Disease Center, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Catholic University of Rome (Italy), Rome 00168, Italy
| | - Maria Elena Ainora
- CEMAD Digestive Disease Center, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Catholic University of Rome (Italy), Rome 00168, Italy
| | - Alberto Nicoletti
- CEMAD Digestive Disease Center, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Catholic University of Rome (Italy), Rome 00168, Italy
| | - Matteo Garcovich
- CEMAD Digestive Disease Center, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Catholic University of Rome (Italy), Rome 00168, Italy
| | - Laura Riccardi
- CEMAD Digestive Disease Center, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Catholic University of Rome (Italy), Rome 00168, Italy
| | - Maurizio Pompili
- CEMAD Digestive Disease Center, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Catholic University of Rome (Italy), Rome 00168, Italy
| | - Antonio Gasbarrini
- CEMAD Digestive Disease Center, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Catholic University of Rome (Italy), Rome 00168, Italy
| | - Maria Assunta Zocco
- CEMAD Digestive Disease Center, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Catholic University of Rome (Italy), Rome 00168, Italy
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Vuille-Lessard É, Rodrigues SG, Berzigotti A. Noninvasive Detection of Clinically Significant Portal Hypertension in Compensated Advanced Chronic Liver Disease. Clin Liver Dis 2021; 25:253-289. [PMID: 33838850 DOI: 10.1016/j.cld.2021.01.005] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Patients with compensated advanced chronic liver disease have different prognoses depending on the presence of portal hypertension. Current non-invasive diagnostic methods allow identification of clinically significant portal hypertension. Portosystemic collaterals on imaging or liver stiffness of more than 20 to 25 kPa by using transient elastography identifies patients with clinically significant portal hypertension. Patients with liver stiffness of less than 20 kPa and platelet count of greater than 150 g/L can avoid endoscopy. This rule could be expanded using spleen stiffness. Methods to risk stratify for portal hypertension in compensated advanced chronic liver disease and successfully treated chronic hepatitis C and B are subject of research.
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Affiliation(s)
- Élise Vuille-Lessard
- Hepatology, University Clinic for Visceral Surgery and Medicine (UVCM), Inselspital, University Hospital of Bern, Freiburgstrasse, 3010 Bern, Switzerland; Department of Biomedical Research, University of Bern, Switzerland
| | - Susana G Rodrigues
- Hepatology, University Clinic for Visceral Surgery and Medicine (UVCM), Inselspital, University Hospital of Bern, Freiburgstrasse, 3010 Bern, Switzerland; Department of Biomedical Research, University of Bern, Switzerland
| | - Annalisa Berzigotti
- Hepatology, University Clinic for Visceral Surgery and Medicine (UVCM), Inselspital, University Hospital of Bern, Freiburgstrasse, 3010 Bern, Switzerland; Department of Biomedical Research, University of Bern, Switzerland.
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Wang H, Wen B, Chang X, Wu Q, Wen W, Zhou F, Guo Y, Ji Y, Gu Y, Lai Q, He Q, Li J, Chen J, Hou J. Baveno VI criteria and spleen stiffness measurement rule out high-risk varices in virally suppressed HBV-related cirrhosis. J Hepatol 2021; 74:584-592. [PMID: 33039403 DOI: 10.1016/j.jhep.2020.09.034] [Citation(s) in RCA: 42] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Revised: 08/29/2020] [Accepted: 09/21/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS There are no data validating the performance of spleen stiffness measurement in ruling out high-risk varices in patients with HBV-related cirrhosis under maintained viral suppression. Thus, we aimed to prospectively validate the performance of spleen stiffness measurement (cut-off 46 kPa) combined with Baveno VI criteria in ruling out high-risk varices in these patients. METHODS Patients with cirrhosis were enrolled from April to December 2019 at the hepatology unit of the Nanfang Hospital, China. Liver and spleen transient elastography and esophagogastroduodenoscopy were performed at enrollment. Antiviral regimen(s) and virological responses, evaluated every 3-6 months, were recorded. RESULTS Overall 341 patients with HBV-related cirrhosis under maintained viral suppression were enrolled, and the prevalence of high-risk varices was 20.5% (70/341). Baveno VI criteria spared 37.0% (126/341) esophagogastroduodenoscopies and no high-risk varices were missed (0/70). Eight cases of high-risk varices (8/70, 11.4%) were misclassified in patients (208/341, 61.0%) within the expanded Baveno VI criteria. The spleen stiffness measurement cut-off (≤46.0 kPa) was shown to safely rule out high-risk varices in these patients (the percentage of missed high-risk varices was 4.3%). Over half (61.6%, 210/341) of patients met the combined model (Baveno VI criteria and spleen stiffness measurement cut-off ≤46 kPa) and 4.3% (3/70) of high-risk varices cases were misclassified. This combined model exhibited a sensitivity of 95.71%, specificity of 76.38%, negative predictive value of 98.57%, and negative likelihood ratio of 0.06 for ruling out high-risk varices. CONCLUSIONS We validated the excellent performance of Baveno VI criteria combined with spleen stiffness measurement (cut-off 46 kPa) for safely ruling out high-risk varices in patients with HBV-related cirrhosis under viral suppression; more than half of esophagogastroduodenoscopy procedures were spared using this combination. CLINICAL TRIAL NUMBER NCT04123509 LAY SUMMARY: Esophageal varices have important prognostic implications in patients with cirrhosis. Thus, their timely identification is important so that treatment can be initiated early. Herein, we validated the excellent performance of the combination of Baveno VI criteria with spleen stiffness measurement (cut-off 46 kPa) for ruling out high-risk esophageal varices in patients with HBV-related cirrhosis under maintained viral suppression (with antiviral treatment). This combined model was able to safely rule out high-risk varices (missed/total <5%) and over half (61.6%) of esophagogastroduodenoscopy procedures were spared.
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Affiliation(s)
- Haiyu Wang
- Hepatology Unit, Department of Infectious Diseases, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Biao Wen
- Hepatology Unit, Department of Infectious Diseases, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Xianyi Chang
- Hepatology Unit, Department of Infectious Diseases, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Qiaoping Wu
- Hepatology Unit, Department of Infectious Diseases, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Weiqun Wen
- Hepatology Unit, Department of Infectious Diseases, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Fuyuan Zhou
- Hepatology Unit, Department of Infectious Diseases, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Yabing Guo
- Hepatology Unit, Department of Infectious Diseases, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Yali Ji
- Hepatology Unit, Department of Infectious Diseases, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Yixiu Gu
- Hepatology Unit, Department of Infectious Diseases, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Qintao Lai
- Hepatology Unit, Department of Infectious Diseases, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Qinjun He
- Hepatology Unit, Department of Infectious Diseases, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Junying Li
- Hepatology Unit, Department of Infectious Diseases, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Jinjun Chen
- Hepatology Unit, Department of Infectious Diseases, Nanfang Hospital, Southern Medical University, Guangzhou, China.
| | - Jinlin Hou
- Hepatology Unit, Department of Infectious Diseases, Nanfang Hospital, Southern Medical University, Guangzhou, China.
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Tanaka T, Hirooka M, Koizumi Y, Watanabe T, Yoshida O, Tokumoto Y, Nakamura Y, Sunago K, Yukimoto A, Abe M, Hiasa Y. Development of a method for measuring spleen stiffness by transient elastography using a new device and ultrasound-fusion method. PLoS One 2021; 16:e0246315. [PMID: 33539456 PMCID: PMC7861355 DOI: 10.1371/journal.pone.0246315] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Accepted: 01/15/2021] [Indexed: 01/06/2023] Open
Abstract
Background Hepatic venous pressure gradient (HVPG) is the gold standard index for evaluating portal hypertension; however, measuring HVPG is invasive. Although transient elastography (TE) is the most common procedure for evaluating organ stiffness, accurate measurement of spleen stiffness (SS) is difficult. We developed a device to demonstrate the diagnostic precision of TE and suggest this technique as a valuable new method to measure SS. Methods Of 292 consecutive patients enrolled in this single-centre, translational, cross-sectional study from June through September in 2019, 200 underwent SS measurement (SSM) using an M probe (training set, n = 130; inspection set, n = 70). We performed TE with B-mode imaging using an ultrasound-fusion method, printed new devices with a three-dimensional printer, and attached the magnetic position sensor to the convex and M probes. We evaluated the diagnostic precision of TE to evaluate the risk of esophagogastric varices (EGVs). Results The median spleen volume was 245 mL (range, 64–1,720 mL), and it took 2 minutes to acquire a B-mode image using the ultrasound-fusion method. The median success rates of TE were 83.3% and 57.6% in patients with and without the new device, respectively (p<0.001); it was 76.9% and 35.0% in patients with and without splenomegaly (<100 mL), respectively (p<0.001). In the prediction of EGVs, the areas under the receiver operating characteristic curve were 0.921 and 0.858 in patients with and without the new device, respectively (p = 0.043). When the new device was attached, the positive and negative likelihood ratios were 3.44 and 0.11, respectively. The cut-off value of SSM was 46.0 kPa. Data that were similar between the validation and training sets were obtained. Conclusions The SS can be precisely measured using this new device with TE and ultrasound-fusion method. Similarly, we can estimate the bleeding risk due to EGV using this method.
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Affiliation(s)
- Takaaki Tanaka
- Department of Gastroenterology and Metabology, Ehime University Graduate School of Medicine, Toon, Ehime, Japan
| | - Masashi Hirooka
- Department of Gastroenterology and Metabology, Ehime University Graduate School of Medicine, Toon, Ehime, Japan
| | - Yohei Koizumi
- Department of Gastroenterology and Metabology, Ehime University Graduate School of Medicine, Toon, Ehime, Japan
| | - Takao Watanabe
- Department of Gastroenterology and Metabology, Ehime University Graduate School of Medicine, Toon, Ehime, Japan
| | - Osamu Yoshida
- Department of Gastroenterology and Metabology, Ehime University Graduate School of Medicine, Toon, Ehime, Japan
| | - Yoshio Tokumoto
- Department of Gastroenterology and Metabology, Ehime University Graduate School of Medicine, Toon, Ehime, Japan
| | - Yoshiko Nakamura
- Department of Gastroenterology and Metabology, Ehime University Graduate School of Medicine, Toon, Ehime, Japan
| | - Koutarou Sunago
- Department of Gastroenterology and Metabology, Ehime University Graduate School of Medicine, Toon, Ehime, Japan
| | - Atsushi Yukimoto
- Department of Gastroenterology and Metabology, Ehime University Graduate School of Medicine, Toon, Ehime, Japan
| | - Masanori Abe
- Department of Gastroenterology and Metabology, Ehime University Graduate School of Medicine, Toon, Ehime, Japan
| | - Yoichi Hiasa
- Department of Gastroenterology and Metabology, Ehime University Graduate School of Medicine, Toon, Ehime, Japan
- * E-mail:
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Aquino-Matus J, Uribe M, Chavez-Tapia N. Liver and spleen elastography as predictor of portal hypertension and esophageal varices. Minerva Gastroenterol (Torino) 2020; 67:122-128. [PMID: 33337116 DOI: 10.23736/s2724-5985.20.02779-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Liver stiffness is related to the degree of hepatic fibrosis which ultimately causes portal hypertension and gastroesophageal varices. Variceal bleeding is a worrisome and potentially fatal complication of cirrhosis, primary prophylaxis has demonstrated a reduction in decompensation and mortality. Portal hypertension and esophageal varices needing treatment could be predicted through noninvasive methods, including elastography, that evaluates the mechanical properties of liver or spleen tissue in concordance to the propagation of mechanical waves. The accurate prediction of the risk of gastroesophageal varices could spare unnecessary endoscopies in patients with low probability of finding varices needing treatment. In the current review, we discuss the elastography modalities available and the current evidence for its implementation in daily clinical practice.
