Spleen stiffness in patients with cirrhosis in predicting esophageal varices

Splenic Stiffness Measurement Combined With Liver Stiffness Measurement Compared With Baveno VII Criteria in Predicting the Presence of Oesophageal and Gastric Varices in Patients With Compensated Advanced Liver Cell Disease (cALCD)

INTRODUCTION

Liver stiffness measurement (LSM) using vibration-controlled transient elastography (VCTE) is being increasingly used as a screening tool to predict varices. Our aim was to test the utility of Baveno VII criteria and other combinations of LSM, platelet count (PC), and splenic stiffness measurement (SSM) to predict the presence of varices in a cohort of Sri Lankan patients with compensated advanced liver cell disease (cALCD).

METHODS

Consecutive patients with newly diagnosed Child-Pugh class A cALCD (non-viral, BMI<30) were recruited prospectively. They underwent gastroscopy. LSM and SSM were taken using vibration-controlled transient elastography (VCTE) (Echosens FibroScan 502 Touch; Echosens SA, Paris, France) by a single operator who was unaware of endoscopy findings. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy of different Baveno VII criteria to predict the varices and different combinations of LSM, SSM, and PC were also explored.

RESULTS

One hundred and seventy-four individuals were recruited. The mean age was 61.4 ((95% CI: 59.7-62.8) years. A total of 110 individuals were males, and 106 had varices. Our results indicated that the three Baveno VII criteria had sensitivities of 61%, 63%, and 42%, and specificities of 79%, 77%, and 87% to predict varices. SSM>30kPa alone and in combination with LSM>15kPa had sensitivities of 81 and 75%, specificities of 72 and 83%, PPVs of 82 and 87%, NPVs of 71% and 67%, and accuracies of 78 and 78%, respectively, to predict varices.

CONCLUSION

Baveno VII criteria had a low sensitivity but high specificity in predicting the presence of varices. However, SSM>30kPa alone or in combination with LSM>15kPa had better sensitivity, specificity, PPV, NPV, and accuracy in predicting varices.

Shear Wave Ultrasonographic Elastography in Pediatric Spleens and Its Role in Differential Diagnosis

Shear wave elastography (SWE) has become popular in clinical practice for many diseases. However, there is not adequate research on spleen-related diseases. This study aimed to investigate the potential of quantitative values obtained through SWE in evaluating spleen pathologies in the pediatric population and to demonstrate its performance to differentiate splenomegaly-related diseases. The research group retrospectively included children with pathological diagnoses related to the spleen from November 2016 to April 2021, and they were categorized into three groups, including portal hypertension (PH), benign lymphoid hyperplasia (BLH), and malignant infiltration (MI). Spleen sizes and parenchymal stiffness were also calculated for each group. Subsequently, mean spleen stiffness in each group was compared with normal values within the same age group. In total, 2781 children (1379 children for the study group; 1402 children for the control group) were enrolled in the study. The highest stiffness was observed in the PH group, which is statistically higher than others (p < 0.05). Although the mean spleen stiffness in the group with BLH was higher than the control and MI group, the difference was not statistically significant (p = 0.08). The mean stiffness in the group with MI was significantly lower than both the control group (p = 0.005) and PH (p = 0.01). In conclusion, using SWE in the differential diagnosis of etiologies causing splenomegaly could make an important contribution.

Evaluation of spleen stiffness by 2D shear wave elastography for ruling out high risk varices in patients with chronic advanced liver disease. A systematic review and meta-analysis

OBJECTIVES

To systematically review the accuracy of spleen stiffness measurement (SSM) by 2D- Shear Wave Elastography (2D-SWE) in predicting high risk for bleeding varices (HRV) in cirrhotic patients.

METHODS

PubMed, Embase, Web of Science, Medline, Cochrane, and Google Scholar databases were searched up to 31/05/2023 for all human studies using 2D-SWE to estimate SSM and endoscopy to detect HRV. Meta-analysis was performed using a generalized linear mixed model. Publication bias was evaluated using the funnel plot asymmetry test. The Area Under the Summarized Receiver Operating Characteristic curve (AUSROC) was estimated using the "mada" package.

RESULTS

A total of 13 studies and 1970 patients were included. Of them, 27.8 % had HRV. The pooled sensitivity and polled specificity of SSM in detecting HRV were 90 % (95 %CI:87-92 %) and 68 % (95 %CI:58-77 %), respectively, with an AUSROC at 0.86 (95 %CI:0.82-0.90). The median cutoff value of SSM in detecting HRV was 34.2 kPa. In studies including exclusively HBV cirrhotic patients, SSM's polled sensitivity and specificity in predicting HRV was 88 % (95 %CI:82-92 %) and 73 % (95 %CI:68-78 %), respectively. The AUSROC was 0.84 (95 %CI:0.81-0.87). The number of repeated measurements per patient (<5 or ≥ 5) did not affect the method's capability. Using Aixplorer to evaluate SSM had a higher sensitivity in ruling out HRV than other 2D-SWE devices.

CONCLUSIONS

Our meta-analysis supports that SSM by 2D-SWE has a good diagnostic performance for ruling out HRV in cirrhosis.

Role of Spleen Stiffness Measurement in the Evaluation of Metabolic Dysfunction-Associated Steatotic Liver Disease

BACKGROUND

Spleen stiffness measurement (SSM) correlates with the severity of portal hypertension.

AIMS

We investigated the utility of SSM in individuals with metabolic dysfunction-associated steatotic liver disease (MASLD) for detecting cirrhosis, esophageal varices (EV), and high-risk EV.

METHODS

154 study participants with MASLD underwent simultaneous liver stiffness measurement (LSM) and SSM. 96 (62%) participants had an upper endoscopy (73 participants, i.e., 47% undergoing within a year). The diagnostic performance of SSM, as well as the BAVENO VII proposed SSM cutoffs (≥ 21 kPa, > 40 kPa, and > 50 kPa), was examined.

RESULTS

The failure rate for SSM was 19% compared to 5% for LSM. An invalid SSM was statistically significantly associated with a higher body mass index, a larger waist circumference, and a lower fibrosis stage. The area under the receiver operating characteristics for SSM to diagnose cirrhosis, EV, and high-risk EV was 0.78 (95% CI 0.70-0.85), 0.74 (95% CI 0.61-0.84), and 0.82 (95% CI 0.75-0.98), respectively. SSM ≥ 21 kPa cutoff had a sensitivity > 96% for all three outcomes, with a positive predictive value (PPV) of 88% for cirrhosis. In contrast, SSM > 40 kPa and SSM > 50 kPa cutoffs had better diagnostic abilities for identifying EV, particularly high-risk EV (sensitivity of 100% and 93% with NPV of 100% and 96%, respectively).

CONCLUSION

SSM has a higher failure rate in individuals who are non-cirrhotic or have a higher BMI, or larger waist circumference. Although useful for diagnosing NASH cirrhosis, SSM is most reliable in excluding EV and high-risk EV.

Our experience with liver and spleen elastography in the prediction of oesophageal varices

Background

Variceal bleeding is an important cause of mortality in patients with chronic liver disease (CLD). The gold standard for detection and grading of oesophageal varices (EV) is upper gastrointestinal endoscopy. However, it is expensive, time-consuming and invasive.

Objectives

This study aimed to find any association between splenic shear wave velocity (SWV) measured by acoustic radiation force imaging (ARFI) and the presence of EV.

Method

The quasi-experimental study included 50 patients with CLD and 50 subjects without CLD as the control group. Both underwent upper abdominal ultrasonography followed by elastographic assessment on a Siemens Acuson S2000TM ultrasound system. A comparison of the findings was made between the control and patient groups.

