Computed tomography vs liver stiffness measurement and magnetic resonance imaging in evaluating esophageal varices in cirrhotic patients: A systematic review and meta-analysis

Computed tomography for the diagnosis of gastroesophageal varices and risk assessment in patients with cirrhosis: a systematic review and meta-analysis

PURPOSE

This meta-analysis aimed to evaluate the diagnostic accuracy of computed tomography (CT) for detecting gastroesophageal varices (GEVs) and identify high-risk GEVs in patients with cirrhosis.

METHODS

A comprehensive search of databases identified 28 studies reporting on CT-based diagnosis for GEVs confirmed via endoscopy. Meta-analyses were conducted to calculate pooled sensitivity (SEN) and pooled specificity (SPE), positive likelihood ratio (PLR) and negative likelihood ratio (NLR), diagnostic odds ratio (DOR), and the area under the curve (AUC).

RESULTS

Based on the number of patients (or varices), the pooled SEN, SPE, PLR, NLR, DOR, and AUC of CT-based diagnosis were estimated at 0.91 (0.92), 0.81 (0.45), 4.82 (1.67), 0.11 (0.17), 42.47 (10.26), and 0.93 (0.94), respectively, for any GEV and at 0.89 (0.89), 0.90 (0.79), 8.86 (4.28), 0.12 (0.14), 75.71 (30.19), and 0.95 (0.85), respectively, for high-risk GEVs. Subgroup analyses indicated that CT had a higher diagnostic accuracy for esophageal varices compared with gastric varices (AUC: 0.93 vs. 0.89, P < 0.05), and the 64-slice CT yielded superior SEN compared with 16-slice and <16-slice CT (AUC: 0.97 vs. 0.92 and 0.82, respectively, P < 0.05). Prospective studies demonstrated higher diagnostic accuracy than retrospective studies (AUC: 0.95 vs. 0.90, P < 0.05). Regarding variceal size, a cut-off of 3 mm and 5 mm discriminated between low- and high-risk individuals, respectively, with high diagnostic accuracy (AUC: 0.992 vs. 0.997, P > 0.05).

CONCLUSION

CT demonstrates promising diagnostic accuracy for identifying gastroesophageal varices and distinguishing high-risk GEVs in patients with cirrhosis. Further research to validate optimal variceal size cut-offs is warranted to enhance clinical utility.

CLINICAL SIGNIFICANCE

Such a high diagnostic accuracy of CT scans for predicting varices is clinically meaningful for patients with cirrhosis accompanied by portal hypertension. If high-risk varices are identified at CT scans, early intervention would be helpful to reduce the risk of variceal bleeding.

3D-Volumetric Shunt Measurement for Detection of High-Risk Esophageal Varices in Liver Cirrhosis

Background and Objectives: Esophageal varices (EV) and variceal hemorrhages are major causes of mortality in liver cirrhosis patients. Detecting EVs early is crucial for effective management. Computed tomography (CT) scans, commonly performed for various liver-related indications, provide an opportunity for non-invasive EV assessment. However, previous CT studies focused on variceal diameter, neglecting the three-dimensional (3D) nature of varices and shunt vessels. This study aims to evaluate the potential of 3D volumetric shunt-vessel measurements from routine CT scans for detecting high-risk esophageal varices in portal hypertension. Methods: 3D volumetric measurements of esophageal varices were conducted using routine CT scans and compared to endoscopic variceal grading. Receiver operating characteristic (ROC) analyses were performed to determine the optimal cutoff value for identifying high-risk varices based on shunt volume. The study included 142 patients who underwent both esophagogastroduodenoscopy (EGD) and contrast-enhanced CT within six months. Results: The study established a cutoff value for identifying high-risk varices. The CT measurements exhibited a significant correlation with endoscopic EV grading (correlation coefficient r = 0.417, p < 0.001). A CT cutoff value of 2060 mm3 for variceal volume showed a sensitivity of 72.1% and a specificity of 65.5% for detecting high-risk varices during endoscopy. Conclusions: This study demonstrates the feasibility of opportunistically measuring variceal volumes from routine CT scans. CT volumetry for assessing EVs may have prognostic value, especially in cirrhosis patients who are not suitable candidates for endoscopy.

