Multidetector CT oesophagography: an alternative screening method for endoscopic diagnosis of oesophageal varices and bleeding risk

The diagnostic accuracy of triphasic abdominal CT in detecting esophageal varices

BACKGROUND

In Tanzania, triphasic abdominal Computed Tomography (CT) is a more accessible and non-invasive alternative for diagnosing esophageal varices, though its accuracy has not been thoroughly evaluated, therefore this study aimed to determine the diagnostic accuracy of triphasic abdominal CT in detecting esophageal varices using esophagogastroduodenoscopy (OGD) as the gold standard among patients with upper gastrointestinal bleeding at Muhimbili National Hospital (MNH).

METHODS

This cross-sectional study was conducted at MNH from January 2021 to May 2023. We sampled upper gastrointestinal bleeding patients who underwent both OGD and triphasic abdominal CT using non-probability consecutive sampling. The sensitivity, specificity, negative predictive value (NPV), positive predictive value (PPV), and accuracy of triphasic abdominal CT were assessed against OGD findings.

RESULTS

In a study of 200 participants, esophageal varices were detected in 54% by OGD and 53.5% by CT. We observed 105 true positives, 2 false positives, 90 true negatives, and 3 false negatives. Triphasic abdominal CT demonstrated a sensitivity of 97.2%, specificity of 97.8%, PPV of 98.1%, NPV of 96.8%, and an accuracy of 97.5%. Extraluminal findings included portal venous thrombosis in (22%), splenic collateral (51.5%), ascites (32%), hepatocellular carcinoma (13%), and periportal fibrosis (32%).

CONCLUSION

Triphasic abdominal Computed Tomography can be used as a reliable and non-invasive alternative modality for diagnosing and screening esophageal varices in resource-limited settings.

Assessment of variceal bleeding in cirrhotic patients: accuracy of multi-detector computed tomography

Background

Esophageal variceal hemorrhage (EVH) has been shown to be a leading cause of mortality in patients with portal hypertension. Our purpose was to assess the utility of multi-detector computed tomography (MDCT) features in the assessment of esophageal varices (EVs) and esophageal variceal hemorrhage (EVH). This prospective study included 85 cirrhotic patients who underwent MDCT and Upper Gastrointestinal Tract (UGIT) endoscopy within 2 weeks. Four radiologists evaluated the presence of EVs and the presence and size of different collaterals. Multivariable logistic regression analysis was calculated to investigate the significant predictors influencing EV and EVH.

Results

Findings of EV with MDCT were the best predictor of EV or EVH. The presence (and/or size) of following collaterals had significant association with both EV and EVH: paraesophageal (p < 0.001, < 0.001), short gastric (p = 0.024, 0.010), gastric varicosities (p < 0.001, < 0.001), coronary (p < 0.001, < 0.001), and main coronary vein (MCV) (p < 0.001, = 0.011). We proposed an imaging-based model (presence of coronary collaterals, main coronary vein size > 3.5 mm, presence of short gastric collaterals, presence of gastric varicosities, size > 1.5 mm) with 97% sensitivity, 91% specificity, and 94% accuracy to predict EVs. We suggested another model (presence of paraesophageal collaterals, presence of short gastric vein (SGC), SGC size > 2.5 mm, main coronary vein size > 3.5 mm, gastric varicosities size > 1.5 mm, size of EVs > 4 mm, and Child C score) to predict EVH with 98% sensitivity, 81% specificity, and 89.5% accuracy. Inter-observer agreement was high in the detection of EVs (W. Kappa = 0.71–0.88).

Conclusion

MDCT is an effective modality in the diagnosis of EVs. At MDCT, the presence and/or size of various collaterals including para-esophageal, short gastric, coronary collaterals, and gastric varicosities are accurate predictors for either EVs existence or EVH. We suggested two computed tomography imaging-based models with high reproducibility and acceptable accuracy for the prediction of EV and EVH. With cirrhotic patients, we recommend that radiologists report collaterals in their daily practice.