Results

Both groups had similar hepatic size while patients with CLD had larger splenic size and area (p < 0.05). The CLD patients had higher mean hepatic and splenic SWV compared with the control group (p < 0.05). The mean splenic size and splenic SWV were higher in patients with varices than in those without varices (p < 0.05).

Conclusion

Chronic liver disease causes significant increase in liver and splenic stiffness with splenic SWV values being higher for patients with varices emphasising the role of elastography as a non-invasive predictor for the presence of EVs. Splenic SWV had the highest sensitivity and specificity, which was augmented by a combination of hepatic and splenic SWV. Thus, splenic SWV alone or in combination with hepatic SWV is a useful technique for prediction of the presence of EVs.

Contribution

This study aims to find an alternative non-invasive and cost-effective technique for screening of EV.

Spleen stiffness measurement predicts decompensation and rules out high-risk oesophageal varices in primary biliary cholangitis

Background & Aims

Primary biliary cholangitis (PBC) may lead to portal hypertension (PH). Spleen stiffness measurement (SSM) by vibration-controlled transient elastography accurately predicts PH. We aimed to assess SSM role in stratifying the risk of liver decompensation in PBC.

Methods

In this monocentric, prospective, cross-sectional study, we included 114 patients with PBC who underwent liver stiffness measurement (LSM) and SSM. In total, 78 and 33 patients underwent two and three sequential vibration-controlled transient elastography examinations, respectively (longitudinal study). Screening for high-risk oesophageal varices by oesophagogastroduodenoscopy was performed according to guidelines and proposed to all patients with SSM >40 kPa.

Results

Among the 114 patients, 20 (17%) had LSM ≥10 kPa, whereas 17 (15%) had SSM >40 kPa. None of the patients with SSM ≤40 kPa had high-risk oesophageal varices, compared with three of 14 patients with SSM >40 kPa (21%; three refused endoscopy); any-size oesophageal varices were found in nine of 14 patients (64%). During a median follow-up of 15 months (IQR 10-31 months), five (4%) patients developed liver decompensation. The probability of liver decompensation was significantly higher among patients with both LSM ≥10 kPa and SSM >40 kPa: 41% at 24 months vs. 0% in other patient groups (i.e. LSM <10 kPa and SSM ≤40 kPa, or LSM ≥10 kPa and SSM ≤40 kPa, or LSM <10 kPa and SSM >40 kPa) (p <0.0001). Among the 78 patients undergoing longitudinal evaluation, four of nine patients (44%) with SSM increase during follow-up experienced liver decompensation, whereas none of those with stable LSM and SSM had liver decompensation.

Conclusions

Both LSM and SSM predict liver decompensation in patients with PBC. SSM ≤40 kPa rules out high-risk oesophageal varices and might be used in combination with LSM to improve the prediction of PH-related complications.

Impact and implications

Spleen stiffness measurement by vibration-controlled transient elastography accurately predicts portal hypertension in patients with chronic viral hepatitis. The present study is the first to demonstrate that in primary biliary cholangitis the combination of liver stiffness and spleen stiffness measurement can significantly improve risk stratification by predicting liver decompensation. Moreover, when spleen stiffness is combined with liver stiffness measurement and platelet count, it aids in identifying individuals with a low probability of having high-risk oesophageal varices, thereby allowing the avoidance of unnecessary endoscopy examinations. Further validation of our results in larger cohorts of patients with primary biliary cholangitis is needed to implement spleen stiffness measurement in clinical practice.

Letter to editor ‘Non-invasive model for predicting high-risk esophageal varices based on liver and spleen stiffness’

This letter to the editor relates to the study entitled "Non-invasive model for predicting high-risk esophageal varices based on liver and spleen stiffness". Acute bleeding caused by esophageal varices is a life-threatening complication in patients with liver cirrhosis. Due to the discomfort, contraindications, and associated complications of upper gastrointestinal endoscopy screening, it is crucial to identify an imaging-based non-invasive model for predicting high-risk esophageal varices in patients with cirrhosis.

Evaluation of liver and splenic stiffness by acoustic radiation force impulse for assessment of esophageal varices

BACKGROUND

In routine clinical practice, assessment of portal hypertension (PHT) among patients with liver cirrhosis is done by a upper gastrointestinal endoscopy (UGIE); however, its invasive nature limits its use. Recent advances in ultrasound imaging make it possible to evaluate the tissue stiffness of the liver and spleen reflecting the severity of underlying fibrosis. Liver stiffness and spleen stiffness can be used to predict the presence of esophageal varices/PHT among cirrhotic patients.

AIM

To predict the presence or absence of esophageal varices by measuring the stiffness of the liver and spleen by ultrasonography (USG)-based acoustic radiation force impulse (ARFI).

METHODS

This cross-sectional study included 90 subjects with liver cirrhosis. Liver and splenic stiffness were measured along with the USG abdomen, UGIE and aspartate aminotransferase to platelet ratio index (APRI).

RESULTS

Liver and spleen stiffness were significantly higher in cirrhotic patients compared to chronic hepatitis B. The best cut-off value of liver stiffness (LS) obtained by the receiver operating characteristic (ROC) curve was 2.16 m/s for predicting esophageal varices (AUROC 0.78, p 0.0002). The best cut-off value of splenic stiffness (SS) obtained by the ROC curve was 3.04 m/s for predicting esophageal varices (AUROC 0.698, p 0.0274). When both LS and SS were taken together, the accuracy in predicting esophageal varices increased to 92.22%. An equation to predict "esophageal varices = (0.225 LS + 0.377SS) - 0.555" was derived.

CONCLUSION

LS and SS values of ≥ 2.16 m/s and 3.04 m/s, respectively, predict esophageal varices independently; however, combined assessment is better with 92% accuracy.

Spleen stiffness determined by spleen-dedicated device accurately predicted esophageal varices in cirrhosis patients

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.

Utility of ElastPQ point-shear wave elastography in the work-up of patients with primary sclerosing cholangitis

Background & Aims

Liver stiffness measurement (LSM) and spleen stiffness measurement (SSM) have been shown to be useful tools for assessing the risk of fibrosis and portal hypertension, respectively. However, data on the accuracy of LSM and SSM measured by point-shear wave elastography (pSWE) in patients affected by primary sclerosing cholangitis (PSC) are still lacking. Thus, we aimed to prospectively assess their performance in a cohort of patients with PSC.

Methods

We determined the correlation between LSM assessed by a pSWE technique (ElastPQ) and by FibroScan-transient elastography (F-TE). Furthermore, we used receiver-operating characteristic curves and area under the curves (AUROC) to evaluate the performance of LSM by ElastPQ for the staging of fibrosis, using F-TE as a reference standard, and the performance of LSM and SSM by ElastPQ in predicting the presence of oesophageal varices (OVs).

Results

One hundred and fifty-two patients with PSC (93 males [61.2%], mean age 46 ± 16 years) were prospectively recruited. ElastPQ and F-TE LSMs were available for all patients, while ElastPQ SSM was available in 109 (72%) patients of whom 35 underwent upper gastrointestinal endoscopy within 1 year of the ultrasound assessment. ElastPQ LSM showed an excellent correlation with F-TE (p <0.001, Spearman's 0.93; Lin's 0.86) and a good diagnostic accuracy for fibrosis staging along all stages of liver fibrosis (AUROCs 0.96, 0.97, 0.97 and 0.99 for fibrosis stages F≥1, F≥2, F≥3 and F=4, respectively), using F-TE as a surrogate of histological fibrosis. ElastPQ SSM showed a good diagnostic performance in predicting the presence of OVs at endoscopy.