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20
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Validation and Refinement of the Baveno VI Criteria for Ruling Out High-Risk Varices. Gastroenterol Res Pract 2020; 2020:4217512. [PMID: 33376483 PMCID: PMC7744238 DOI: 10.1155/2020/4217512] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Revised: 11/02/2020] [Accepted: 11/17/2020] [Indexed: 12/14/2022] Open
Abstract
In the past decade, numerous studies have evaluated the roles of noninvasive methods for diagnosing or excluding varices and high-risk varices in patients with liver cirrhosis. The Baveno VI criteria recommend the use of a simple algorithm based on a liver stiffness measurement < 20 kPa through transient elastography and a platelet count > 150 × 109/L for ruling out high-risk varices in patients with compensated advanced chronic liver disease. A large number of studies have validated the clinical usefulness of Baveno VI criteria for excluding high-risk varices. Several strategies have been proposed to refine the Baveno VI criteria; however, currently there is no review to summarize the diagnostic accuracy and limitations of the Baveno VI criteria after extensive validation. In this review, we summarize the diagnostic accuracy and limitations of the Baveno VI criteria after extensive validation. We also discuss methods to refine these criteria.
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Patel M, Tann M, Liangpunsakul S. CT-scan Based Liver and Spleen Volume Measurement as a Prognostic Indicator for Patients with Cirrhosis. Am J Med Sci 2020; 362:252-259. [PMID: 33947583 DOI: 10.1016/j.amjms.2020.10.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2020] [Revised: 10/07/2020] [Accepted: 10/30/2020] [Indexed: 11/17/2022]
Abstract
BACKGROUND Complications of patients with liver disease generally occurs as the consequence of advanced fibrosis and portal hypertension. Non-invasive tools to predict the complications may allow for better risk-stratification and medical management in patients with cirrhosis. The goals of this study were to determine the utility of CT-scan based liver and spleen volume measurement in association with complications and outcomes in patients with cirrhosis. METHODS Baseline demographic and clinical characteristics of 556 patients with cirrhosis who underwent CT scan of the abdomen between January 1-June 30,2009 were reviewed. Liver and spleen volume were measured using semi-automated interactive software and compared to 47 healthy controls. The association between liver and spleen volume and complications of cirrhosis was determined. Independent predictors of survival were analyzed with Cox regression model. RESULTS Patients with cirrhosis had significantly lower total and functional liver volume, larger total and functional spleen volume, and significantly lower total liver to spleen volume ratio when compared to controls. Liver volume, spleen volume, and liver to spleen volume ratio were significantly altered in patients with decompensated stage. Patients with hepatic encephalopathy had significantly lower total liver volume and spleen size was associated with the presence of esophageal varices. Patients with cirrhosis who underwent liver transplantation had significantly lower total liver volume and larger total spleen volume. However, spleen volume was not an independent predictor for mortality. CONCLUSIONS Baseline liver and spleen volume and its ratio are significantly altered in patients with cirrhosis. Spleen volume is also associated with the presence of esophageal varices.
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Affiliation(s)
- Milan Patel
- Department of Medicine, Virginia Commonwealth University, Richmond, VA, United States
| | - Mark Tann
- Department of Radiology and Imaging Sciences, Indiana University School of Medicine, Indianapolis, IN, United States.
| | - Suthat Liangpunsakul
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, IN, United States; Roudebush Veterans Administration Medical Center, Indianapolis, IN, United States; Department of Biochemistry and Molecular Biology, Indiana University School of Medicine, Indianapolis, IN, United States.
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22
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Kennedy P, Bane O, Hectors SJ, Fischman A, Schiano T, Lewis S, Taouli B. Noninvasive imaging assessment of portal hypertension. Abdom Radiol (NY) 2020; 45:3473-3495. [PMID: 32926209 PMCID: PMC10124623 DOI: 10.1007/s00261-020-02729-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 08/16/2020] [Accepted: 08/30/2020] [Indexed: 02/07/2023]
Abstract
Portal hypertension (PH) is a spectrum of complications of chronic liver disease (CLD) and cirrhosis, with manifestations including ascites, gastroesophageal varices, splenomegaly, hypersplenism, hepatic hydrothorax, hepatorenal syndrome, hepatopulmonary syndrome and portopulmonary hypertension. PH can vary in severity and is diagnosed via invasive hepatic venous pressure gradient measurement (HVPG), which is considered the reference standard. Accurate diagnosis of PH and assessment of severity are highly relevant as patients with clinically significant portal hypertension (CSPH) are at higher risk for developing acute variceal bleeding and mortality. In this review, we discuss current and upcoming noninvasive imaging methods for diagnosis and assessment of severity of PH.
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23
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Diagnostic accuracy of spleen stiffness to evaluate portal hypertension and esophageal varices in chronic liver disease: a systematic review and meta-analysis. Eur Radiol 2020; 31:2392-2404. [PMID: 32974686 PMCID: PMC7979650 DOI: 10.1007/s00330-020-07223-8] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2020] [Revised: 06/25/2020] [Accepted: 08/21/2020] [Indexed: 02/06/2023]
Abstract
Objectives To systematically review studies on the diagnostic accuracy of spleen stiffness measurement (SSM) for the detection of clinical significant portal hypertension (CSPH), severe portal hypertension (SPH), esophageal varices (EV), and high-risk esophageal varices (HREV) in patients with chronic liver diseases (CLD). Methods Through a systematic search, we identified 32 studies reporting the accuracy of SSM for the diagnosis of portal hypertension (PH) and/or EV in adults with CLD. A bivariate random-effects model was performed to estimate pooled sensitivity, specificity, likelihood ratio, positive predictive value (PPV), negative predictive value (NPV), and diagnostic odds ratios (DOR). The clinical utility of SSM was evaluated by Fagan plot. Results A total of 32 studies assessing 3952 patients were included in this meta-analysis. The pooled sensitivities of SSM were 0.85 (95% confidence interval (CI), 0.69–0.93) for CSPH; 0.84 (95% CI, 0.75–0.90) for SPH; 0.90 (95% CI, 0.83–0.94) for any EV; and 0.87 (95% CI, 0.77–0.93) for HREV. The pooled specificities of SSM were 0.86 (95% CI, 0.74–0.93) for CSPH; 0.84 (95% CI, 0.72–0.91) for SPH; 0.73 (95% CI, 0.66–0.79) for EV; and 0.66 (95% CI, 0.53–0.77) for HREV. Summary PPV and NPV of SSM for detecting HREV were 0.54 (95% CI, 0.47–0.62) and 0.88 (95% CI, 0.81–0.95), respectively. Conclusions Our meta-analysis suggests that SSM could be used as a helpful surveillance tool in management of CLD patients and was quite useful for ruling out the presence of HREV thereby avoiding unnecessary endoscopy. Key Points • SSM could be used to rule out the presence of HREV in patients with CLD thereby avoiding unnecessary endoscopy. • SSM has significant diagnostic value for CSPH and SPH with high sensitivity and specificity in patients with CLD. • SSM could be used as a helpful surveillance tool for clinicians managing CLD patients. Electronic supplementary material The online version of this article (10.1007/s00330-020-07223-8) contains supplementary material, which is available to authorized users.
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Giunta M, La Mura V, Conti CB, Casazza G, Tosetti G, Gridavilla D, Segato S, Nicolini A, Primignani M, Lampertico P, Fraquelli M. The Role of Spleen and Liver Elastography and Color-Doppler Ultrasound in the Assessment of Transjugular Intrahepatic Portosystemic Shunt Function. ULTRASOUND IN MEDICINE & BIOLOGY 2020; 46:1641-1650. [PMID: 32402671 DOI: 10.1016/j.ultrasmedbio.2020.04.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Revised: 03/11/2020] [Accepted: 04/09/2020] [Indexed: 06/11/2023]
Abstract
The reference standard for assessing transjugular intrahepatic portosystemic shunt (TIPS) function is venography with portosystemic pressure gradient (PPG) measurement. This procedure is invasive and expensive; thus, we assessed the feasibility, reproducibility and diagnostic accuracy of color-Doppler ultrasound (CDUS) and spleen and liver stiffness (LS) measurements for identifying TIPS dysfunction. Twenty-four patients (15 undergoing TIPS placement and nine undergoing TIPS revision) consecutively underwent CDUS examination and LS and spleen stiffness (SS) determination by transient elastography (TE) and point shear-wave elastography (pSWE). All parameters were taken before TIPS placement/revision (1-15 d before) and 24 h after, just before revision by venography. pSWE inter-observer agreement was assessed by intra-class correlation coefficient (ICC). CDUS and elastographic data were correlated (Pearson coefficient) with pressure gradients (hepatic venous pressure gradient [HVPG], PPG). Main determinants of TIPS dysfunction were investigated by linear regression. Forty-nine paired examinations were performed in total: 49 (100%) SS reliable measurements by pSWE and 38 (88%) by TE. The ICC for pSWE values was 0.90 (95% confidence interval [CI] 0.81‒0.94). SS values significantly correlated with HVPG and PPG (R = 0.51, p = 0.01). The area under the Receiver-Operating Characteristic (AUROC) curve of SS for diagnosing TIPS dysfunction was 0.86 (95% CI 0.70‒0.96) using a 25 kPa cutoff. At multivariate analysis, the flow direction of the intrahepatic portal vein branches and SS values were independently associated to TIPS dysfunction. The intrahepatic portal vein branches flow direction and SS value are two simple, highly sensitive parameters accurately excluding TIPS dysfunction. SS measurement by pSWE is feasible, reproducible and both positively and significantly correlates with HVPG and PPG values.