Computed tomography for the prediction of oesophageal variceal bleeding: A surrogate or complementary to the gold standard?

In this editorial we comment on the in-press article in the World Journal of Gastrointestinal endoscopy about the role of computed tomography (CT) for the prediction of esophageal variceal bleeding. The mortality and morbidity are much increased in patients with chronic liver diseases when complicated with variceal bleeding. Predicting the patient at a risk of bleeding is extremely important and receives a great deal of attention, paving the way for primary prophylaxis either using medical treatment including carvedilol or propranolol, or endoscopic band ligation. Endoscopic examination and the hepatic venous pressure gradient are the gold standards in the diagnosis and prediction of variceal bleeding. Several non-invasive laboratory and radiological examinations are used for the prediction of variceal bleeding. The contrast-enhanced multislice CT is a widely used non-invasive, radiological examination that has many advantages. In this editorial we briefly comment on the current research regarding the use of CT as a non-invasive tool in predicting the variceal bleeding.

Guidelines for the Management of Esophagogastric Variceal Bleeding in Cirrhotic Portal Hypertension

To standardize the diagnosis, treatment, and management of esophagogastric variceal bleeding (EVB) in patients with cirrhotic portal hypertension, the Chinese Society of Hepatology, the Chinese Society of Gastroenterology, and the Chinese Society of Digestive Endoscopy of the Chinese Medical Association brought together relevant experts, reviewed the latest national and international progress in clinical research on EVB in cirrhotic portal hypertension, and followed evidence-based medicine to update the Guidelines on the Management of EVB in Cirrhotic Portal Hypertension. The guidelines provide recommendations for the diagnosis, treatment, and management of EVB in cirrhotic portal hypertension and with the aim to improve the level of clinical treatment of EVB in patients with cirrhotic portal hypertension.

Vascular pathology in patients with alveolar echinococcosis: framework for assessment and clinical management - a retrospective case series

OBJECTIVE

Alveolar echinococcosis (AE) is a parasitic liver disease with infiltrative growth similar to solid organ malignancies. Major vascular damage is frequent and often remains untreated until catastrophic events precipitate. Detailed clinical and radiological assessment is required to guide individualised treatment decisions. Standardised radiological reporting templates of malignancies with profiles resembling AE are candidates for adaptation. Our objectives are to describe vascular pathology in AE and establish a framework for structured evaluation as the basis for treatment decisions and monitoring.

DESIGN

Retrospective case series.

RESULTS

69 patients (37.1%) had vascular involvement: portal vein (PV) 24.7%, hepatic vein (HV) 22.6% inferior vena cava (IVC) 13.4%. Significant stenosis/occlusion of vessels was present in 15.1% of PV, in 13.4% of HV and in 7.5% of IVC involvement. Vascular pathology needing specific treatment or monitoring was present in 8.6% of patients. The most frequent clinical presentation was high grade IVC stenosis or occlusion which was seen in 11 patients of the cohort.

CONCLUSION

Advanced AE requires early multidisciplinary assessment to prevent progressive impairment of liver function due to vascular damage. The focus at first presentation is on complete evaluation of vascular (and biliary) involvement. The focus in non-resectable AE is on prevention of vascular (and biliary) complications while suppressing growth of AE lesions by benzimidazole treatment to improve the quality of life of patients. We developed a framework for standardised vascular assessment and follow-up of patients with AE to recognise and treat complications early.