Conclusions

LSM and SSM by ElastPQ can be used as accurate tools for liver fibrosis risk assessment and fibrosis staging, as well as for predicting the presence of OVs in the work-up of patients with PSC.

Impact and implications

Liver and spleen stiffness measurement (LSM and SSM, respectively) by ElastPQ point-shear wave elastography in patients with primary sclerosing cholangitis represent reliable and reproducible tools for non-invasively staging the severity of liver disease and stratifying patients according to their risk of developing liver-related outcomes. In particular, LSM shows good accuracy for staging liver fibrosis and therefore detecting those patients at high risk of having compensated advanced chronic liver disease who require close monitoring. SSM seems to be promising to detect the risk of portal hypertension and therefore of oesophageal varices, enabling the triaging of patients who really need to undergo a screening endoscopy.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

Predicting the Severity of Esophageal Varices in Patients with Hepatic Cirrhosis Using Non-Invasive Markers

Background

The presence and extent of severity of esophageal varices (EV) in patients with liver cirrhosis (LC) are predicted using noninvasive clinical, biochemical, and imaging parameters. The aim of this study was to investigate the accuracy of noninvasive predictors of EV, such as the platelet count-to-spleen diameter ratio (PSR), platelet count-to-spleen volume ratio (PSVR), spleen size (SZ), and a combination of these markers in determining the severity of EV in patients with cirrhosis.

Methods

We recruited 82 inpatients with LC from the Department of Gastroenterology at the First Affiliated Hospital of Guangxi Medical University between January 2018 and December 2019 for this diagnostic investigation. All patients underwent endoscopy, ultrasound, computed tomography, and routine laboratory investigations. For the study, we evaluated and compared the diagnostic accuracy of PSR, PSVR, SZ, and their combinations.

Results

There were significant differences in the area under the receiver operating characteristic (ROC) curve (AUC) in the prediction of severe and moderate/severe EV for all the variables. PSR+PSVR had the highest AUC at 0.735 (95% CI: 0.626-0.826) and 0.765 (95% CI: 0.659-0.852) for predicting severe and moderate/severe EV, respectively. There were statistically significant differences in the AUCs (95% CI) for PSR, PSVR, and PSR+PSVR in predicting the existence of EV. As per the overall model quality chart, the combination of PSR+PSVR was the best indicator for detecting the presence of EV (AUC, 0.696; 95% CI: 0.584-0.792).

Conclusion

In our study, we found that these noninvasive parameters could predict the extent of severity of EV in patients with LC. We anticipate the use of a combination of PSR + PSVR to emerge as the superior indicator as studies progress.

Liver stiffness-spleen diameter to platelet ratio score (LSPS model) predicts variceal rebleeding for cirrhotic patients

PURPOSE

The liver stiffness- spleen diameter to platelet ratio score (LSPS model) can identify a high risk of decompensated events in cirrhotic patients. We aimed to evaluate the value of the LSPS model as a risk stratification strategy in the secondary prevention for cirrhotic patients with esophageal and gastric variceal bleeding (EGVB).

METHODS

Consecutive EGVB patients who underwent liver stiffness measurement by acoustic radiation force impulse, platelet count and ultrasonography were enrolled between January 2013 and December 2019. We calculated the LSPS of all patients and followed up for over 2 years. The primary outcome was rebleeding. Transplant-free survival and overt hepatic encephalopathy (OHE) were the secondary outcomes.

RESULTS

A total of 131 patients were analyzed. The median value of the LSPS model is 0.1879. We developed risk stratification based on the LSPS model and divided the patients into two groups: the high-LSPS (LSPS > 0.1879) group and the low-LSPS (LSPS ≤ 0.1879) group. Sixty-two (47.33%) patients suffered rebleeding, in which there were 21 (31.92%) patients with low LSPS and 41 (63.08%) patients with high LSPS (hazard ratio 2.883; 95% confidence interval, 1.723-4.822, P  < 0.001). For the whole cohort, the rates of transplant-free survival and OHE were consistently similar between the two groups at 2 years.

CONCLUSION

The LSPS is a reliable, noninvasive method for the detection of a high risk of rebleeding for the secondary prevention of EGVB.

High accuracy of spleen stiffness measurement in diagnosing clinically significant portal hypertension in metabolic-associated fatty liver disease

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.

Splenic Stiffness Is the Best Predictor of Clinically Significant Varices in Children With Portal Hypertension

BACKGROUND AND AIMS

We studied splenic stiffness measurement (SSM) by transient elastography (TE) and portal hemodynamics parameters (PHDp) on Doppler as predictors of clinically significant varices (CSV) in children.

METHODS

All children of 6 months to 18 years of age with portal hypertension (PHT) (chronic liver disease, CLD and non-cirrhotic portal hypertension, NCPH) were enrolled. TE for spleen (SSM) and liver (liver stiffness measurement, LSM) and PHDp by Doppler ultrasonography were measured. Noninvasive indices for PHT were calculated. CSV were defined as esophageal varices ≥grade 2 and/or gastric varix. Binary logistic regression analysis (LRA) and receiver operating characteristic statistics were applied.

RESULTS

A total of 150 (120 CLD and 30 NCPH) children formed the study cohort. Prevalence of CSV was higher in NCPH than CLD [73.3% vs 53.3%, Odd's ratio (OR) 2.369, P = 0.04]. On LRA, SSM was found to be the only independent predictor of CSV in children with CLD [OR 1.19 (95% Confidence Interval (CI) 1.018-1.16), P = 0.000] as well as in NCPH [OR 1.088 (95% CI 1.018-1.16), P = 0.013]. This model improved prediction of CSV in CLD from 52.5% to 83.9% and in NCPH from 73.3% to 86.7%. In children with CLD, SSM at a cut-off ≥27.6 kPa and in NCPH, SSM at a cut-off ≥29.5 kPa predicted CSV. In children with CLD, SSM correlated with LSM ( R = 0.610, P <0.001) and with noninvasive PHT indices except aspartate aminotransferase-to-platelet ratio index.

CONCLUSION

SSM is the best noninvasive predictor of CSV in childhood CLD and NCPH and can be used as screening test for endoscopy in children with PHT.

Non-invasive tools for compensated advanced chronic liver disease and portal hypertension after Baveno VII - an update

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.

Liver and spleen stiffness for the diagnosis of oesophageal varices in adults with chronic liver disease

This is a protocol for a Cochrane Review (diagnostic). The objectives are as follows:

To assess the diagnostic accuracy of liver stiffness and spleen stiffness, separately or in combination, as measured by vibration‐controlled transient elastography (VCTE) in detection of any oesophageal varices in adults with chronic liver disease. We will regard a combination of tests as positive when at least one is positive.

To compare the diagnostic accuracy of individual tests (liver stiffness and spleen stiffness measured by VCTE) directly and versus the combination of both tests (considering positive when at least one is positive) in detecting any oesophageal varices.

To assess the diagnostic accuracy of liver stiffness and spleen stiffness, separately or in combination, as measured by other elastography techniques (2D‐shear wave elastography (2D‐SWE), point shear wave elastography (pSWE), magnetic resonance elastography (MRE)) in detection of any oesophageal varices in adults with chronic liver disease. We will regard a combination of tests as positive when at least one is positive.

To compare the diagnostic accuracy of liver stiffness and spleen stiffness measured by VCTE with other techniques (pSWE, 2D‐SWE, MRE) in detection of any oesophageal varices in adults with chronic liver disease.