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Affiliation(s)
- Mariangela Giunta
- Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, UOC Gastroenterologia ed Endoscopia, Milan, Italy
| | - Vincenzo La Mura
- Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, UOC Medicina Generale, Emostasi e Trombosi, Milan, Italy; Dipartimento di Scienze Biomediche per la Salute, Università degli Studi di Milano, Milan, Italy; Centro di Ricerca Coordinata "A.M. e A. Migliavacca" per lo Studio e la Cura delle Malattie del Fegato, Milan, Italy; Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, UOC Gastroenterologia ed Epatologia, Milan, Italy
| | - Clara Benedetta Conti
- Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, UOC Gastroenterologia ed Endoscopia, Milan, Italy
| | - Giovanni Casazza
- Dipartimento di Scienze Biomediche e Cliniche "L. Sacco", Universita' degli Studi di Milano, Milan, Italy
| | - Giulia Tosetti
- Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, UOC Medicina Generale, Emostasi e Trombosi, Milan, Italy; Dipartimento di Scienze Biomediche per la Salute, Università degli Studi di Milano, Milan, Italy; Centro di Ricerca Coordinata "A.M. e A. Migliavacca" per lo Studio e la Cura delle Malattie del Fegato, Milan, Italy
| | - Daniele Gridavilla
- Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, UOC Gastroenterologia ed Endoscopia, Milan, Italy
| | - Simone Segato
- Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, UOC Gastroenterologia ed Endoscopia, Milan, Italy
| | - Antonio Nicolini
- Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, UOC Radiologia, Milan, Italy
| | - Massimo Primignani
- Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, UOC Medicina Generale, Emostasi e Trombosi, Milan, Italy; Dipartimento di Scienze Biomediche per la Salute, Università degli Studi di Milano, Milan, Italy; Centro di Ricerca Coordinata "A.M. e A. Migliavacca" per lo Studio e la Cura delle Malattie del Fegato, Milan, Italy
| | - Pietro Lampertico
- Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, UOC Medicina Generale, Emostasi e Trombosi, Milan, Italy; Dipartimento di Scienze Biomediche per la Salute, Università degli Studi di Milano, Milan, Italy; Centro di Ricerca Coordinata "A.M. e A. Migliavacca" per lo Studio e la Cura delle Malattie del Fegato, Milan, Italy
| | - Mirella Fraquelli
- Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, UOC Gastroenterologia ed Endoscopia, Milan, Italy.
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Li Y, Li L, Weng HL, Liebe R, Ding HG. Computed tomography vs liver stiffness measurement and magnetic resonance imaging in evaluating esophageal varices in cirrhotic patients: A systematic review and meta-analysis. World J Gastroenterol 2020; 26:2247-2267. [PMID: 32476790 PMCID: PMC7235201 DOI: 10.3748/wjg.v26.i18.2247] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Revised: 03/19/2020] [Accepted: 04/24/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Computed tomography (CT), liver stiffness measurement (LSM), and magnetic resonance imaging (MRI) are non-invasive diagnostic methods for esophageal varices (EV) and for the prediction of high-bleeding-risk EV (HREV) in cirrhotic patients. However, the clinical use of these methods is controversial.
AIM To evaluate the accuracy of LSM, CT, and MRI in diagnosing EV and predicting HREV in cirrhotic patients.
METHODS We performed literature searches in multiple databases, including PubMed, Embase, Cochrane, CNKI, and Wanfang databases, for articles that evaluated the accuracy of LSM, CT, and MRI as candidates for the diagnosis of EV and prediction of HREV in cirrhotic patients. Summary sensitivity and specificity, positive likelihood ratio and negative likelihood ratio, diagnostic odds ratio, and the areas under the summary receiver operating characteristic curves were analyzed. The quality of the articles was assessed using the quality assessment of diagnostic accuracy studies-2 tool. Heterogeneity was examined by Q-statistic test and I2 index, and sources of heterogeneity were explored using meta-regression and subgroup analysis. Publication bias was evaluated using Deek’s funnel plot. All statistical analyses were conducted using Stata12.0, MetaDisc1.4, and RevMan5.3.
RESULTS Overall, 18, 17, and 7 relevant articles on the accuracy of LSM, CT, and MRI in evaluating EV and HREV were retrieved. A significant heterogeneity was observed in all analyses (P < 0.05). The areas under the summary receiver operating characteristic curves of LSM, CT, and MRI in diagnosing EV and predicting HREV were 0.86 (95% confidence interval [CI]: 0.83-0.89), 0.91 (95%CI: 0.88-0.93), and 0.86 (95%CI: 0.83-0.89), and 0.85 (95%CI: 0.81-0.88), 0.94 (95%CI: 0.91-0.96), and 0.83 (95%CI: 0.79-0.86), respectively, with sensitivities of 0.84 (95%CI: 0.78-0.89), 0.91 (95%CI: 0.87-0.94), and 0.81 (95%CI: 0.76-0.86), and 0.81 (95%CI: 0.75-0.86), 0.88 (95%CI: 0.82-0.92), and 0.80 (95%CI: 0.72-0.86), and specificities of 0.71 (95%CI: 0.60-0.80), 0.75 (95%CI: 0.68-0.82), and 0.82 (95%CI: 0.70-0.89), and 0.73 (95%CI: 0.66-0.80), 0.87 (95%CI: 0.81-0.92), and 0.72 (95%CI: 0.62-0.80), respectively. The corresponding positive likelihood ratios were 2.91, 3.67, and 4.44, and 3.04, 6.90, and2.83; the negative likelihood ratios were 0.22, 0.12, and 0.23, and 0.26, 0.14, and 0.28; the diagnostic odds ratios were 13.01, 30.98, and 19.58, and 11.93, 49.99, and 10.00. CT scanner is the source of heterogeneity. There was no significant difference in diagnostic threshold effects (P > 0.05) or publication bias (P > 0.05).
CONCLUSION Based on the meta-analysis of observational studies, it is suggested that CT imaging, a non-invasive diagnostic method, is the best choice for the diagnosis of EV and prediction of HREV in cirrhotic patients compared with LSM and MRI.
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Affiliation(s)
- Yue Li
- Department of Gastroenterology and Hepatology, Beijing You’an Hospital Affiliated with Capital Medical University, Beijing 100069, China
| | - Lei Li
- Department of Gastroenterology and Hepatology, Beijing You’an Hospital Affiliated with Capital Medical University, Beijing 100069, China
| | - Hong-Lei Weng
- Department of Medicine II, Section Molecular Hepatology, Medical Faculty Mannheim, Heidelberg University, Mannheim 68167, Germany
| | - Roman Liebe
- Department of Medicine II, Saarland University Medical Center, Homburg 66424, Germany
| | - Hui-Guo Ding
- Department of Gastroenterology and Hepatology, Beijing You’an Hospital Affiliated with Capital Medical University, Beijing 100069, China
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Stefanescu H, Marasco G, Calès P, Fraquelli M, Rosselli M, Ganne-Carriè N, de Ledinghen V, Ravaioli F, Colecchia A, Rusu C, Andreone P, Mazzella G, Festi D. A novel spleen-dedicated stiffness measurement by FibroScan® improves the screening of high-risk oesophageal varices. Liver Int 2020; 40:175-185. [PMID: 31444849 DOI: 10.1111/liv.14228] [Citation(s) in RCA: 46] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Revised: 07/23/2019] [Accepted: 08/20/2019] [Indexed: 02/13/2023]
Abstract
BACKGROUND & AIMS Several non-invasive tests (NITs) have been developed to diagnose oesophageal varices (EV), including the recent Baveno VI criteria to rule out high-risk varices (HRV). Spleen stiffness measurement (SSM) with the standard FibroScan® (SSM@50Hz) has been evaluated. However, the EV grading could be underestimated because of a ceiling threshold (75 kPa) of the SSM@50Hz. The aims were to evaluate SSM by a novel spleen-dedicated FibroScan® (SSM@100Hz) for EV diagnosis compared with SSM@50Hz, other validated NITs and Baveno VI criteria. METHODS This prospective multicentre study consecutively enrolled patients with chronic liver disease; blood data, endoscopy, liver stiffness measurement (LSM), SSM@50Hz and SSM@100Hz were collected. RESULTS Two hundred and sixty patients met inclusion criteria. SSM@100Hz success rate was significantly higher than that of SSM@50Hz (92.5% vs 76.0%, P < .001). SSM@100Hz accuracy for the presence of EV (AUC = 0.728) and HRV (AUC = 0.756) was higher than in other NITs. SSM@100Hz AUC for large EV (0.782) was higher than SSM@50Hz (0.720, P = .027). AUC for HRV with SSM@100Hz (0.780) was higher than with LSM (0.615, P < .001). The spared endoscopy rate of Baveno VI criteria (8.1%) was significantly increased by the combination to SSM@50Hz (26.5%) or SSM@100Hz (38.9%, P < .001 vs others). The missed HRV rate was, respectively, 0% and 4.7% for combinations. CONCLUSIONS SSM@100Hz is a new performant non-invasive marker for EV and HRV providing a higher accuracy than SSM@50Hz and other NITs. The combination of Baveno VI criteria and SSM@100Hz significantly increased the spared endoscopy rate compared to Baveno VI criteria alone or combined with SSM@50Hz. Clinical trial number: NCT02180113.
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Affiliation(s)
- Horia Stefanescu
- Liver Unit, Regional Institute of Gastroenterology and Hepatology, Cluj-Napoca, Romania
| | - Giovanni Marasco
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Paul Calès
- Hepato-Gastroenterology Department, University hospital, Angers, France
| | - Mirella Fraquelli
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Matteo Rosselli
- Institute for Liver and Digestive Health, Royal Free Hospital, University College of London, London, UK
| | - Nathalie Ganne-Carriè
- INSERM UMR 1162, Hepato-Gastroenterology Department, APHP Jean Verdier Hospital, University Paris 13, Paris, France
| | | | - Federico Ravaioli
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Antonio Colecchia
- Gastroenterology Unit, University Hospital Borgo Trento, Verona, Italy
| | - Corina Rusu
- Liver Unit, Regional Institute of Gastroenterology and Hepatology, Cluj-Napoca, Romania
| | - Pietro Andreone
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Giuseppe Mazzella
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Davide Festi
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
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27
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Fierbinteanu-Braticevici C, Tribus L, Peagu R, Petrisor A, Baicus C, Cretoiu D, Pasternak A, Oprea G, Purcareanu A, Moldoveanu AC. Spleen Stiffness as Predictor of Esophageal Varices in Cirrhosis of Different Etiologies. Sci Rep 2019; 9:16190. [PMID: 31700031 PMCID: PMC6838194 DOI: 10.1038/s41598-019-52407-y] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Accepted: 10/09/2019] [Indexed: 02/06/2023] Open
Abstract
The purpose of this study is to determine whether esophageal varices (EV) can be identified through the evaluation of spleen stiffness (SSM) via acoustic radiation force impulse (ARFI). A total of 135 patients suffering from cirrhosis underwent a clinical exam, laboratory tests, abdominal ultrasound, liver stiffness (LSM) measurement, SSM evaluation and upper gastrointestinal endoscopy. Based on the endoscopy results, the patients were classified into three groups: those with no evident EV, those with small EV and those with varices needing treatment (VNT). Patients with EV of any grade had significantly higher average SSM values over those with no EV (3.37 m/s versus 2.79 m/s, p-value < 0.001), while patients with VNT showed an even greater difference (3.96 m/s versus 2.93 m/s, p-value < 0.001). SSM proved to be an excellent method of predicting patients with VNT.