The efficacy of contrast-enhanced computed tomography on the management of gastroesophageal varices in patients with hepatocellular carcinoma

The screening of gastroesophageal varices (GEV) is critical in hepatocellular carcinoma (HCC) management. Contrast-enhanced computed tomography (CECT) is often performed in patients with HCC. Therefore, this study aimed to examine the use of CECT in screening for GEV and predicting GEV bleeding. This retrospective study enrolled 312 consecutive patients who are initially diagnosed with HCC, measured the lower esophageal (EIV) and fundal intramural vessel (FIV) diameter on CECT, examined the changes after 1, 2, and 3 years, and verified the relationship with GEV bleeding. The EIV and FIV diameter on CECT correlates well with endoscopic variceal classification. EIV significantly worsened after 2 and 3 years. FIV showed worsening at both 1, 2, and 3 years. Cumulative GEV bleeding rates were 3.7% at 1 year and 6.2% at 3 years. The multivariate analysis revealed that EIV, FIV, and portal vein tumor thrombus were associated with GEV bleeding. Furthermore, EIV deterioration at 1, 2, and 3 years correlated with GEV bleeding. In conclusion, CECT is useful in variceal management during the longitudinal clinical course of HCC, and has the potential to decrease screening endoscopy. With deterioration in EIV, treatments should be considered due to a high-risk GEV bleeding.

Combinations of liver lobe and spleen volumes obtained on magnetic resonance imaging to predict esophagogastric variceal bleeding in hepatitis B-related cirrhotic patients: A prospective cohort study

To evaluate whether combinations of liver lobe and spleen volumes obtained on magnetic resonance imaging (MRI) could predict esophagogastric variceal bleeding (EVB) in hepatitis B-related cirrhotic patients. Ninety-six consecutive patients with hepatitis B-related cirrhosis underwent upper abdominal contrast-enhanced MRI within 1 week after initial hospitalization, and grouped based on outcomes of EVB during the 2 years' follow-up after being discharged. Total liver volume (TLV), spleen volume (SV) and 4 liver lobe volumes including right lobe volume (RV), left medial lobe volume (LMV), left lateral lobe volume (LLV), and caudate lobe volume (CV) were measured on MRI. Percentages of individual liver lobe volumes in TLV (including RV/TLV, LMV/TLV, LLV/TLV, and CV/TLV), ratios of SV to individual liver lobe volumes (including SV/RV, SV/LMV, SV/LLV, and SV/CV), and SV/TLV were statistically analyzed to predict EVB. Patients with EVB had lower RV than without EVB (P value = .001), whereas no differences in LMV, LLV, CV, and TLV were found (P values >.05 for all). Among percentages of individual liver lobe volumes in TLV, RV/TLV was lower whereas LMV/TLV and LLV/TLV were greater in patients with EVB than without EVB (P values <.05 for all). SV, ratios of SV to individual liver lobe volumes, and SV/TLV in patients with EVB were larger than without EVB (P values <.05 for all). Among parameters with difference between patients with and without EVB, SV/RV could best predict EVB with an area under receiver operating characteristic curve of 0.84. SV/RV could best predict EVB in hepatitis B-related cirrhotic patients.

Esophageal variceal hemorrhage: the role of MDCT characteristics in predicting the presence of varices and bleeding risk

PURPOSE

To investigate the associated Multi-Detector Computed Tomography (MDCT) features for esophageal varices (EVs) and esophageal variceal hemorrhage (EVH), with particular emphasis on different collateral veins.

MATERIALS AND METHODS

All cirrhotic patients who had undergone both Upper Gastrointestinal Tract (UGIT) endoscopy and contrast-enhanced MDCT within 6 months from 2013 to 2019 were included in the study. MDCT of 124 patients, 76 males and 48 females, aged between 21 and 73 years old were evaluated for presence of EV and presence and size of different collaterals. The presence and size of collaterals in patients with high-risk EVs or EVH were compared with others.