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

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

The Value of Liver and Spleen Stiffness for Evaluation of Portal Hypertension in Compensated Cirrhosis

Patients with compensated advanced chronic liver disease who develop clinically significant portal hypertension (CSPH) are at high risk for hepatic decompensation and mortality if left untreated. Liver biopsy and hepatic venous pressure gradient (HVPG) measurements are the current gold standard procedures for determining fibrosis severity and diagnosing CSPH, respectively; however, both are invasive, limiting their use in clinical practice and larger trials of novel agents. As such, there is an unmet clinical need for reliable, validated, noninvasive measures to detect CSPH and to further assess portal hypertension (PH) severity. Alterations in the biomechanical properties of the liver or spleen in patients with cirrhosis can be quantified by tissue elastography, which examines the elastic behavior of tissue after a force has been applied. A variety of methods are available, including magnetic resonance elastography, shear-wave elastography, and the most thoroughly investigated measure, vibration-controlled transient elastography. Liver stiffness (LS) and spleen stiffness (SS) measurements offer valuable alternatives to detect and monitor CSPH. Both LS and SS correlate well with HVPG, with thresholds of LS >20-25 kPa and SS >40-45 kPa indicating a high likelihood of CSPH. Because SS is a direct and dynamic surrogate of portal pressure, it has the potential to monitor PH severity and assess PH improvement as a surrogate marker for clinical outcomes. Importantly, SS seems to be superior to LS for monitoring treatment response in clinical trials focusing on reducing PH.

Detection of liver and spleen stiffness in rats with portal hypertension by two-dimensional shear wave elastography

BACKGROUND

The measurement of liver stiffness (LS) and spleen stiffness (SS) based on ultrasound elastography can be used for non-invasive assessment of portal hypertension (PH). However, there are few studies on the corresponding mechanism of increased spleen stiffness. Our aim was to use two-dimensional shear wave elastrography (2D-SWE) to evaluate the relationship between LS and SS and the severity of PH in rats. And explore the mechanism of the increase of LS and SS in PH.

METHODS

Sixty male Sprague-Dawley rats were randomly divided into portal hypertension (PH group, n = 45) and normal control (NC group, n = 15). At 12 weeks, LS and SS was detected by 2D-SWE in vivo. Related hemodynamic parameters and portal vein pressure (PVP) was measured. Spleen and liver 2D-SWE detection was performed again after sacrifice. Pathological changes were observed.

RESULTS

The SS and LS were increased in PH group (P < 0.05). The SS decreased after sacrifice, and what's more the magnitude of SS decline significantly higher in PH group than in NC group (P < 0.05). The correlation between SS and PVP is stronger than LS (r = 0.624, P < 0.001). SS has positive correlation with indexes of hyperdynamic circulation, but LS was weakly. The correlation between SS and the pathological grade (r = 0.633, P < 0.001) was lower than that in LS (r = 0.905, P < 0.001). Multiple linear regression analysis revealed that SS, portal vein inner diameter (PVD) and splenic vein blood flow velocity (SVV) were significantly associated with PH.

CONCLUSIONS

Spleen and liver measurement by 2D-SWE may be helpful in evaluating PVP. The correlation between SS and PVP is stronger than LS in rats measured by 2D-SWE. Hemodynamic circulation are important in the elevation of SS with portal hypertension. Pathological changes also have a degree of influence, but have more significance for the elevation of LS. SS may be a more effective noninvasive predictor of PH than LS.

Quantitative Assessment of Portal Hypertension by Two-Dimensional Shear Wave Elastography in Rat Models of Nonalcoholic Fatty Liver Disease: Comparison With Four Composite Scores

Background

Measurement of hepatic venous pressure gradients is the gold standard for assessing portal hypertension (PH) but is invasive with potential complications. We aimed to assess the performance in liver and spleen stiffness measurement (LSM and SSM, respectively) by two-dimensional shear wave elastography (2D-SWE) and composite scores including liver stiffness-spleen diameter to platelet ratio score (LSPS), platelet (PLT) count/spleen diameter ratio (PSR), aspartate aminotransferase (AST)/alanine aminotransferase ratio (AAR), and AST-to-PLT ratio index (APRI) for diagnosing PH in nonalcoholic fatty liver disease (NAFLD) rat models.

Methods

Animal models with PH in NAFLD were established in 65 rats, which then underwent 2D-SWE measurements. Morphological and biological parameters were collected for calculation of four composite scores. Correlations of noninvasive methods with portal venous pressure were evaluated by Spearman correlation analysis. The area under the receiver operating characteristic curve (AUC) was used to assess the performance of noninvasive methods in predicting PH.

Results

LSM and SSM were significantly associated with portal venous pressure (r = 0.636 and 0.602, respectively; all P < 0.001). The AUCs of LSM and SSM in the diagnosis of PH were 0.906 (95% confidence interval [CI]:0.841–0.97) and 0.87 (95% CI:0.776–0.964), respectively, and were significantly higher than those in composite scores. The AUCs for LSPS, PSR, AAR, and APRI were 0.793, 0.52, 0.668, and 0.533, respectively, for diagnosing PH. The AUCs of the combined models of LSM and SSM, LSM and PLT, SSM and PLT, and LSM, SSM and PLT were 0.923, 0.913, 0.872, and 0.923, respectively. The four combined models showed no statistical differences compared to LSM and SSM in evaluating PH (all P > 0.05).

Conclusions

LSM and SSM by 2D-SWE can be used as promising noninvasive parameters for diagnosing PH in NAFLD and have higher accuracy than composite scores. The combined models, compared to LSM and SSM, did not significantly improve the performance in diagnosing PH.

Comparison between spleen and liver stiffness measurements by sound touch elastography for diagnosing cirrhosis at different aminotransferase levels: a prospective multicenter study

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.

Plasma Cyclic Guanosine Monophosphate Is a Promising Biomarker of Clinically Significant Portal Hypertension in Patients With Liver Cirrhosis

Introduction: Despite intensive research, reliable blood-derived parameters to detect clinically significant portal hypertension (CSPH) in patients with cirrhosis are lacking. As altered homeostasis of cyclic guanosine monophosphate (cGMP), the central mediator of vasodilatation, is an essential factor in the pathogenesis of portal hypertension, the aim of our study was to evaluate plasma cGMP as potential biomarker of cirrhotic portal hypertension.

Methods: Plasma cGMP was analyzed in cirrhotic patients with CSPH (ascites, n = 39; esophageal varices, n = 31), cirrhotic patients without CSPH (n = 21), patients with chronic liver disease without cirrhosis (n = 11) and healthy controls (n = 8). cGMP was evaluated as predictor of CSPH using logistic regression models. Further, the effect of transjugular intrahepatic portosystemic shunt (TIPS) placement on plasma cGMP was investigated in a subgroup of cirrhotic patients (n = 13).

Results: Plasma cGMP was significantly elevated in cirrhotic patients with CSPH compared to cirrhotic patients without CSPH [78.1 (67.6–89.2) pmol/ml vs. 39.1 (35.0–45.3) pmol/l, p < 0.001]. Of note, this effect was consistent in the subgroup of patients with esophageal varices detected at screening endoscopy who had no prior manifestations of portal hypertension (p < 0.001). Cirrhotic patients without CSPH displayed no significant elevation of plasma cGMP compared to patients without cirrhosis (p = 0.347) and healthy controls (p = 0.200). Regression analyses confirmed that cGMP was an independent predictor of CSPH (OR 1.042, 95% CI 1.008–1.078, p = 0.016). Interestingly, portal decompression by TIPS implantation did not lead to normalization of plasma cGMP levels (p = 0.101).