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Affiliation(s)
- Carmen Fierbinteanu-Braticevici
- Medical Clinic II and Gastroenterology, Carol Davila University of Medicine and Pharmacy, Bucharest, 050474, Romania.,Department of Gastroenterology, Bucharest Emergency University Hospital, Bucharest, 050098, Romania
| | - Laura Tribus
- Medical Clinic II and Gastroenterology, Carol Davila University of Medicine and Pharmacy, Bucharest, 050474, Romania.,Department of Gastroenterology, Bucharest Emergency University Hospital, Bucharest, 050098, Romania
| | - Razvan Peagu
- Medical Clinic II and Gastroenterology, Carol Davila University of Medicine and Pharmacy, Bucharest, 050474, Romania.,Department of Gastroenterology, Bucharest Emergency University Hospital, Bucharest, 050098, Romania
| | - Ana Petrisor
- Medical Clinic II and Gastroenterology, Carol Davila University of Medicine and Pharmacy, Bucharest, 050474, Romania.,Department of Gastroenterology, Bucharest Emergency University Hospital, Bucharest, 050098, Romania
| | - Cristian Baicus
- Department of Clinical Epidemiology and Biostatistics, Carol Davila University of Medicine and Pharmacy Bucharest, Bucharest, 050474, Romania
| | - Dragos Cretoiu
- Department of Cellular and Molecular Biology and Histology, Carol Davila University of Medicine and Pharmacy, Bucharest, 050474, Romania. .,Fetal Medicine Excellence Research Center, Alessandrescu-Rusescu National Institute for Mother and Child Health, Bucharest, 011062, Romania.
| | - Artur Pasternak
- Department of Anatomy, Jagiellonian University Medical College, Krakow, 31-008, Poland
| | - Gabriela Oprea
- Medical Clinic II and Gastroenterology, Carol Davila University of Medicine and Pharmacy, Bucharest, 050474, Romania.,Department of Gastroenterology, Bucharest Emergency University Hospital, Bucharest, 050098, Romania
| | - Adina Purcareanu
- Medical Clinic II and Gastroenterology, Carol Davila University of Medicine and Pharmacy, Bucharest, 050474, Romania.,Department of Internal Medicine, Bucharest Emergency University Hospital, Bucharest, 050098, Romania
| | - Alexandru C Moldoveanu
- Medical Clinic II and Gastroenterology, Carol Davila University of Medicine and Pharmacy, Bucharest, 050474, Romania.,Department of Gastroenterology, Bucharest Emergency University Hospital, Bucharest, 050098, Romania
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28
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Peng W, Zhang XY, Li C, Wen TF, Yan LN, Yang JY. Spleen stiffness and volume help to predict posthepatectomy liver failure in patients with hepatocellular carcinoma. Medicine (Baltimore) 2019; 98:e15458. [PMID: 31045820 PMCID: PMC6504243 DOI: 10.1097/md.0000000000015458] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Posthepatectomy liver failure (PHLF) is the main cause of perioperative death, and liver cirrhosis is one of the most important risk factors for PHLF. Spleen stiffness (SS) is a novel ultrasonic indicator for liver cirrhosis and portal hypertension, however, it is not clear that whether it has a significant influence on PHLF. Future remnant liver volume (FRLV) is a significant factor for liver regeneration after hepatectomy, spleen volume (SV) could also predict the degree of liver cirrhosis, and recent literatures reported that SV to FRLV ratio (SV/FRLV) could predict small for size syndrome (SFSS) in liver transplantation, however, the relationship between SV/FRLV and PHLF in patients receiving hepatectomy is not known. Systemic inflammatory response (SIR) plays a significant role in the pathogenesis and progression of liver cirrhosis, however, it is not very clear about the exact relationship between SIR and PHLF.We prospectively collected the medical data of consecutive patients diagnosed with hepatocellular carcinoma (HCC) who underwent hepatectomy from August 2015 to February 2016. Preoperative measurements of SS, liver stiffness (LS), SV, FRLV, and SIR were performed on all patients. A univariate analysis was performed to find the risk factors of PHLF and a multivariate analysis was used to identify independent risk factors. The predictive efficiency of the risk factors was evaluated by receiver operating characteristic (ROC) curve.Twenty three (23) (14.6%) patients developed PHLF. Univariate analysis found several variables significantly related to PHLF, they were as follows: tumor diameter (P = .01), cirrhosis (P = .001), neutrophil to lymphocyte ratio (NLR) (P = .018), LS (P = .001), SS (P = .001), SV/FRLV (P < .001), operation duration (P = .003), transfusion (P = .009), hepatic inflow occlusion (HIO) (P = .001). Finally, SV/FRLV (P < .001, hazard ratio (HR) = 26.356, 95% confidence interval (CI) 1.627-425.21), SS (P = .009, HR = 1.077, 95%CI 1.017-1.141), and HIO time (P = .002, HR = 1.043, 95%CI 1.014-1.072) were determined as the independent risk factors of PHLF by multivariate analysis.SS and SV/FRLV help to predict the development of PHLF in patients with hepatocellular carcinoma.
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29
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Paternostro R, Reiberger T, Bucsics T. Elastography-based screening for esophageal varices in patients with advanced chronic liver disease. World J Gastroenterol 2019; 25:308-329. [PMID: 30686900 PMCID: PMC6343095 DOI: 10.3748/wjg.v25.i3.308] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Revised: 11/27/2018] [Accepted: 12/20/2018] [Indexed: 02/06/2023] Open
Abstract
Elastography-based liver stiffness measurement (LSM) is a non-invasive tool for estimating liver fibrosis but also provides an estimate for the severity of portal hypertension in patients with advanced chronic liver disease (ACLD). The presence of varices and especially of varices needing treatment (VNT) indicates distinct prognostic stages in patients with compensated ACLD (cACLD). The Baveno VI guidelines suggested a simple algorithm based on LSM < 20 kPa (by transient elastography, TE) and platelet count > 150 G/L for ruling-out VNT in patients with cACLD. These (and other) TE-based LSM cut-offs have been evaluated for VNT screening in different liver disease etiologies. Novel point shear-wave elastography (pSWE) and two-dimensional shear wave elastography (2D-SWE) methodologies for LSM have also been evaluated for their ability to screen for “any” varices and for VNT. Finally, the measurement of spleen stiffness (SSM) by elastography (mainly by pSWE and 2D-SWE) may represent another valuable screening tool for varices. Here, we summarize the current literature on elastography-based prediction of “any” varices and VNT. Finally, we have summarized the published LSM and SSM cut-offs in clinically useful scale cards.
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Affiliation(s)
- Rafael Paternostro
- Department of Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna A-1090, Austria
| | - Thomas Reiberger
- Department of Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna A-1090, Austria
| | - Theresa Bucsics
- Department of Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna A-1090, Austria
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30
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Reiberger T, Bucsics T, Paternostro R, Pfisterer N, Riedl F, Mandorfer M. Small Esophageal Varices in Patients with Cirrhosis-Should We Treat Them? CURRENT HEPATOLOGY REPORTS 2018; 17:301-315. [PMID: 30546995 PMCID: PMC6267385 DOI: 10.1007/s11901-018-0420-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE OF REVIEW The natural history and classification systems of small varices (≤ 5 mm in diameter) in cirrhotic patients with portal hypertension are summarized. Studies that assessed the course of and therapeutic intervention for small varices are discussed. RECENT FINDINGS Current non-invasive methods show suboptimal sensitivity to detect small varices in patients with cirrhosis. Next to etiological therapy, hepatic venous pressure gradient (HVPG)-guided non-selective betablocker or carvedilol treatment has shown to impact on natural history of small varices. SUMMARY The main therapeutic focus in cirrhotic patients with small varices is the cure of the underlying etiology. The optimal management of small varices should include measurement of HVPG. A pharmacological decrease in HVPG by non-selective betablocker therapy of ≥ 10% reduces the risk of progression to large varices, first variceal bleeding, and hepatic decompensation. If HVPG is not available, we would recommend carvedilol 12.5 mg q.d. for treatment of small varices in compensated patients without severe ascites. Only if small esophageal varices (EV) are not treated or in hemodynamic non-responders, follow-up endoscopies should be performed in 1-2 years of intervals considering the activity of liver disease or if hepatic decompensation occurs.
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Affiliation(s)
- Thomas Reiberger
- Vienna Hepatic Hemodynamic Lab, Medical University of Vienna, Vienna, Austria
- Division of Gastroenterology & Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Theresa Bucsics
- Vienna Hepatic Hemodynamic Lab, Medical University of Vienna, Vienna, Austria
- Division of Gastroenterology & Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Rafael Paternostro
- Vienna Hepatic Hemodynamic Lab, Medical University of Vienna, Vienna, Austria
- Division of Gastroenterology & Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Nikolaus Pfisterer
- Vienna Hepatic Hemodynamic Lab, Medical University of Vienna, Vienna, Austria
- Division of Gastroenterology & Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria
- Division of Gastroenterology, Krankenanstalt Rudolfstiftung, Vienna, Austria
| | - Florian Riedl
- Vienna Hepatic Hemodynamic Lab, Medical University of Vienna, Vienna, Austria
- Division of Gastroenterology & Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria
- Division of Gastroenterology, Medicine II, Universitätsklinikum St. Pölten, St. Pölten, Austria
| | - Mattias Mandorfer
- Vienna Hepatic Hemodynamic Lab, Medical University of Vienna, Vienna, Austria
- Division of Gastroenterology & Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria
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31
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Manatsathit W, Samant H, Kapur S, Ingviya T, Esmadi M, Wijarnpreecha K, McCashland T. Accuracy of liver stiffness, spleen stiffness, and LS-spleen diameter to platelet ratio score in detection of esophageal varices: Systemic review and meta-analysis. J Gastroenterol Hepatol 2018; 33:1696-1706. [PMID: 29736946 DOI: 10.1111/jgh.14271] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2017] [Revised: 03/19/2018] [Accepted: 04/18/2018] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND AIM There is increasing evidence of non-invasive measurement using elastography such liver stiffness (LS), spleen stiffness (SS), and LS-spleen diameter to platelet ratio score (LSPS) for detection of esophageal varices (EV); however, data regarding comparison between these three parameters are limited. METHODS We performed a systemic review and meta-analysis of studies evaluating performance of LS, SS, and LSPS for detection of EV and high risk/clinically significant EV (HREV). Pooled sensitivity, specificity, log diagnostic odd ratio (LDOR), and area under the receiver operating characteristic curve (AUC) of LS, SS, and LSPS for detection of EV and HREV were analyzed and compared. Publication bias was assessed by Deeks' funnel plot. RESULTS SS and LSPS were superior to LS for detection of EV with higher sensitivity (0.90 and 0.91 vs 0.85), specificity (0.73 and 0.76 vs 0.64), LDOR (3.24 and 3.35 vs 2.26), and AUC (0.899 and 0.851 vs 0.817). For HREV, SS had the highest sensitivity (0.87) followed by LS (0.85) and LSPS (0.82); however, SS had the lowest specificity (0.52), LDOR (2.09), and AUC (0.807) whereas LSPS had the highest specificity (0.77), LDOR (2.74), and AUC (0.861). CONCLUSION For detection of EV, we prefer using LSPS and SS over LS when available, while LS, SS, and LSPS cannot be recommended for detection of HREV due to their moderate sensitivity and specificity.