Diagnostic Accuracy of Portal Vein Flow Velocity for Esophageal Varices in Cirrhotic Patients

Background Variceal bleeding is a life-threatening complication of cirrhosis. Traditionally, endoscopy has been utilized as a preferred modality for the detection and grading of esophageal varices. However, endoscopy is an invasive procedure and may not be readily available in resource-limited settings. To overcome this limitation, various non-invasive tests, including Doppler ultrasonography (DUS) with portal vein (PV) velocity measurement, have been investigated to predict the presence of esophageal varices (EV). This study aimed to evaluate the potential utility of portal vein flow velocity (PVFV) as a non-invasive alternative to endoscopic screening for predicting the presence of esophageal varices among cirrhotic patients. Methodology This validation cross-sectional study was carried out at the Department of Gastroenterology and Hepatology, Pakistan Kidney and Liver Institute & Research Centre (PKLI&RC), Lahore, Pakistan from June 8, 2022, to March 8, 2023. Cirrhotic patients were enrolled based on clinical, laboratory, and radiological assessments. Doppler ultrasonography was performed to measure portal vein flow velocity along other relevant indices. Subsequently, all patients underwent endoscopic evaluation to screen and grade the esophageal varices. Univariate and multivariate logistic regression analyses were performed to identify significant clinical predictors of EV based on the results of the independent sample t-tests or Mann-Whitney U tests. Receiver operating characteristic (ROC) curves were employed to determine the optimal cut-off value for portal vein flow velocity (PVFV). Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and diagnostic accuracy were calculated based on the identified cut-off value. A p-value ≤ 0.05 was considered statistically significant. Results A cohort of 137 cirrhotic patients was enrolled. The study population consisted of 92 males (67.2%) and 45 females (32.8%). Endoscopic screening confirmed the presence of esophageal varices in 81 patients (59.91%). A multivariate analysis revealed that aspartate aminotransferase to platelet ratio index (APRI) (p=0.008) and portal vein flow velocity (p=0.001) were significant factors associated with esophageal varices and were used for receiver operating characteristic (ROC) analysis. The area under the curve (AUC) for PVFV was 0.981, and for APRI, it was 0.711. At a cut-off value of 18 cm/sec for PVFV, the sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and diagnostic accuracy for esophageal varices were found to be 93.83%, 92.86%, 95%, 91.23%, and 93.43%, respectively. Conclusion Measurement of portal vein flow velocity using Doppler ultrasonography (DUS) is a reliable screening method for predicting the presence of esophageal varices (EV) in patients with liver cirrhosis. DUS offers several advantages, including its non-invasive nature, cost-effectiveness, and widespread availability, making it a recommended approach due to its high diagnostic accuracy.

Autoimmune Hepatitis and Fibrosis

Autoimmune hepatitis (AIH) is a chronic immune-inflammatory disease of the liver, generally considered a rare condition. The clinical manifestation is extremely varied and can range from paucisymptomatic forms to severe hepatitis. Chronic liver damage causes activation of hepatic and inflammatory cells leading to inflammation and oxidative stress through the production of mediators. This results in increased collagen production and extracellular matrix deposition leading to fibrosis and even cirrhosis. The gold standard for the diagnosis of fibrosis is liver biopsy; however, there are serum biomarkers, scoring systems, and radiological methods useful for diagnosis and staging. The goal of AIH treatment is to suppress fibrotic and inflammatory activities in the liver to prevent disease progression and achieve complete remission. Therapy involves the use of classic steroidal anti-inflammatory drugs and immunosuppressants, but in recent years scientific research has focused on several new alternative drugs for AIH that will be discussed in the review.

Nomogram for Predicting Postoperative Portal Venous Systemic Thrombosis in Patients with Cirrhosis Undergoing Splenectomy and Esophagogastric Devascularization

OBJECTIVES

The aim of the study is to develop a nomogram for predicting postoperative portal venous systemic thrombosis (PVST) in patients with cirrhosis undergoing splenectomy and esophagogastric devascularization.

METHODS

In total, 195 eligible patients were included. Demographic characteristics were collected, and the results of perioperative routine laboratory investigations and ultrasound examinations were also recorded. Blood cell morphological traits, including the red cell volume distribution width (RDW), mean platelet volume, and platelet distribution width, were identified. Univariate and multivariate logistic regressions were implemented for risk factor filtration, and an integrated nomogram was generated and then validated using the bootstrap method.