Conclusions: Plasma cGMP is a promising biomarker of CSPH in patients with cirrhosis, especially with respect to screening for esophageal varices. The lacking normalization of plasma cGMP after portal decompression suggests that elevated plasma cGMP in cirrhotic portal hypertension is mainly a correlate of systemic and splanchnic vasodilatation, as these alterations have been shown to persist after TIPS implantation.

Diagnostic value of conventional ultrasound and shear wave elastography in detecting transjugular intrahepatic portosystemic shunt dysfunction

BACKGROUND

Transjugular intrahepatic portosystemic shunt (TIPS) dysfunction can cause recurrent portal hypertension (PH)-related complications such as ascites and gastroesophageal variceal bleeding. Portography is invasive and costly limits its use as a screening modality.

PURPOSE

To assess the clinical value of conventional ultrasound in combination with point shear wave elastography (pSWE) to predict TIPS dysfunction.

MATERIAL AND METHODS

A total of 184 patients with cirrhosis scheduled for TIPS implantation were enrolled in this study and evaluated retrospectively. The splenoportal venous blood flow parameter, liver stiffness (LS), and spleen stiffness (SPS) were measured. Outcome measures included differences in portal vein velocity (PVV), splenic vein velocity (SPVV), LS, and SPS. The accuracy of change in PVV (ΔPVV), SPVV (ΔSPVV), and SPS (ΔSPS) to diagnose TIPS dysfunction was investigated.

RESULTS

TIPS dysfunction occurred in 28 of 184 patients (15.2%). Eighteen (64.3%) patients had shunt stenoses and 10 (35.7%) had shunt occlusion. Portal vein diameter (PVD), PVV, splenic vein diameter (SPVD), SPVV, LS, and SPS were not significantly different between the TIPS normal and TIPS dysfunction groups. Compared with the TIPS normal group, PVV and SPVV of the TIPS dysfunction group decreased significantly, whereas SPS increased significantly (P < 0.001). The values of areas under the receiver operating characteristic curves of ΔPVV, ΔSPVV, and ΔSPS for the diagnosis of TIPS dysfunction were 0.97, 0.96, and 0.87, respectively.

CONCLUSION

pSWE showed a diagnostic efficacy comparable to conventional ultrasound for diagnosing TIPS dysfunction and can be used routinely after TIPS procedures.

Elastography as a predictor of liver cirrhosis complications after hepatitis C virus eradication in the era of direct-acting antivirals

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.

Diabetes mellitus and postoperative blood glucose value help predict posthepatectomy liver failure in patients with hepatocellular carcinoma

Background

Many complications after hepatectomy can lead to perioperative death, among which posthepatectomy liver failure (PHLF) is the leading one. Existing studies suggest that one of the most important risk factors for PHLF is cirrhosis. Hepatitis B virus (HBV) infection is an important factor in the occurrence of cirrhosis, and the exact relationship between HBV infection and PHLF is not obvious. Diabetes mellitus and postoperative blood glucose are closely associated with liver regeneration, but its exact relationship with PHLF remains unclear.

Methods

We collected clinical indicators from 920 adult patients treated at the Liver Surgery and Transplantation Center of West China Hospital of Sichuan University from April 2009 and April 2019. We conducted a univariate analysis find out the risk factors of PHLF, follow by a multivariate analysis to ascertain the independent risk factors. Receiver operating characteristic (ROC) curves were plotted to evaluate the predictive efficiency of each risk factor.

Results

Following hepatectomy, 205 (22.2%) of patients were diagnosed with PHLF. Several variables were confirmed to related with PHLF significantly: diabetes [P<0.01, odds ratio (OR) =10.845, 95% confidence interval (CI): 5.450-21.579], HBV (P<0.01, OR =0.345, 95% CI: 0.187-0.635), blood glucose on the first postoperative day (post-BG1) (P=0.027, OR =1.059, 95% CI: 1.006-1.115), blood glucose on the third postoperative day (post-BG3) (P=0.021, OR =1.085, 95% CI: 1.012-1.162), blood glucose on the fifth postoperative day (post-BG5) (P=0.014, OR =1.119, 95% CI: 1.023-1.225), postoperative total bilirubin (post-TB) (P<0.01, OR =1.160, 95% CI: 1.133-1.187), and liver cirrhosis (P<0.01, OR =0.982, 95% CI: 0.561-1.717) identified to be independent risk factors of PHLF.

Conclusions

Diabetes, HBV, post-BG1, post-BG3, and post-BG5 are related to the development of PHLF, and diabetes and post-BG can be used as predictors of the development of PHLF in patients with hepatocellular carcinoma (HCC).

Stiffer Spleen Predicts Higher Bone Marrow Fibrosis and Higher JAK2 Allele Burden in Patients With Myeloproliferative Neoplasms

A total of 63 myeloproliferative neoplasms [MPN; 9 polycythemia vera (PV), 32 essential thrombocythemia (ET), and 22 myelofibrosis (MF)] underwent spleen stiffness (SS) measurement by vibration-controlled transient elastography equipped with a novel spleen-dedicated module. Higher SS values significantly correlated with grade 2-3 bone marrow (BM) fibrosis (p=0.035), with hemoglobin level <10 g/dl (p=0.014) and with white blood cells ≥10,000/μl (p=0.008). Median SS was significantly higher in MF patients compared to ET and PV (p=0.015). SS also correlated with higher JAK2 variant allele frequency (p=0.02). This study identifies SS as a potential noninvasive tool that reflects BM fibrosis and the mutational burden in MPN.

Noninvasive Detection of Clinically Significant Portal Hypertension in Compensated Advanced Chronic Liver Disease

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.

Spleen Stiffness for Predicting Varices Needing Treatment: Comparison between Two Different Elastography Techniques (Point vs. 2D-SWE)

The study aimed to establish the benefits of using spleen stiffness values measured by two elastography techniques as noninvasive markers for predicting varices needing treatment and comparing their performances. A prospective study was performed, including 107 subjects with compensated liver cirrhosis, who underwent upper digestive endoscopy, as well as spleen stiffness measurements by means of two elastography techniques: pSWE (point shear wave elastography using Virtual Touch Quantification-Siemens Acuson S2000) and 2D-SWE (2D-shear wave elastography-LOGIQ E9, General Electric). Reliable spleen stiffness measurements were obtained in 96.2% (103/107) patients by means of 2D-SWE and in 94.4% (101/107) subjects with pSWE; therefore, 98 subjects were included in the final analysis, of which 40.8% (40/98) had varices needing treatment. The optimal spleen stiffness cut-off value by 2D-SWE for predicting varices needing treatment was 13.2 kPa (AUROC 0.84), while for pSWE, it was 2.91 m/s (AUROC 0.90). Based on AUROC comparison, no difference between the performance of the two techniques for predicting varices needing treatment was found (p=0.1606). In conclusion, spleen stiffness measured by either 2D-SWE or pSWE is a reliable surrogate marker, with good feasibility, applicability, and predictive accuracy for varices needing treatment, with no significant difference between techniques.

Small-diameter TIPS combined with splenic artery embolization in the management of refractory ascites in cirrhotic patients

PURPOSE

Maximally decreasing portal pressures with transjugular intrahepatic portosystemic shunt (TIPS) is associated with improved ascites control but also increased encephalopathy incidence. Since splenic venous flow contributes to portal hypertension, we assessed if combining small-diameter TIPS with splenic artery embolization could improve ascites while minimizing encephalopathy.