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Affiliation(s)
- Wuttiporn Manatsathit
- Division of Gastroenterology and Hepatology, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Hrishikesh Samant
- Division of Gastroenterology, Louisiana State University Health Science Center, Shreveport, Louisiana, USA
| | - Saurabh Kapur
- Division of Gastroenterology and Hepatology, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Thammasin Ingviya
- Department of Environmental Health and Engineering, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- Department of Family Medicine and Preventive Medicine, Prince of Songkhla University, Songkhla, Thailand
| | - Mohammad Esmadi
- Department of Internal Medicine, Methodist Physicians Clinic, Council Bluffs, Iowa, USA
| | - Karn Wijarnpreecha
- Department of Internal Medicine, Bassett Medical Center, Cooperstown, New York, USA
| | - Timothy McCashland
- Division of Gastroenterology and Hepatology, University of Nebraska Medical Center, Omaha, Nebraska, USA
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33
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Tseng Y, Li F, Wang J, Chen S, Jiang W, Shen X, Wu S. Spleen and liver stiffness for noninvasive assessment of portal hypertension in cirrhotic patients with large esophageal varices. JOURNAL OF CLINICAL ULTRASOUND : JCU 2018; 46:442-449. [PMID: 30132919 DOI: 10.1002/jcu.22635] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/12/2017] [Revised: 12/26/2017] [Accepted: 03/02/2018] [Indexed: 06/08/2023]
Abstract
PURPOSE Noninvasive evaluation of portal hypertension is needed for cirrhotic patients with large esophageal varices. This study was aimed at assessing the diagnostic value of liver/spleen stiffness in predicting hepatic vein pressure gradient (HVPG) in this special population. METHODS In the present prospective cohort study, liver/spleen stiffness was measured by transient elastography. Patients also underwent HVPG assessment, upper gastrointestinal endoscopy, and other noninvasive serum models. RESULTS Ninety-nine cirrhotic patients with large esophageal varices were enrolled. Liver/spleen stiffness strongly correlated with HVPG. In regards to significant portal hypertension, area under receiver operating characteristic curves (AUROCs) for liver/spleen stiffness were 0.74 and 0.91. Accuracy for detecting significant portal hypertension was 79% for spleen stiffness of 48.9 kPa (sensitivity: 76%, specificity: 100%, positive predictive value: 100%, negative predictive value: 38%) and 75% for liver stiffness of 16.0 kPa (sensitivity: 78%, specificity: 54%, positive predictive value: 92%, negative predictive value: 27%). Similarly, spleen stiffness had significant higher AUROCs for predicting HVPG ≥16 and ≥20 mm Hg than that of liver stiffness and other noninvasive serum models. CONCLUSION In cirrhotic patients with large esophageal varices, liver stiffness and spleen stiffness correlate with HVPG, and spleen stiffness is superior to liver stiffness in predicting portal hypertension.
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Affiliation(s)
- Yujen Tseng
- Department of Gastroenterology and Hepatology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Feng Li
- Department of Gastroenterology and Hepatology, Zhongshan Hospital, Fudan University, Shanghai, China
- Shanghai Institute of Liver Diseases, Shanghai, China
| | - Jian Wang
- Department of Gastroenterology and Hepatology, Zhongshan Hospital, Fudan University, Shanghai, China
- Shanghai Institute of Liver Diseases, Shanghai, China
| | - Shiyao Chen
- Department of Gastroenterology and Hepatology, Zhongshan Hospital, Fudan University, Shanghai, China
- Endoscopy Center, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Wei Jiang
- Department of Gastroenterology and Hepatology, Zhongshan Hospital, Fudan University, Shanghai, China
- Shanghai Institute of Liver Diseases, Shanghai, China
| | - Xizhong Shen
- Department of Gastroenterology and Hepatology, Zhongshan Hospital, Fudan University, Shanghai, China
- Shanghai Institute of Liver Diseases, Shanghai, China
| | - Shengdi Wu
- Department of Gastroenterology and Hepatology, Zhongshan Hospital, Fudan University, Shanghai, China
- Shanghai Institute of Liver Diseases, Shanghai, China
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34
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Bastard C, Miette V, Calès P, Stefanescu H, Festi D, Sandrin L. A Novel FibroScan Examination Dedicated to Spleen Stiffness Measurement. ULTRASOUND IN MEDICINE & BIOLOGY 2018; 44:1616-1626. [PMID: 29731186 DOI: 10.1016/j.ultrasmedbio.2018.03.028] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/06/2017] [Revised: 03/08/2018] [Accepted: 03/29/2018] [Indexed: 06/08/2023]
Abstract
Esophageal varices (EVs) are among the most severe complications of cirrhosis, with a prevalence of 50% to 60% among cirrhotic patients. International guidelines therefore recommend that cirrhotic patients should be screened for the presence of EVs. The main objective of this study was to introduce a new spleen-dedicated FibroScan (Echosens, Paris, France) examination and to assess its performance in detecting large EVs (grade 2 and 3). This novel examination has been validated in simulation and phantom studies and has been used in a population of patients with chronic liver disease. The study described here suggests that the novel spleen-dedicated FibroScan examination performs better than the standard FibroScan for the detection of large EVs (area under the curve = 0.70 for the standard examination and 0.79 [p <0.01] for the spleen examination), but further clinical studies are needed to investigate the role of spleen stiffness in the management of cirrhotic patients.
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Affiliation(s)
| | | | - Paul Calès
- Hepato-Gastroenterology Department, Angers University Hospital, Angers, France
| | - Horia Stefanescu
- Regional Institute of Gastroenterology and Hepatology, Cluj-Napoca, Romania
| | - Davide Festi
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
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Sami SS, Harman D, Ragunath K, Böhning D, Parkes J, Guha IN. Non-invasive tests for the detection of oesophageal varices in compensated cirrhosis: systematic review and meta-analysis. United European Gastroenterol J 2018; 6:806-818. [PMID: 30023058 PMCID: PMC6047293 DOI: 10.1177/2050640618767604] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2017] [Accepted: 02/27/2018] [Indexed: 12/15/2022] Open
Abstract
INTRODUCTION Conclusive data on the accuracy and clinical applicability of non-invasive screening tests for oesophageal varices (OV) in patients with compensated cirrhosis remain lacking. We conducted this study to identify currently available tests, estimate their diagnostic performance and then exemplify how these could be utilized in clinical practice. MATERIALS AND METHODS A systematic literature search was performed to identify all primary studies that reported accuracy using oesophagogastroduodenoscopy (OGD) as the gold standard. Sources searched included Ovid MEDLINE, Ovid EMBASE and The Cochrane Library databases. RESULTS Twenty-one studies with a total of 2471 patients were identified. Several tests were evaluated in more than three studies. Platelet count/spleen diameter ratio (PSR) had the highest summary area under the curve for detection of any size OV of 0.85 (95% confidence interval 0.78-0.92). At a cut-off of 909 (n = 4 studies) and prevalence rates of 10, 20, 30, 40 and 50% for OV, PSR screening correctly avoided the need for OGD in 70, 62, 55, 47 and 39% of patients, respectively. CONCLUSIONS PSR appears to be the most accurate and validated non-invasive screening test for OV in patients with compensated cirrhosis. At a cut-off of 909, PSR could be clinically useful to avoid OGDs in a significant proportion of patients.
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Affiliation(s)
- Sarmed S. Sami
- NIHR Nottingham Digestive Diseases
Biomedical Research Centre (BRC), Nottingham University Hospitals NHS Trust and the
University of Nottingham, Nottingham, United Kingdom
| | - David Harman
- NIHR Nottingham Digestive Diseases
Biomedical Research Centre (BRC), Nottingham University Hospitals NHS Trust and the
University of Nottingham, Nottingham, United Kingdom
| | - Krish Ragunath
- NIHR Nottingham Digestive Diseases
Biomedical Research Centre (BRC), Nottingham University Hospitals NHS Trust and the
University of Nottingham, Nottingham, United Kingdom
| | - Dankmar Böhning
- Statistical Sciences Research Institute,
University of Southampton, Southampton, United Kingdom
| | - Julie Parkes
- Public Health Sciences & Medical
Statistics, University of Southampton, Southampton, United Kingdom
| | - Indra Neil Guha
- NIHR Nottingham Digestive Diseases
Biomedical Research Centre (BRC), Nottingham University Hospitals NHS Trust and the
University of Nottingham, Nottingham, United Kingdom
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36
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Cheng F, Cao H, Liu J, Jiang L, Han H, Zhang Y, Guo D. Meta-analysis of the accuracy of transient elastography in measuring liver stiffness to diagnose esophageal varices in cirrhosis. Medicine (Baltimore) 2018; 97:e11368. [PMID: 29995773 PMCID: PMC6076160 DOI: 10.1097/md.0000000000011368] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2017] [Accepted: 06/11/2018] [Indexed: 01/30/2023] Open
Abstract
BACKGROUD To assess the diagnostic performance of transient elastography (TE) in detecting the presence and size of esophageal varices (EV) in cirrhotic patients. METHODS We searched PubMed, Web of Science, Wiley Online Library, Science Direct, China National Knowledge Infrastructure, WeiPu, WanFang database, and Baidu Scholar to identify studies that evaluated the diagnostic accuracy of TE in liver stiffness measurement, compared with esophagogastroduodenoscopy (EGD), for the detection of the presence and degree of EV in cirrhosis. RESULTS We included 32 studies in the presence of any EV (grade 1-3; n = 4082), 27 studies on substantial EV (grade 2-3; n = 5221) and 5 studies on large EV (grade 3). The pooled sensitivity, specificity, and diagnostic odds ratio (DOR) were 0.8 (95% CI, 0.78-0.86), 0.68 (95% CI, 0.62-0.74), and 10 (95% CI, 7-14) for any EV; 0.81 (95% CI, 0.77-0.85), 0.72 (95% CI, 0.66-0.77), and 11 (95% CI, 8-15) for substantial EV; and 0.92 (95% CI, 0.83-0.96), 0.78 (95% CI, 0.70-0.85), and 40 (95% CI, 15-107) for large EV. Subgroup analysis revealed that the heterogeneity among studies on any EV could potentially be explained by study location, proportion of Child A, and time interval between TE and EGD; for substantial EV, the proportion of Child A, etiology of cirrhosis, and the time interval between TE and EGD were important heterogeneity factors. Publication bias was found among studies evaluating diagnostic performance of TE for any EV. CONCLUSION TE is a good tool for detecting the presence and degree of EV; however, in determination of the liver stiffness cutoff values means that TE is only cautiously used in clinical practice.