RESULTS

Findings of EV in MDCT analysis were the best predictor of EV or EVH, and presence (and/or size) of following collaterals showed a significant relationship with both EV and EVH: coronary (p = 0.006, 0.002), short gastric (SGC) (p = 0.02, < 0.001), and paraesophageal (p = 0.04, 0.01). Those presenting each aforementioned collaterals or with higher collateral size were more likely to develop the EV or EVH. Yet, other collaterals indicated no similar association: para-umbilical, omental, perisplenic, and splenorenal. Main coronary vein (p = 0.02, 0.03) and fundus (p = 0.006, 0.001) varices' sizes were also significantly higher in patients with EV or EVH. Finally, we suggested an imaging-based model (presence of SGC, SGC size > 2.5 mm, presence of EV, and coronary vein size > 3.5 mm) with 75.86% sensitivity, 76.92% specificity, and 76.36% accuracy to predict the presence of EVs according to UGIT endoscopy. Furthermore, we presented another model (presence of SGC, SGC size > 2.5 mm, presence of EV, and MELD score > 11.5 mm) to predict the occurrence of EVH with 75.86% sensitivity, 76.92% specificity, and 76.36% accuracy.

CONCLUSION

We suggested imaging characteristics for predicting EV and EVH with especial emphasis on the presence and size of various collaterals; then, we recommended reliable imaging criteria with high specificity and accuracy for predicting the EV and EVH.

Can the Computed Tomographic Aspect of Porto-Systemic Circulation in Cirrhotic Patients be Associated with the Presence of Variceal Hemorrhage?

Background and objectives: Variceal bleeding is a serious complication caused by portal hypertension, frequently encountered among cirrhotic patients. The purpose of this study was to determine whether the aspect of the collateral, porto-systemic circulation, as detected by CT are associated with the presence variceal hemorrhage (VH). Materials and Methods: 81 cirrhotic patients who underwent a contrast-enhanced CT examination were retrospectively included in the study. Patients were divided into two groups: Cirrhotic patients with variceal hemorrhage during the hospital admission concomitant, with the CT examination (n = 33) and group 2-cirrhotic patients, without any variceal hemorrhage in their medical history (n = 48). The diameter of the left gastric vein, the presence or absence and dimensions of oesophageal and gastric varices, paraumbilical veins and splenorenal shunts were the indicators assessed on CT. Results: The univariate analysis showed a significant association between the presence of upper GI bleeding and the diameters of paraoesophageal veins, paragastric veins and left gastric vein respectively, all of these CT parameters being higher in patients with variceal bleeding. In the multivariate logistic regression analysis, only the diameter of the left gastric vein was independently associated with the presence of variceal hemorrhage (OR = 1.6 (95% CI: 1.17-2.19), p = 0.003). We found an optimal cut-off value of 3 mm for the diameter of the left gastric vein useful to discriminate among patients with variceal hemorrhage from the ones without it, with a good diagnostic performance (AUC = 0.78, Se = 97%, Sp = 45.8%, PPV = 55.2%, NPV = 95.7%).Conclusions: Our observations point out that an objective CT quantification of porto-systemic circulation can be correlated with the presence of variceal hemorrhage and the diameter of the left gastric vein can be a reliable parameter associated with this condition.

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

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.

Multiparametric radiomics nomogram may be used for predicting the severity of esophageal varices in cirrhotic patients

Background

To explore whether a multiparametric radiomics nomogram on computed tomography (CT) images based on radiomics and relevant parameters of esophageal varices (EV) can be used for predicting the EV severity in patients with cirrhotic livers.

Methods

From January 2016 to August 2018, 136 consecutive patients with clinicopathologically confirmed liver cirrhosis were included for the development of a predictive model. The patients were then divided into two groups, including non-conspicuous EV group (mild-to-moderate EV, n=30) and conspicuous EV group (severe EV, n=106) by using the endoscopic validation as the reference standard. The radiomic scores (Rad scores) were constructed using the binary logistic regression model from the radiomics features of regions of interest (ROIs) in the left liver (LL) and right liver (RL), respectively. The multiparametric nomogram combined the best performance Rad-score and EV-relevant factors, and the calibration, discrimination, and clinical usefulness of developed nomogram were evaluated using calibration curves, decision curve analysis (DCA) and net reclassification index (NRI) analysis respectively.