METHODS

Fifty-five patients underwent TIPS creation for refractory ascites. Subjects underwent creation of 8 mm TIPS followed by proximal splenic artery embolization (group A, n=8), or of 8 mm (group B, n=6) or 10 mm TIPS (group C, n=41) without splenic embolization. Data were retrospectively reviewed.

RESULTS

In group A, median portosystemic gradient decreased from 19 mmHg to 9 mmHg after TIPS, and 8 mmHg after subsequent splenic artery embolization. In groups B and C, gradient decreased from 15 mmHg to 8 mmHg and 16 mmHg to 6 mmHg. All patients except for one in group A and two in C had greater than 50% reduction in the number of paracenteses in 3 months. Any postprocedural encephalopathy incidence was 62%, 50%, 83% in groups A, B, and C, respectively. Overall, 20% of subjects with 10 mm TIPS required TIPS reduction/closure compared to 7% of subjects with 8 mm TIPS.

CONCLUSION

We found that 8 mm diameter TIPS provided similar ascites control compared to 10 mm TIPS regardless of splenic embolization. While more patients with 10 mm TIPS required reduction/closure for severe encephalopathy, the study was underpowered for definitive assessment. Splenic embolization might have the potential to further decrease portosystemic gradient and ascites as an alternative to dilation of TIPS to 10 mm minimizing the risk of encephalopathy, but larger studies are warranted.

Application of Hepatic Transit Time and Shear Wave Velocity in Assessing Portal Pressure in Patients with Cirrhotic Portal Hypertension

The aim of the study described here was to explore the value of hepatic transit time (HTT) and shear wave velocity (SWV) in diagnosing cirrhotic portal hypertension. Fifty-seven patients had undergone esophagogastric varicose vein embolization (group OBS) and 50 healthy controls (group CON) were retrospectively compared with respect to HTT (arterial-hepatic vein [HA-HVTT], portal vein-hepatic vein [PV-HVTT], liver parenchyma-hepatic vein [PA-HVTT]) and SWV to analyze their efficacy in diagnosing cirrhotic portal hypertension. The correlations between SWV/HTT and free portal pressure (FPP) in group OBS were also analyzed. Compared with group CON, group OBS had a shorter HTT and faster SWV. The area under the curve (AUC) of PV-HVTT (0.93) was higher than those of HA-HVTT (0.75) and PA-HVTT (0.64), the AUCs of PV-HVTT (0.93, threshold 7.9 s) and SWV (0.91, threshold 2.0 cm/s) did not statistically differ (z = 0.35, p = 0.73). HTT and FPP in group OBS had a negative correlation. In conclusion, HTT and SWV can be used to diagnose cirrhotic portal hypertension without difference in diagnostic efficacy, and HTT is more meaningful for assessing the changes in portal pressure.

Spleen stiffness measurement by shear wave elastography using acoustic radiation force impulse in predicting the etiology of splenomegaly

PURPOSE

To measure spleen stiffness by shear wave elastography (SWE) using acoustic radiation force impulse (ARFI) in patients with splenomegaly and to evaluate utility of elastography technique in identifying etiology of splenomegaly.

METHODS

Sixty-one treatment-naïve patients with splenomegaly were enrolled. The control group consisted of 20 healthy subjects without history of any disease including diabetes and hypertension, alcohol consumption, or biochemical or ultrasonographic findings indicating hepatic and renal diseases. B-mode ultrasonography and elastographic examinations were performed by a radiologist blinded to the participants. Spleen stiffness was measured by SWE using ARFI. Shear wave velocity (SWV) values were given in m/s.

RESULTS

Splenomegaly patients were assigned into three groups according to their etiologies as hepatoportal (n = 21), myeloproliferative (n = 23), and infectious (n = 17). Splenomegaly groups and control group were comparable regarding age and sex. Spleen size was higher in the splenomegaly groups than in the controls. Median SWV was significantly higher in the hepatoportal (3.85 m/s) and myeloproliferative (3.42 m/s) groups than in the infectious (2.66 m/s) and control (2.22 m/s) groups. The correlation between SWV and spleen size was not significant in any of the groups. The cut-off value was 3.42 (sensitivity 80.9%, specificity 56.5%) in distinguishing hepatoportal from myeloproliferative etiology; 3.02 (sensitivity 100%, specificity 100%) in distinguishing hepatoportal from infectious etiology; and 2.84 (sensitivity 91.3%, specificity 88.2%) in distinguishing myeloproliferative from infectious etiology.

CONCLUSION

Spleen stiffness measured by elastographic techniques in splenomegaly patients was higher than that in healthy subjects. SWV appeared to be beneficial in predicting the etiology of splenomegaly.

Spleen Stiffness Probability Index (SSPI): A simple and accurate method to detect esophageal varices in patients with compensated liver cirrhosis

INTRODUCTION AND OBJECTIVES

Recent findings pointed out that even low-risk esophageal varices (EVs) are markers of severe prognosis. Accordingly, we analyzed spleen stiffness (SS) as a non-invasive method to predict EVs of any grade in a cohort of patients with compensated liver cirrhosis.

METHOD

We measured SS and liver stiffness (LS) using point-Shear-Wave Elastography (pSWE) with Philips Affiniti 70 system in 210 cirrhotic patients who had undergone endoscopic screening for EVs. We compared SS and LS predictive capability for EVs of any grade.

RESULTS

SS was higher in cirrhotic patients with EVs if compared to patients without EVs (p<0.001). The cut-off analysis detected 31kPa (100% sensitivity and negative predictive value) as the value to rule-out EVs and 69kPa (100% specificity and positive predictive value) to rule-in EVs. Besides, we developed the Spleen Stiffness Probability Index (SSPI), that can provide a probability of presence/absence of EVs. SSPI was the best model according to all discriminative and calibration metrics (AIC=120, BIC=127, AUROC=0.95, Pseudo-R2=0.74). SS demonstrated higher correlation with spleen bipolar diameter and spleen surface (r=0.52/0.55) if compared to LS (r=0.30/0.25) - and with platelet count as well (r=0.67 vs r=0.4).

CONCLUSION

SS showed significantly higher performance than other parameters, proving to be the best non-invasive test in the screening of EVs: by directly applying SS cut-off of 31kPa, our department could have safely avoided endoscopy in 36% of patients. Despite cut-off analyses, it was possible to create a probability model that could further stratify low-risk from high-risk patients (for any grade of EVs).

Spleen and Liver Stiffness for Predicting High-Risk Varices in Patients with Compensated Liver Cirrhosis

The study evaluates the utility of spleen (SS) and liver stiffness (LS) associated with spleen size (SSZ) as non-invasive markers for predicting high-risk varices (HRV). One hundred thirty-two patients with compensated liver cirrhosis who underwent abdominal ultrasound SS (SSM) and LS measurements (LSM) using a 2-D shear wave elastography (2-D-SWE) technique from General Electric and upper endoscopy were included. Similar rates of reliable SSM and LSM were obtained (95.4% and 97.7% respectively); therefore, 124 patients were included in the final analysis. The optimal cutoff values for SS, LS and SSZ for predicting HRV were 13.2 kPa (area under the receiver operating characteristic curve [AUROC] = 0.84), 12.1 kPa (AUROC = 0.86) and 12.9 cm (AUROC = 0.71), respectively. Including these factors in multiple regression analysis, we obtained the scores for predicting HRV: 0.053 × SS + 0.054 × LS + 0.059 × SSZ - 1.84. The score's optimal cutoff value for predicting HRV was >0.34 (AUROC = 0.93). By comparing the AUROC's, the score including SSZ, SSM and LSM performed better than each independent factor for predicting HRV (p = 0.0091; p = 0.0341; p < 0.0001).