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Affiliation(s)
- Fan Cheng
- Department of Health Statistics, School of Public Health
| | - Hongyan Cao
- Department of Health Statistics, School of Public Health
- Department of Mathematics, School of Basic Medicine, Shanxi Medical University
| | - Jinchun Liu
- Department of Gastroenterology, The First Affiliated Hospital of Shanxi Medical University, Taiyuan, Shanxi, China
| | - Lijun Jiang
- Department of Gastroenterology, The First Affiliated Hospital of Shanxi Medical University, Taiyuan, Shanxi, China
| | - Hongjuan Han
- Department of Health Statistics, School of Public Health
- Department of Mathematics, School of Basic Medicine, Shanxi Medical University
| | - Yanbo Zhang
- Department of Health Statistics, School of Public Health
- Molecular Imaging Precision Medicine Collaborative Innovation Center, Shanxi Medical University,Taiyuan, Shanxi, China
| | - Dongxing Guo
- Department of Health Statistics, School of Public Health
- Department of Mathematics, School of Basic Medicine, Shanxi Medical University
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37
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Noninvasive Assessment of Portal Hypertension in Advanced Chronic Liver Disease: An Update. Gastroenterol Res Pract 2018; 2018:4202091. [PMID: 29977287 PMCID: PMC6011072 DOI: 10.1155/2018/4202091] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Accepted: 04/30/2018] [Indexed: 12/14/2022] Open
Abstract
The assessment of portal hypertension is a relevant step in the evaluation of newly diagnosed advanced chronic liver disease (ACLD). The current gold standard includes the invasive evaluation of hepatic venous pressure gradient (HVPG) and endoscopy. However, noninvasive or minimally invasive techniques to assess portal hypertension have been proposed and well established. In the present manuscript, we review clinical studies on the use of noninvasive or minimally invasive techniques to assess portal hypertension in ACLD patients.
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Karatzas A, Konstantakis C, Aggeletopoulou I, Kalogeropoulou C, Thomopoulos K, Triantos C. Νon-invasive screening for esophageal varices in patients with liver cirrhosis. Ann Gastroenterol 2018; 31:305-314. [PMID: 29720856 PMCID: PMC5924853 DOI: 10.20524/aog.2018.0241] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2017] [Accepted: 01/26/2018] [Indexed: 12/11/2022] Open
Abstract
Esophageal varices are one of the main complications of liver cirrhosis. Upper gastrointestinal endoscopy is the gold standard for the detection of esophageal varices. Many less invasive methods for screening of varices have been investigated and the most recent Baveno VI guidelines suggest that endoscopy is not necessary in patients with liver stiffness <20 kPa and platelets >150,000/μL. A critical review of the literature was performed concerning non-invasive or minimally invasive methods of screening for esophageal varices. Liver and spleen elastography, imaging methods including computed tomography, magnetic resonance imaging and ultrasound, laboratory tests and capsule endoscopy are discussed. The accuracy of each method, and its advantages and limitations compared to endoscopy are analyzed. There are data to support the Baveno VI guidelines, but there is still a lack of large prospective studies and low specificity has been reported for the liver stiffness and platelet count combination. Spleen elastography has shown promising results, as there are data to support its superiority to liver elastography, but it needs further assessment. Computed tomography has shown high diagnostic accuracy and can be part of the diagnostic work up of cirrhotic patients in the future, including screening for varices.
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Affiliation(s)
- Andreas Karatzas
- Department of Radiology, Olympion Therapeutirio (Andreas Karatzas)
| | | | - Ioanna Aggeletopoulou
- Department of Gastroenterology, University Hospital of Patras (Ioanna Aggeletopoulou, Konstantinos Thomopoulos, Christos Triantos)
| | - Christina Kalogeropoulou
- Department of Radiology, University Hospital of Patras (Christina Kalogeropoulou), Patras, Achaia, Greece
| | - Konstantinos Thomopoulos
- Department of Gastroenterology, University Hospital of Patras (Ioanna Aggeletopoulou, Konstantinos Thomopoulos, Christos Triantos)
| | - Christos Triantos
- Department of Gastroenterology, University Hospital of Patras (Ioanna Aggeletopoulou, Konstantinos Thomopoulos, Christos Triantos)
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39
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Kennedy P, Wagner M, Castéra L, Hong CW, Johnson CL, Sirlin CB, Taouli B. Quantitative Elastography Methods in Liver Disease: Current Evidence and Future Directions. Radiology 2018; 286:738-763. [PMID: 29461949 DOI: 10.1148/radiol.2018170601] [Citation(s) in RCA: 183] [Impact Index Per Article: 30.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Chronic liver diseases often result in the development of liver fibrosis and ultimately, cirrhosis. Treatment strategies and prognosis differ greatly depending on the severity of liver fibrosis, thus liver fibrosis staging is clinically relevant. Traditionally, liver biopsy has been the method of choice for fibrosis evaluation. Because of liver biopsy limitations, noninvasive methods have become a key research interest in the field. Elastography enables the noninvasive measurement of tissue mechanical properties through observation of shear-wave propagation in the tissue of interest. Increasing fibrosis stage is associated with increased liver stiffness, providing a discriminatory feature that can be exploited by elastographic methods. Ultrasonographic (US) and magnetic resonance (MR) imaging elastographic methods are commercially available, each with their respective strengths and limitations. Here, the authors review the technical basis, acquisition techniques, and results and limitations of US- and MR-based elastography techniques. Diagnostic performance in the most common etiologies of chronic liver disease will be presented. Reliability, reproducibility, failure rate, and emerging advances will be discussed. © RSNA, 2018 Online supplemental material is available for this article.
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Affiliation(s)
- Paul Kennedy
- From the Translational and Molecular Imaging Institute (P.K., B.T.) and Department of Radiology (B.T.), Icahn School of Medicine at Mount Sinai, 1470 Madison Ave, New York, NY 10029; Department of Radiology, Sorbonne Universités, UPMC, Hôpital Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Paris, France (M.W.); Department of Hepatology, University Paris-VII, Hôpital Beaujon, Clichy, France (L.C.); Liver Imaging Group, Department of Radiology, University of California-San Diego, San Diego, Calif (C.W.H., C.B.S.); Department of Biomedical Engineering, University of Delaware, Newark, Del (C.L.J.)
| | - Mathilde Wagner
- From the Translational and Molecular Imaging Institute (P.K., B.T.) and Department of Radiology (B.T.), Icahn School of Medicine at Mount Sinai, 1470 Madison Ave, New York, NY 10029; Department of Radiology, Sorbonne Universités, UPMC, Hôpital Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Paris, France (M.W.); Department of Hepatology, University Paris-VII, Hôpital Beaujon, Clichy, France (L.C.); Liver Imaging Group, Department of Radiology, University of California-San Diego, San Diego, Calif (C.W.H., C.B.S.); Department of Biomedical Engineering, University of Delaware, Newark, Del (C.L.J.)
| | - Laurent Castéra
- From the Translational and Molecular Imaging Institute (P.K., B.T.) and Department of Radiology (B.T.), Icahn School of Medicine at Mount Sinai, 1470 Madison Ave, New York, NY 10029; Department of Radiology, Sorbonne Universités, UPMC, Hôpital Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Paris, France (M.W.); Department of Hepatology, University Paris-VII, Hôpital Beaujon, Clichy, France (L.C.); Liver Imaging Group, Department of Radiology, University of California-San Diego, San Diego, Calif (C.W.H., C.B.S.); Department of Biomedical Engineering, University of Delaware, Newark, Del (C.L.J.)
| | - Cheng William Hong
- From the Translational and Molecular Imaging Institute (P.K., B.T.) and Department of Radiology (B.T.), Icahn School of Medicine at Mount Sinai, 1470 Madison Ave, New York, NY 10029; Department of Radiology, Sorbonne Universités, UPMC, Hôpital Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Paris, France (M.W.); Department of Hepatology, University Paris-VII, Hôpital Beaujon, Clichy, France (L.C.); Liver Imaging Group, Department of Radiology, University of California-San Diego, San Diego, Calif (C.W.H., C.B.S.); Department of Biomedical Engineering, University of Delaware, Newark, Del (C.L.J.)
| | - Curtis L Johnson
- From the Translational and Molecular Imaging Institute (P.K., B.T.) and Department of Radiology (B.T.), Icahn School of Medicine at Mount Sinai, 1470 Madison Ave, New York, NY 10029; Department of Radiology, Sorbonne Universités, UPMC, Hôpital Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Paris, France (M.W.); Department of Hepatology, University Paris-VII, Hôpital Beaujon, Clichy, France (L.C.); Liver Imaging Group, Department of Radiology, University of California-San Diego, San Diego, Calif (C.W.H., C.B.S.); Department of Biomedical Engineering, University of Delaware, Newark, Del (C.L.J.)
| | - Claude B Sirlin
- From the Translational and Molecular Imaging Institute (P.K., B.T.) and Department of Radiology (B.T.), Icahn School of Medicine at Mount Sinai, 1470 Madison Ave, New York, NY 10029; Department of Radiology, Sorbonne Universités, UPMC, Hôpital Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Paris, France (M.W.); Department of Hepatology, University Paris-VII, Hôpital Beaujon, Clichy, France (L.C.); Liver Imaging Group, Department of Radiology, University of California-San Diego, San Diego, Calif (C.W.H., C.B.S.); Department of Biomedical Engineering, University of Delaware, Newark, Del (C.L.J.)
| | - Bachir Taouli
- From the Translational and Molecular Imaging Institute (P.K., B.T.) and Department of Radiology (B.T.), Icahn School of Medicine at Mount Sinai, 1470 Madison Ave, New York, NY 10029; Department of Radiology, Sorbonne Universités, UPMC, Hôpital Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Paris, France (M.W.); Department of Hepatology, University Paris-VII, Hôpital Beaujon, Clichy, France (L.C.); Liver Imaging Group, Department of Radiology, University of California-San Diego, San Diego, Calif (C.W.H., C.B.S.); Department of Biomedical Engineering, University of Delaware, Newark, Del (C.L.J.)
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40
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Mazur R, Celmer M, Silicki J, Hołownia D, Pozowski P, Międzybrodzki K. Clinical applications of spleen ultrasound elastography - a review. J Ultrason 2018; 18:37-41. [PMID: 29844939 PMCID: PMC5911717 DOI: 10.15557/jou.2018.0006] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2017] [Revised: 12/24/2017] [Accepted: 12/28/2017] [Indexed: 12/22/2022] Open
Abstract
In the last few years, notable technical progress has taken place in ultrasound elastography. Qualitative methods have been replaced by quantitative ones, such as: transient elastography, acoustic radiation force impulse and shear wave elastography. Owing to the fact that the spleen is superficially located, it is possible to obtain reliable measuring accuracy of its hardness using sonoelastography. Lately, many researchers have been investigating how spleen elasticity changes in patients infected with hepatitis B virus or hepatitis C virus and in patients suffering from liver fibrosis, portal hypertension, esophageal varices or myelofibrosis. In this article, we review the role and current status of accessible qualitative ultrasound elastography methods, including recent advances in the evaluation of spleen stiffness and its clinical utility. As study results demonstrate, spleen stiffness correlates with liver fibrosis and is helpful in determining the level of fibrosis in the METAVIR scoring system. In patients infected with hepatitis B virus or hepatitis C virus, spleen stiffness increases even when liver elasticity remains unaltered. Furthermore, it is useful in diagnosing portal hypertension or predicting existence of esophageal varices. Moreover, in patients suffering from biliary atresia after Kasai portoenterostomy, spleen sonoelastography may be helpful in selecting patients for liver transplantation as well as for choosing the best strategy for portal vein reconstruction before liver transplantation. In myelofibrosis, spleen stiffness correlates with bone marrow fibrosis and may be used to assess the response to treatment. Spleen sonoelastography is also useful in the monitoring of transjugular intrahepatic portosystemic shunt function.