Results

The LL Rad-score calculated from radiomics features was selected with a relatively higher area under the curve (AUC) (AUC; 0.88, training cohort; 0.87, the validation cohort) compared with RL Rad-score (AUC; 0.86, training cohort; 0.83, the validation cohort). In addition, cross-sectional surface area (CSA) was identified as the important predictor (P<0.05), the multiparametric nomogram containing LL Rad-score and CSA was shown to have a better predictive performance and good calibration in the training model (C-index, 0.953, 95% CI, 0.892 to 0.973) and the validation cohort (C-index, 0.938, 95% CI, 0.841 to 0.961), resulting in an improved NRI (categorical NRI of 25.9%, P=0.0128; continuous NRI of 120%, P<0.001) and integrated discriminatory improvement (IDI) (IDI =13.9%, P<0.001). DCA demonstrated that the multiparametric radiomics nomogram was clinically useful.

Conclusions

A multiparametric radiomics nomogram, which incorporates the liver radiomics signature and EV-relevant indices, is a useful tool for noninvasively predicting EV severity and may complement the standard endoscopy for evaluating EV severity in patients with cirrhosis.

Computed Tomographic Portography with Esophageal Variceal Measurements in the Evaluation of Esophageal Variceal Severity and Assessment of Esophageal Variceal Volume Efficacy

RATIONALE AND OBJECTIVES

The aim of our study is to evaluate the severity of esophageal varices (EV), based on the computed tomographic portography (CTP) measurement of EV in the distal esophagus and to assess the prediction value of EV volume.

PATIENTS AND METHODS

A total of 53 EV patients examined by CTP within 4 weeks of upper endoscopy were evaluated, the patients were divided into a nonconspicuous EV group (mild-to-moderate EV, n = 28) and a conspicuous EV group (severe EV, n = 25) according to endoscopy results. The diameter, cross-sectional surface area (CSA), and volume of EV were measured independently using 3D-slicer (Boston) by two experienced abdominal radiologists blinded to endoscopy findings. The averaged values measured by the two observers were used in the final dataset, these indicators' predictive performances were studied by using receiver operating characteristic curve analysis, and the area under the curve (A_z) and the cutoff values were calculated to distinguish mild-to-moderate from severe EV.

RESULTS

The A_z values of volume, diameter and CSA in differentiating severe EV were 0.817, 0.794, and 0.784 for observer-1, corresponding values for observer-2 were 0.796, 0.774, and 0.707, there was almost perfect interobserver agreement for all measurements. All indices were larger in the conspicuous group than the nonconspicuous group in both observers (p ≤ 0.01). In the final dataset, application of a 654.0-mm³-volume criterion yielded sensitivity, specificity of 96%, 50%, application of a 5.2-mm-diameter criterion yielded sensitivity, specificity of 80%, 75%, and application of a 68.6-mm²-CSA criterion yielded sensitivity, specificity of 52%, 93%.

CONCLUSION

The volume of EV could be used as a new effective indictor for evaluating EV, and use of volume, diameter, and CSA of EV based on CTP allows discrimination between mild-to-moderate and severe EV in cirrhotic patients.

Computed tomography for the diagnosis of varices in liver cirrhosis: a systematic review and meta-analysis of observational studies

OBJECTIVES

This systematic review and meta-analysis aimed to evaluate the diagnostic accuracy of contrast-enhanced computed tomography (CT) for varices in liver cirrhosis.

METHODS

PubMed and EMBASE databases were searched for the literature identification. The area under the summary receiver operating characteristic curve (AUSROC), sensitivity, specificity, positive and negative likelihood ratio (PLR and NLR), and diagnostic odds ratio (DOR) were calculated. We performed the subgroup analyses according to the location of varices, CT technique, and study design. The study quality was assessed according to the QUADAS-2 tool.