Validation and Refinement of the Baveno VI Criteria for Ruling Out High-Risk Varices

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.

Noninvasive scores for the prediction of esophageal varices and risk stratification in patients with cirrhosis

The primary purpose of variceal screening in patients with cirrhosis is to detect gastroesophageal varices at high risk of hemorrhage and implement preventative intervention(s). It was previously recommended that all patients with cirrhosis undergo initial and periodic longitudinal variceal screening via upper endoscopy. However, there has been growing interest and methods to identify patients with cirrhosis who may not have clinically significant portal hypertension and therefore be unlikely to have varices requiring intervention or benefit from upper endoscopy. Because the population of patients with compensated advanced chronic liver disease continues to grow, it is neither beneficial nor cost-effective to perform endoscopic variceal screening in all patients. Therefore, there is ongoing research into the development of methods to non-invasively risk stratify patients with cirrhosis for the presence of high-risk esophageal varices and effectively limit the population that undergoes endoscopic variceal screening. This is particularly important and timely in light of increasing healthcare reform and barriers to healthcare. In this review, we discuss and compare, with respect to test characteristics and clinical applicability, the available methods used to non-invasively predict the presence of esophageal varices.

CT-scan Based Liver and Spleen Volume Measurement as a Prognostic Indicator for Patients with Cirrhosis

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.

Noninvasive imaging assessment of portal hypertension

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.

Diagnostic accuracy of liver and spleen stiffness measured by fibroscan® in the prediction of esophageal varices in HCV-related cirrhosis patients treated with oral antivirals

INTRODUCTION

The aim of this study was to investigate the accuracy of liver and spleen stiffness measurement by transient elastography for the prediction of gastroesophageal varices in patients with HCV-associated cirrhosis treated with new direct-acting antiviral agents.

PATIENTS AND METHODS

This cross-sectional observational study included patients with compensated HCV-related cirrhosis and sustained virological response after direct-acting antiviral therapy. Patients underwent liver and spleen stiffness measurement, abdominal ultrasound and oesophago-gastroduodenoscopy. Clinical and laboratory data and non-invasive markers such as the liver stiffness-spleen diameter to platelet ratio score, variceal risk index and platelet count to spleen diameter ratio were analyzed.

RESULTS

Ninety-seven consecutive patients were included. Liver stiffness measurement (12.2 vs 16; p=0.02), spleen stiffness measurement (39.4 vs 46.05; p=0.04), liver stiffness-spleen diameter to platelet ratio score (1.21 vs 2.02; p=0.008), platelet count to spleen diameter ratio (1102.19 vs 829.7; p=0.04) and variceal risk index (-3.4 vs -1.02; p=0.01) showed significant differences between patients without/with gastroesophageal varices. The best cut-off value to discard the presence of gastroesophageal varices was 12.3kPa for liver stiffness measurement and 27kPa for spleen stiffness measurement. However, diagnostic accuracy was moderate (AUROC: 0.671 and 0.624 respectively). Combining different non-invasive parameters did not significantly improve the overall performance.

DISCUSSION

Liver and spleen stiffness measurement showed suboptimal results for non-invasive assessment of gastroesophageal varices in HCV cirrhotic patients treated with direct-acting antiviral agents. Our results suggest that non-invasive methods cannot substitute standard procedures for predicting gastroesophageal varices in this population.

Quantitative assessment of portal hypertension with bi-parametric dual-frequency hepatic MR elastography in mouse models

OBJECTIVES

To determine the potential of bi-parametric dual-frequency hepatic MR elastography (MRE) for predicting portal pressure (PP) in mouse models of portal hypertension (PHTN) with the presence of varying hepatic fibrosis.

METHODS

We studied 73 wild-type male mice, including 22 mice with hepatic congestion, 20 mice with cholestatic liver injury, and 31 age-matched sham mice. Hepatic shear stiffness (SS) and volumetric strain (VS) were calculated by 3D MRE acquired at 80 and 200 Hz. We measured PP immediately after MRE. Liver fibrosis was verified by hydroxyproline assay. We predicted PP by fitting generalized linear models with single- and dual-frequency SS and VS, respectively. The relationship between predicted and actual PP was evaluated by Spearman's correlation. We compared the prediction accuracy of portal hypertension for all models with DeLong tests at a significance level of 0.05.

RESULTS

Animals with congestive or cholestatic liver disease developed significant PHTN and hepatic fibrosis to varying degrees. In both models, SS increased, while VS decreased significantly compared with shams. All bi-parametric models had high diagnostic accuracy for PHTN. The dual-frequency models (AUCs: 0.90 [81-95%], 0.91 [81-95%]) had substantially or significantly higher accuracy than single-frequency ones (AUCs: 0.83 [71-91%], and 0.78 [66-87%]). The predicted PP of dual-frequency models also showed stronger correlations with actual PP than single-frequency predictions.

CONCLUSIONS

The bi-parametric dual-frequency model improved the diagnostic accuracy of liver MRE in diagnosing PHTN in preclinical models. This technical advance has the potential to monitor PHTN progression and treatment efficacy in the presence of varying fibrosis.

KEY POINTS

• Bi-parametric hepatic MR elastography can predict portal pressure. • The prediction models of shear stiffness and volumetric strain with dual-frequency measurements demonstrate high diagnostic accuracy (AUCs > 0.9) in two different portal hypertension mouse models with varying fibrosis.

Diagnostic accuracy of spleen stiffness to evaluate portal hypertension and esophageal varices in chronic liver disease: a systematic review and meta-analysis

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.

Evaluation of spleen stiffness in healthy volunteers using point shear wave elastography

INTRODUCTION AND OBJECTIVES

This study aims to measure the values of spleen stiffness (SS) in healthy subjects, the inter-operator agreement in SS measurement, and to detect statistically significant correlations between SS and age, sex, weight, BMI, portal vein dynamics and splenic dimensions.

MATERIALS AND METHODS

The study included 100 healthy volunteers who had no substantial alcohol intake (<30g/daily for man, <20g/daily women), were negative on hepatitis B, hepatitis C, HIV blood serology, and had any history of lymphoproliferative disorders. Abdominal ultrasound, liver and spleen elastography were performed on each patient to search for focal splenic lesions, bile tract or portal vein dilatation, moderate/severe liver steatosis, and to measure liver and spleen stiffness.

RESULTS

The mean value was 18.14 (±3.08) kPa. In the group of men (n=49), the mean was 17.73 (±2.91) kPa, whereas in the group of women (n=51) it was 16.72 (±3.32) kPa. Statistical analyses showed no correlation between spleen stiffness and sex, age, weight, and BMI. Regarding their splenoportal axis, statistically significant differences in SS were found in the means of the two subgroups of subjects stratified by their portal flow velocity (p=0.003) and spleen area (p<0.001). Spearman's rank showed a weak association between SS and portal flow velocty (r=0.271) and splenic area (r=-0.237). ICC showed excellent (0.96) inter-operator agreement and Bland-Altman plot demonstrated no systematic over/under-estimation of spleen stiffness values.

CONCLUSIONS

Our results may serve as a reference point in the evaluation of SS especially in patients affected by advanced liver disease.