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Affiliation(s)
- Rafał Mazur
- Department of General and Pediatric Radiology, University Teaching Hospital, Wrocław, Poland
- Department of Radiology, Wrocław Medical University, Wroclaw, Poland
| | - Milena Celmer
- Department of General and Pediatric Radiology, University Teaching Hospital, Wrocław, Poland
- Department of Radiology, Wrocław Medical University, Wroclaw, Poland
| | - Jurand Silicki
- Department of General and Pediatric Radiology, University Teaching Hospital, Wrocław, Poland
- Department of Radiology, Wrocław Medical University, Wroclaw, Poland
| | - Daniel Hołownia
- Department of General and Pediatric Radiology, University Teaching Hospital, Wrocław, Poland
| | - Patryk Pozowski
- Faculty of Medicine, Wrocław Medical University, Wrocław, Poland
| | - Krzysztof Międzybrodzki
- Department of General and Pediatric Radiology, University Teaching Hospital, Wrocław, Poland
- Department of Radiology, Wrocław Medical University, Wroclaw, Poland
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41
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De Santis A, Nardelli S, Bassanelli C, Lupo M, Iegri C, Di Ciesco CA, Forlino M, Farcomeni A, Riggio O. Modification of splenic stiffness on acoustic radiation force impulse parallels the variation of portal pressure induced by transjugular intrahepatic portosystemic shunt. J Gastroenterol Hepatol 2018; 33:704-709. [PMID: 28753738 DOI: 10.1111/jgh.13907] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2017] [Revised: 06/25/2017] [Accepted: 07/17/2017] [Indexed: 01/06/2023]
Abstract
BACKGROUND AND AIM Spleen and liver stiffness (LS) measured by acoustic radiation force impulse (ARFI) imaging has been shown to be useful in identifying patients with portal hypertension. The study aims to establish if the modification of portal pressure induced by a transjugular intrahepatic portosystemic shunt (TIPS) parallels the modification of spleen or LS measured by ARFI in order to understand if ARFI may be used to monitor the modification of portal pressure in patients with cirrhosis. METHODS Thirty-eight patients with severe portal hypertension underwent LS and spleen stiffness (SS) before TIPS and 1 week after TIPS. Portal atrial gradient (PAG) was measured before and after the shunt opening. RESULTS Portal atrial gradient decreased significantly from 19.5 to 6 mmHg (P < 0.001). SS decreased significantly after TIPS (pre-TIPS 3.7 m/s vs post-TIPS 3. 1 m/s; P < 0.001), and LS was also significantly modified by TIPS (pre-TIPS 2.8 m/s vs post-TIPS 2.4 m/s; P = 0.003). PAG and SS values measured before and after TIPS were significantly correlated (r = 0.56; P < 0.001); on the other hand, PAG and LS were not (r = 0.19; P = 0.27). Two patients developed a persistent hepatic encephalopathy refractory to medical treatment and were submitted to the reduction of the stent diameter. The modification of SS was parallel to the modification of PAG. CONCLUSION Spleen stiffness is superior to LS in detecting the modification of portal pressure induced by TIPS. This makes SS a potential non-invasive method to monitor the modification of portal hypertension. Further investigations are needed to establish applicability and clinical utility of this promising tool in the treatment of portal hypertension.
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Affiliation(s)
- Adriano De Santis
- Department of Clinical Medicine, Gastroenterology Unit and Center for the study of Portal Hypertension, Sapienza University of Rome, Rome, Italy
| | - Silvia Nardelli
- Department of Clinical Medicine, Gastroenterology Unit and Center for the study of Portal Hypertension, Sapienza University of Rome, Rome, Italy
| | - Chiara Bassanelli
- Department of Clinical Medicine, Gastroenterology Unit and Center for the study of Portal Hypertension, Sapienza University of Rome, Rome, Italy
| | - Marinella Lupo
- Department of Clinical Medicine, Gastroenterology Unit and Center for the study of Portal Hypertension, Sapienza University of Rome, Rome, Italy
| | - Claudia Iegri
- Department of Clinical Medicine, Gastroenterology Unit and Center for the study of Portal Hypertension, Sapienza University of Rome, Rome, Italy
| | - Carmela Anna Di Ciesco
- Department of Clinical Medicine, Gastroenterology Unit and Center for the study of Portal Hypertension, Sapienza University of Rome, Rome, Italy
| | - Mariana Forlino
- Department of Clinical Medicine, Gastroenterology Unit and Center for the study of Portal Hypertension, Sapienza University of Rome, Rome, Italy
| | - Alessio Farcomeni
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy
| | - Oliviero Riggio
- Department of Clinical Medicine, Gastroenterology Unit and Center for the study of Portal Hypertension, Sapienza University of Rome, Rome, Italy
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Roccarina D, Rosselli M, Genesca J, Tsochatzis EA. Elastography methods for the non-invasive assessment of portal hypertension. Expert Rev Gastroenterol Hepatol 2018; 12:155-164. [PMID: 28856972 DOI: 10.1080/17474124.2017.1374852] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The gold standard to assess the presence and severity of portal hypertension remains the hepatic vein pressure gradient, however the recent development of non-invasive assessment using elastography techniques offers valuable alternatives. In this review, we discuss the diagnostic accuracy and utility of such techniques in patients with portal hypertension due to cirrhosis. Areas covered: A literature search focused on liver and spleen stiffness measurement with different elastographic techniques for the assessment of the presence and severity of portal hypertension and oesophageal varices in people with chronic liver disease. The combination of elastography with parameters such as platelet count and spleen size is also discussed. Expert commentary: Non-invasive assessment of liver fibrosis and portal hypertension is a validated tool for the diagnosis and follow-up of patients. Baveno VI recommended the combination of transient elastography and platelet count for ruling out varices needing treatment in patients with compensated advanced chronic liver disease. Assessment of aetiology specific cut-offs for ruling in and ruling out clinically significant portal hypertension is an unmet clinical need. The incorporation of spleen stiffness measurements in non-invasive algorithms using validated software and improved measuring scales might enhance the non-invasive diagnosis of portal hypertension in the next 5 years.
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Affiliation(s)
- Davide Roccarina
- a UCL Institute for Liver and Digestive Health , Royal Free Hospital and UCL , London , UK
| | - Matteo Rosselli
- a UCL Institute for Liver and Digestive Health , Royal Free Hospital and UCL , London , UK
| | - Joan Genesca
- b Liver Unit, Department of Internal Medicine , Valld'Hebron University Hospital, VHIR, Universitat Autònoma de Barcelona, CIBERehd , Barcelona , Spain
| | - Emmanuel A Tsochatzis
- a UCL Institute for Liver and Digestive Health , Royal Free Hospital and UCL , London , UK
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43
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Berzigotti A, Ferraioli G, Bota S, Gilja OH, Dietrich CF. Novel ultrasound-based methods to assess liver disease: The game has just begun. Dig Liver Dis 2018; 50:107-112. [PMID: 29258813 DOI: 10.1016/j.dld.2017.11.019] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2017] [Revised: 11/08/2017] [Accepted: 11/27/2017] [Indexed: 12/11/2022]
Abstract
In the last 10 years the availability of ultrasound elastography allowed to diagnose and stage liver fibrosis in a non-invasive way and changed the clinical practice of hepatology. Newer ultrasound-based techniques to evaluate properties of the liver tissue other than fibrosis are emerging and will lead to a more complete characterization of the full spectrum of diffuse and focal liver disease. Since these methods are currently undergoing validation and go beyond elastography for liver tissue evaluation, they were not included in the recent guidelines regarding elastography issued by the European Federation of Societies in Ultrasound in Medicine and Biology. In this review paper, we outline the major advances in the field of ultrasound for liver applications, with special emphasis on techniques that could soon be part of the future armamentarium of ultrasound specialists devoted to the assessment of liver disease. Specifically, we discuss current and future ultrasound assessment of steatosis, spleen stiffness for portal hypertension, and elastography for the evaluation of focal liver lesions; we also provide a short glimpse into the next generation of ultrasound diagnostic methods.
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Affiliation(s)
- Annalisa Berzigotti
- Hepatology, University Clinic for Visceral Surgery and Medicine, Inselspital, University of Bern, Berne, Switzerland.
| | - Giovanna Ferraioli
- Clinical Sciences and Infectious Diseases Department, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy.
| | - Simona Bota
- Department of Gastroenterology, Hepatology, Nephrology and Endocrinology, Klinikum Klagenfurt, Klagenfurt am Wörthersee, Austria.
| | - Odd Helge Gilja
- National Centre for Ultrasound in Gastroenterology, Haukeland University Hospital, Bergen and Department of Clinical Medicine, University of Bergen, Norway.
| | - Christoph F Dietrich
- Department of Internal Medicine 2, Caritas Krankenhaus, Bad Mergentheim, Germany.
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Pateu E, Oberti F, Calès P. The noninvasive diagnosis of esophageal varices and its application in clinical practice. Clin Res Hepatol Gastroenterol 2018; 42:6-16. [PMID: 28870440 DOI: 10.1016/j.clinre.2017.07.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2017] [Accepted: 07/31/2017] [Indexed: 02/04/2023]
Abstract
Here, we review recent improvements made to different noninvasive tests used for the diagnosis of esophageal varices (EV) in the light of the recent Baveno VI recommendation and with an emphasis on clinical application. Like for fibrosis tests, these noninvasive EV tests can be classified as direct markers when they provide a visualization of EV (including all imaging procedures like endoscopy or radiology) and as indirect markers when they do not (blood markers or elastometry). Clinical descriptors expressed as percentages, especially the spared endoscopy rate and the missed high-risk esophageal varices (HREV) rate, are more eloquent in this setting than classical statistical descriptors like accuracy. Single biomarkers are insufficient, generally due to a missed HREV rate exceeding the acceptable limit of 5% indicated in the Baveno VI consensus. Thus, biomarker combinations are currently garnering the most interest. The Baveno VI recommendation states that in alcoholic and viral cirrhoses, screening endoscopy can be safely set aside for patients with liver stiffness<20kPa and platelets>150G/L. The Baveno rule's mean missed HREV rate is<5% but its spared endoscopy rate is<20%. New combinations or stepwise algorithms show promise but must be validated. Going forward, the Baveno rule provides a simple noninvasive method to rule out HREV in clinical practice but the need for further research continues. The noninvasive diagnosis of HREV will be significantly improved by new, simple and affordable combinations.
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Affiliation(s)
- Etienne Pateu
- Hepato-Gastroenterology Department, University Hospital, 49933 Angers, France
| | - Frédéric Oberti
- Hepato-Gastroenterology Department, University Hospital, 49933 Angers, France; HIFIH Laboratory, University Angers, Bretagne-Loire University, 49045 Angers, France
| | - Paul Calès
- Hepato-Gastroenterology Department, University Hospital, 49933 Angers, France; HIFIH Laboratory, University Angers, Bretagne-Loire University, 49045 Angers, France.