RESULTS

Seventeen papers were eligible. The study quality was modest. The AUSROC was 0.8975 and 0.9494 for predicting any size and high-risk varices, respectively. Summary sensitivity, specificity, PLR, NLR, and DOR of CT for predicting any size and high-risk varices were 0.87/0.80/3.67/0.18/22.70 and 0.87/0.88/7.52/0.12/65.55, respectively. According to the location of varices, the AUSROC was 0.9127 for predicting any size gastric varices alone; and the AUSROC was 0.8958 and 0.9461 for predicting any size and high-risk esophageal varices alone, respectively. According to the CT technique, the AUSROC of multi-detector CT (MDCT) was 0.9047 and 0.9490 for predicting any size and high-risk varices, respectively; and the AUSROC of MDCT esophagograms for predicting any size and high-risk varices was 0.8735 and 0.9664, respectively. In the subgroup analysis of prospective studies, the AUSROC was 0.9122 and 0.9507 for predicting any size and high-risk varices, respectively.

CONCLUSION

CT had a high accuracy for the diagnosis of varices in liver cirrhosis.

Diagnostic accuracy of contrast-enhanced computed tomography for esophageal varices in liver cirrhosis: a retrospective observational study

BACKGROUND AND AIM

Esophageal variceal bleeding is a life-threatening complication of liver cirrhosis. Upper gastrointestinal endoscopy was the gold standard for the diagnosis of esophageal varices (EVs). The study aimed to evaluate the accuracy of contrast-enhanced computed tomography (CT) in the diagnosis of EVs and moderate-severe EVs in patients with liver cirrhosis.

METHODS

Medical records in cirrhotic patients who were admitted to our hospital between June 2012 and June 2014 were retrospectively reviewed. Two observers reviewed the contrast-enhanced CT scans to evaluate the presence and diameter of EVs. Area under curve (AUC), sensitivity, and specificity were calculated.

RESULTS

A total of 52 cirrhotic patients were included in our study. According to the endoscopic results, 13.5% of these patients did not have any EVs, 11.5% had mild EVs, and 75% had moderate-severe EVs. The AUC of contrast-enhanced CT scans for the diagnosis of EVs was 0.835. The sensitivity and specificity were 95.56% and 71.43%, respectively. The AUC of contrast-enhanced T scans for the diagnosis of moderate-severe EVs was 0.821. When the cut-off value for the diameter of EVs on contrast-enhanced CT scans was 3.9 mm, the sensitivity and specificity were 89.74% and 69.23%, respectively.

CONCLUSIONS

Contrast-enhanced CT scans had a moderate diagnostic accuracy for EVs in liver cirrhosis. It might be useful to decrease the use of upper gastrointestinal endoscopy in clinical practice.

Computed tomography in evaluating gastroesophageal varices in patients with portal hypertension: A meta-analysis

AIMS

Gastroesophageal varices (GOV) is a common complication in patients with portal hypertension. We conducted a meta-analysis in attempt to evaluate the diagnostic accuracy of computed tomography (CT) as a noninvasive imaging tool for identifying GOV in reference to esophagogastroduodenoscopy (EGD).

METHODS

A systemic literature search of multiple databases were conducted to identify articles that investigated the diagnostic performance of CT for GOV, while employing EGD as reference standard. A 2×2 table was conducted according to the available published data for both esophageal varices (EV) and gastric varices (GV) as individual subgroups. The following indices were calculated: pooled sensitivity and specificity, positive and negative likelihood ratio, diagnostic odds ratio, and area under receiver operating characteristics. All statistical analyses were conducted via STATA13.0 and RevMan5.3.

RESULTS

A total of 11 studies were included in this meta-analysis, 10 articles evaluated the diagnostic accuracy of CT for EV (807 subjects) and 7 articles for GV (583 subjects). The pooled sensitivity and specificity for identifying EV were 0.896 (95% CI, 0.841-0.934) and 0.723 (95% CI, 0.644-0.791), respectively, with an AUROC of 0.86. The pooled sensitivity and specificity for identifying GV were 0.955 (95% CI, 0.903-0.980) and 0.658 (95% CI, 0.433-0.829), respectively, with an AUROC of 0.95. A subgroup analysis suggested varying CT technology could serve as a potential source of heterogeneity between included studies. A Deek's funnel plot indicated a low probability for publication bias.

CONCLUSION

Computed tomography could potentially replace EGD as a primary screening tool for diagnosing GOV, however results should be interpreted with caution given its suboptimal specificity.