Screening for esophageal varices in cirrhotic patients - Non-invasive methods

Variceal bleeding is a dramatic complication of cirrhosis. Primary prophylaxis against variceal bleeding is indicated for patients with high-risk varices. In order for these patients to be identified, endoscopic screening for esophageal varices has been traditionally recommended at the time of the diagnosis of cirrhosis. Considering that many patients do not have esophageal varices in the early stages of cirrhosis and, therefore, are submitted to endoscopy unnecessarily, non-invasive methods for variceal screening have been studied. Among these non-invasive methods, the most extensively studied probably are platelet count/spleen diameter ratio, liver stiffness, spleen stiffness and an association between liver stiffness and platelet count, referred to as the Baveno VI criteria. The Baveno VI criteria has recently been recommended by different medical associations for variceal screening. This is a critical review on the non-invasive methods for variceal screening, in which the performances of the different methods are presented and the limitations of the existing evidence is discussed. Despite reasonable performances of some of these methods, especially platelet count/spleen diameter ratio and the association between liver stiffness and platelet count, we understand that the available evidence still has relevant limitations and that physicians should decide on screening cirrhotic patients for esophageal varices with endoscopy or non-invasive methods on a case-by-case basis.

Application of Baveno Criteria and Modified Baveno Criteria with Shear-wave Elastography in Compensated Advanced Chronic Liver Disease

BACKGROUND

We aimed to validate Baveno VI and expanded Baveno VI criteria using two dimensional shear-wave elastography (2D-SWE) in compensated advanced chronic liver disease (cACLD) patients with alcohol as the main etiology.

METHODS

Clinical data from 305 patients with cACLD who underwent a liver stiffness measurement (LSM) with 2D-SWE and endoscopy were consecutively collected.

RESULTS

Among 305 patients, high-risk varix (HRV) was identified in 21.3% (n = 65). The main etiology was alcoholic liver disease (51.8%), followed by hepatitis B virus (29.8%) and hepatitis C virus (9.1%). Baveno VI criteria spared endoscopy in 118 of the 305 (38.7%) patients, and 7 (5.9%) were missed with HRV. Expanded Baveno VI criteria spared more endoscopies (60.0%), but missed more HRV (9.8%) compared with Baveno VI criteria. The other classification described as the modified Baveno VI criteria were LSM < 25 kPa and PLT ≥ 150 × 10³/mm³. In total, 131 of the 305 (43.0%) patients were within the modified Baveno VI criteria, of whom seven (5.3%) had missed HRV. After adding spleen diameter < 12 cm to the modified Baveno VI criteria, the number of spared endoscopies increased by 106/305 (34.8%), with three (2.8%) presenting with HRV, indicating a risk of missing HRV.

CONCLUSION

Baveno VI and expanded Baveno VI criteria with 2D-SWE were insufficient with an HRV miss rate of over 5%. The modified Baveno VI criteria with spleen diameters < 12 cm with 2D-SWE spared more endoscopies with a minimal risk of missing HRV in cACLD patients with alcohol as the main etiology.

Organ Stiffness in the Work-Up of Myelofibrosis and Philadelphia-Negative Chronic Myeloproliferative Neoplasms

To define the role of spleen stiffness (SS) and liver stiffness (LS) in myelofibrosis and other Philadelphia (Ph)-negative myeloproliferative neoplasms (MPNs), we studied, by ultrasonography (US) and elastography (ES), 70 consecutive patients with myelofibrosis (MF) (no.43), essential thrombocythemia (ET) (no.10), and polycythemia vera (PV) (no.17). Overall, the median SS was not different between patients with MF and PV (p = 0.9); however, both MF and PV groups had significantly higher SS than the ET group (p = 0.011 and p = 0.035, respectively) and healthy controls (p < 0.0001 and p = 0.002, respectively). In patients with MF, SS values above 40 kPa were significantly associated with worse progression-free survival (PFS) (p = 0.012; HR = 3.2). SS also correlated with the extension of bone marrow fibrosis (BMF) (p < 0.0001). SS was higher in advanced fibrotic stages MF-2, MF-3 (W.H.O. criteria) than in pre-fibrotic/early fibrotic stages (MF-0, MF-1) (p < 0.0001) and PFS was significantly different in the two cohorts, with values of 63% and 85%, respectively (p = 0.038; HR = 2.61). LS significantly differed between the patient cohort with MF and healthy controls (p = 0.001), but not between the patient cohorts with ET and PV and healthy controls (p = 0.999 and p = 0.101, respectively). We can conclude that organ stiffness adds valuable information to the clinical work-up of MPNs and could be employed to define patients at a higher risk of progression.

The Role of Spleen and Liver Elastography and Color-Doppler Ultrasound in the Assessment of Transjugular Intrahepatic Portosystemic Shunt Function

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.

Nonalcoholic fatty liver disease and portal hypertension

Nonalcoholic fatty liver disease (NAFLD) is a substantial and growing problem worldwide and has become the second most common indication for liver transplantation as it may progress to cirrhosis and develop complications from portal hypertension primarily caused by advanced fibrosis and erratic tissue remodeling. However, elevated portal venous pressure has also been detected in experimental models of fatty liver and in human NAFLD when fibrosis is far less advanced and cirrhosis is absent. Early increases in intrahepatic vascular resistance may contribute to the progression of liver disease. Specific pathophenotypes linked to the development of portal hypertension in NAFLD include hepatocellular lipid accumulation and ballooning injury, capillarization of liver sinusoidal endothelial cells, enhanced contractility of hepatic stellate cells, activation of Kupffer cells and pro-inflammatory pathways, adhesion and entrapment of recruited leukocytes, microthrombosis, angiogenesis and perisinusoidal fibrosis. These pathological events are amplified in NAFLD by concomitant visceral obesity, insulin resistance, type 2 diabetes and dysbiosis, promoting aberrant interactions with adipose tissue, skeletal muscle and gut microbiota. Measurement of the hepatic venous pressure gradient by retrograde insertion of a balloon-tipped central vein catheter is the current reference method for predicting outcomes of cirrhosis associated with clinically significant portal hypertension and guiding interventions. This invasive technique is rarely considered in the absence of cirrhosis where currently available clinical, imaging and laboratory correlates of portal hypertension may not reflect early changes in liver hemodynamics. Availability of less invasive but sufficiently sensitive methods for the assessment of portal venous pressure in NAFLD remains therefore an unmet need. Recent efforts to develop new biomarkers and endoscopy-based approaches such as endoscopic ultrasound-guided measurement of portal pressure gradient may help achieve this goal. In addition, cellular and molecular targets are being identified to guide emerging therapies in the prevention and management of portal hypertension.

Update to the Society of Radiologists in Ultrasound Liver Elastography Consensus Statement

This multidisciplinary update of the Society of Radiologists in Ultrasound consensus statement on liver elastography incorporates the large volume of new information available in the literature since the initial publication. The recommended procedure for acquiring stiffness measurements is reviewed. There has been substantial improvement in the acoustic radiation force impulse (ARFI) technology-most notably the addition of a quality assessment of the shear wave propagation. Due to the efforts of the Quantitative Imaging Biomarkers Alliance, or QIBA, the variability of liver stiffness measurements between systems had decreased. There are now effective treatments for hepatitis B and hepatitis C, and follow-up after effective treatment should be based on the use of the delta change of the value obtained at viral eradication or suppression. Because the detection of compensated advanced chronic liver disease (cACLD) is very important, the new guidelines are made based on the probability of cACLD for given stiffness values. The panel recommends a vendor-neutral rule of four for interpretation for ARFI techniques. This new method simplifies interpretation of liver stiffness results and is more clinically relevant.