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Li T, Qu Y, Yang B, Xue Y, Wang L. Evaluation of large esophageal varices in cirrhotic patients by transient elastography: a meta-analysis. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2017; 108:464-72. [PMID: 27444047 DOI: 10.17235/reed.2016.3980/2015] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND PURPOSE Transient elastography (TE) has been shown to be a valuable tool for the prediction of large esophageal varices. However, the conclusions have not been always consistent throughout the different studies. Therefore, we performed a further meta-analysis in order to evaluate the diagnostic accuracy of transient elastography for the prediction of large esophageal varices. METHODS We performed a systematic literature search in PubMed, EMBASE, Web of Science, and CENTRAL in The Cochrane Library without time restriction. The strategy we used was "(fibroscan OR transient elastography OR stiffness) AND esophageal varices". Accuracy measures such as pooled sensitivity, specificity, among others, were calculated using Meta-DiSc statistical software. RESULTS Twenty studies (2,994 patients) were included in our meta-analysis. The values of pooled sensitivity, specificity, positive and negative likelihood ratios and diagnostic odds ratio were as follows: 0.81 (95% CI, 0.79-0.84), 0.71 (95% CI, 0.69-0.73), 2.63 (95% CI, 2.15-3.23), 0.27 (95% CI, 0.22-0.34) and 10.30 (95% CI, 7.33-14.47). The area under the receiver operating characteristics curve was 0.83. The Spearman correlation coefficient was 0.246 with a p-value of 0.296, indicating the absence of any significant threshold effects. In our subgroup analysis, the heterogeneity could be partially explained by the geographical origin of the study or etiology; or it could be partially explained blindingly, through the appropriate interval and cut-off value of the liver stiffness (LS). CONCLUSIONS Transient elastography could be used as a valuable non-invasive screening tool for the prediction of large esophageal varices. However, since LS cut-off values vary throughout the different studies and significant heterogeneity also exists among them, we need more reasonable approaches or flow diagram in order to improve the operability of this technology.
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Affiliation(s)
- Tao Li
- Department of Infectious Diseases and Hepatology, the Second Hospital of Shandong University, China
| | - Yundong Qu
- Department of Infectious Diseases and Hepatology, the Second Hospital of Shandong University, China
| | - Baohua Yang
- Department of Infectious Diseases and Hepatology, the Second Hospital of Shandong University, China
| | - Yan Xue
- Department of Infectious Diseases and Hepatology, the Second Hospital of Shandong University, China
| | - Lei Wang
- Department of Infectious Diseases and Hepatology, the Second Hospital of Shandong University, China
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46
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Non-invasive evaluation of portal hypertension using ultrasound elastography. J Hepatol 2017; 67:399-411. [PMID: 28223101 DOI: 10.1016/j.jhep.2017.02.003] [Citation(s) in RCA: 167] [Impact Index Per Article: 23.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2016] [Revised: 02/04/2017] [Accepted: 02/06/2017] [Indexed: 02/06/2023]
Abstract
Portal hypertension (PH) leads to serious complications, such as bleeding from gastroesophageal varices, ascites and portosystemic encephalopathy in patients with chronic liver disease (CLD). Gold standard methods for assessing PH and its complications include the measurement of hepatic venous pressure gradient and endoscopy; however, these are invasive, expensive and not available at all centres. Therefore, non-invasive alternatives have been the subject of extensive investigation over the last 20years. The present review focuses on the role of ultrasound elastography - a novel group of non-invasive techniques used to measure stiffness in target organs. In the context of CLD these methods are used to identify the presence of PH, its severity, and the risk of PH-related complications. The rationale, accumulated evidence, advantages and limitations of liver and spleen stiffness measurements evaluated by different ultrasound elastography techniques in patients with advanced CLD is discussed. Recent data regarding the use of ultrasound elastography techniques in patients with non-cirrhotic forms of PH are also described.
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Singh S, Muir AJ, Dieterich DT, Falck-Ytter YT. American Gastroenterological Association Institute Technical Review on the Role of Elastography in Chronic Liver Diseases. Gastroenterology 2017; 152:1544-1577. [PMID: 28442120 DOI: 10.1053/j.gastro.2017.03.016] [Citation(s) in RCA: 191] [Impact Index Per Article: 27.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Chronic liver diseases (CLDs), due to chronic hepatitis C; hepatitis B; nonalcoholic fatty liver diseases (NAFLD); and alcoholic liver disease, are a leading cause of morbidity and mortality globally. Early identification of patients with cirrhosis at high risk of progression to liver-related complications may facilitate timely care and improve outcomes. With risks and misclassification associated with invasive tests, such as liver biopsy, noninvasive imaging modalities for liver fibrosis assessment have gained popularity. Therefore, the American Gastroenterological Association prioritized clinical guidelines on the role of elastography in CLDs, focusing on vibration-controlled transient elastography (VCTE) and magnetic resonance elastography (MRE). To inform these clinical guidelines, the current technical review was developed in accordance with the Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework for diagnostic accuracy studies. This technical review addresses focused questions related to: (1) comparative diagnostic performance of VCTE and MRE relative to nonproprietary, serum-based fibrosis markers for detection of cirrhosis in patients with hepatitis C virus (HCV), hepatitis B virus (HBV), NAFLD, and alcoholic liver diseases; (2) performance of specific VCTE-defined liver stiffness cutoffs as a test replacement strategy (to replace liver biopsy) in making key decisions in the management of patients with CLDs; and (3) performance of specific VCTE-defined liver stiffness cutoffs as a triage test to identify patients with low likelihood of harboring high-risk esophageal varices (EVs) or having clinically significant portal hypertension (for presurgical risk stratification). This technical review does not address performance of other noninvasive modalities for assessing fibrosis (eg, acoustic radiation force pulse imaging or shear wave elastography) or steatosis (controlled attenuation parameter or magnetic resonance imaging-estimated proton density fat fraction).
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Affiliation(s)
- Siddharth Singh
- Division of Gastroenterology, University of California San Diego, La Jolla, California
| | - Andrew J Muir
- Division of Gastroenterology, Duke University School of Medicine, Durham, North Carolina
| | | | - Yngve T Falck-Ytter
- Division of Gastroenterology and Hepatology, Cleveland VA Medical Center and University Hospitals, Case Western Reserve University, Cleveland, Ohio
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48
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Lee CK. Biomarkers and imaging studies to predict portal hypertension and varices. Clin Liver Dis (Hoboken) 2017; 9:94-98. [PMID: 30992968 PMCID: PMC6467149 DOI: 10.1002/cld.627] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2016] [Accepted: 01/28/2017] [Indexed: 02/04/2023] Open
Affiliation(s)
- Christine K. Lee
- Division of Gastroenterology, Hepatology and NutritionBoston Children's Hospital300 Longwood AvenueBostonMA
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Platelet Count to Spleen Diameter Ratio for the Diagnosis of Gastroesophageal Varices in Liver Cirrhosis: A Systematic Review and Meta-Analysis. Gastroenterol Res Pract 2017; 2017:7407506. [PMID: 28270848 PMCID: PMC5320338 DOI: 10.1155/2017/7407506] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2016] [Accepted: 11/30/2016] [Indexed: 12/15/2022] Open
Abstract
Platelet count to spleen diameter ratio (PSR) was studied extensively as a noninvasive method of diagnosis for varices. The present study aimed to systematically assess the performance of PSR in the diagnosis of varices. PubMed, EMBASE, and article references were searched. The summary receiver operating characteristic curves (AUSROCs), sensitivities, specificities, positive and negative likelihood ratio, and diagnostic odds ratio were calculated. The heterogeneity, quality, and publication bias of studies were evaluated. Subgroup and sensitivity analyses were performed. A total of 49 papers were included. The AUSROCs of PSR for any varices and high-risk varices were 0.8719 and 0.8132, respectively. The summary sensitivities of PSR for any varices and high-risk varices were 0.84 and 0.78, respectively. The summary specificities of PSR for any varices and high-risk varices were 0.78 and 0.67, respectively. The AUSROC of PSR for any varices at the threshold of 909 was 0.8867. The AUSROC of PSR for any varices in viral liver cirrhosis was 0.8675. The overall quality of studies was moderate. Significant heterogeneity and publication bias existed in the study. In conclusion, PSR can be used to identify varices in liver cirrhosis. PSR had a high sensitivity in viral liver cirrhosis.
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Pu K, Shi JH, Wang X, Tang Q, Wang XJ, Tang KL, Long ZQ, Hu XS. Diagnostic accuracy of transient elastography (FibroScan) in detection of esophageal varices in patients with cirrhosis: A meta-analysis. World J Gastroenterol 2017; 23:345-356. [PMID: 28127208 PMCID: PMC5236514 DOI: 10.3748/wjg.v23.i2.345] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2016] [Revised: 09/29/2016] [Accepted: 10/31/2016] [Indexed: 02/06/2023] Open
Abstract
AIM To investigate the diagnostic accuracy of FibroScan (FS) in detecting esophageal varices (EV) in cirrhotic patients.
METHODS Through a systemic literature search of multiple databases, we reviewed 15 studies using endoscopy as a reference standard, with the data necessary to calculate pooled sensitivity (SEN) and specificity (SPE), positive and negative LR, diagnostic odds ratio (DOR) and area under receiver operating characteristics (AUROC). The quality of the studies was rated by the Quality Assessment of Diagnostic Accuracy studies-2 tool. Clinical utility of FS for EV was evaluated by a Fagan plot. Heterogeneity was explored using meta-regression and subgroup analysis. All statistical analyses were conducted via Stata12.0, MetaDisc1.4 and RevMan5.
RESULTS In 15 studies (n = 2697), FS detected the presence of EV with the summary sensitivities of 84% (95%CI: 81.0%-86.0%), specificities of 62% (95%CI: 58.0%- 66.0%), a positive LR of 2.3 (95%CI: 1.81-2.94), a negative LR of 0.26 (95%CI: 0.19-0.35), a DOR of 9.33 (95%CI: 5.84-14.92) and an AUROC of 0.8262. FS diagnosed the presence of large EV with the pooled SEN of 0.78 (95%CI: 75.0%-81.0%), SPE of 0.76 (95%CI: 73.0%-78.0%), a positive and negative LR of 3.03 (95%CI: 2.38-3.86) and 0.30 (95%CI: 0.23-0.39) respectively, a summary diagnostic OR of 10.69 (95%CI: 6.81-16.78), and an AUROC of 0.8321. A meta-regression and subgroup analysis indicated different etiology could serve as a potential source of heterogeneity in the diagnosis of the presence of EV group. A Deek’s funnel plot suggested a low probability for publication bias.
CONCLUSION Using FS to measure liver stiffness cannot provide high accuracy for the size of EV due to the various cutoff and different etiologies. These limitations preclude widespread use in clinical practice at this time; therefore, the results should be interpreted cautiously given its SEN and SPE.
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