RESULTS

A color Doppler abdominal ultrasound examination on a postoperative day (POD) 7 (38.97%) revealed that 76 patients had PVST. The results of the multivariate logistic regression suggested that a higher RDW on POD3 (RDW3) (odds ratio (OR): 1.188, 95% confidence interval (CI): 1.073-1.326), wider portal vein diameter (OR: 1.387, 95% CI: 1.203-1.642), history of variceal hemorrhage (OR: 3.407, 95% CI: 1.670-7.220), and longer spleen length (OR: 1.015, 95% CI: 1.001-1.029) were independent risk parameters for postoperative PVST. Moreover, the nomogram integrating these four parameters exhibited considerable capability in PVST forecasting. The nomogram's receiver operating characteristic curve reached 0.83 and achieved a sensitivity and specificity of 0.711 and 0.848, respectively, at its cutoff. The nomogram's calibration curve demonstrated that it was well calibrated.

CONCLUSION

The nomogram exhibited excellent performance in PVST prediction and might assist surgeons in identifying vulnerable patients and administering timely prophylaxis.

Small varices in chronic liver diseases

PURPOSE OF REVIEW

Gastroesophageal varices are common complications of chronic liver diseases (CLDs) and portal hypertension. Small varices have the risk of progressing to larger varices, causing bleeding or even death. Thus, early detection and appropriate management of small varices are necessary. The purpose of this review is to summarize the advance in the recent 5years about diagnosing and managing the small varices in CLDs.

RECENT FINDINGS

The diagnosing methods of small varices in recent studies include improved endoscopic examinations, such as capsule endoscopy, and many noninvasive methods, including blood tests, ultrasound, computed tomography and magnetic resonance. For the management of small varices, though it is controversial, prevention using nonselective beta-blockers is still an essential part.

SUMMARY

In this review, we summarize the classification of varices, the invasive and noninvasive diagnostic methods, their performances, and the emerging progression in the management of small varices in the recent 5 years. We hope that this review provides relevant information to understand better and appropriately manage small varices.

A novel machine learning-based radiomic model for diagnosing high bleeding risk esophageal varices in cirrhotic patients

BACKGROUND AND AIM

To develop and validate a novel machine learning-based radiomic model (RM) for diagnosing high bleeding risk esophageal varices (HREV) in patients with cirrhosis.

METHODS

A total of 796 qualified participants were enrolled. In training cohort, 218 cirrhotic patients with mild esophageal varices (EV) and 240 with HREV RM were included to training and internal validation groups. Additionally, 159 and 340 cirrhotic patients with mild EV and HREV RM, respectively, were used for external validation. Interesting regions of liver, spleen, and esophagus were labeled on the portal venous-phase enhanced CT images. RM was assessed by area under the receiver operating characteristic curves (AUROC), sensitivity, specificity, calibration and decision curve analysis (DCA).

RESULTS

The AUROCs for mild EV RM in training and internal validation were 0.943 and 0.732, sensitivity and specificity were 0.863, 0.773 and 0.763, 0.763, respectively. The AUROC, sensitivity, and specificity were 0.654, 0.773 and 0.632, respectively, in external validation. Interestingly, the AUROCs for HREV RM in training and internal validation were 0.983 and 0.834, sensitivity and specificity were 0.948, 0.916 and 0.977, 0.969, respectively. The related AUROC, sensitivity and specificity were 0.736, 0.690 and 0.762 in external validation. Calibration and DCA indicated RM had good performance. Compared with Baveno VI and its expanded criteria, HREV RM had a higher accuracy and net reclassification improvements that were as high as 49.0% and 32.8%.

CONCLUSION

The present study developed a novel non-invasive RM for diagnosing HREV in cirrhotic patients with high accuracy. However, this RM still needs to be validated by a large multi-center cohort.