Esophageal varices in patients with cirrhosis: multidetector CT esophagography--comparison with endoscopy

Screening for exclusion of high-risk bleeding features of esophageal varices in cirrhosis through CT and MRI

BACKGROUND & AIM

Esophageal varices (EV) screening guidelines have evolved with improved risk stratification to avoid unnecessary esophagogastroduodenoscopy (EGD) in individuals with low bleeding risks. However, uncertainties persist in the recommendations for certain patient groups, particularly those with hepatocellular carcinoma (HCC) and/or receiving non-selective beta-blockers (NSBB) without prior endoscopy. This study assessed the efficacy of imaging in ruling out EVs and their high-risk features associated with bleeding in patients with cirrhosis and with HCC. We also evaluated the impact of NSBB on the detection of these characteristics.

METHODS

A total of 119 patients undergoing EGD with CT and/or MRI within 90 days of the procedure were included. 87 patients had HCC. A new imaging grading system was developed utilizing the size of EVs and the extent of their protrusion into the esophagus lumen. The negative predictive value (NPV) of EVimaging(-) versus EVimaging (+) (grades 1-3) in ruling out the presence of EV and/or high-risk features by EGD was calculated. The predictive performance of imaging was determined by logistic regression.

RESULTS

The NPV of imaging for detecting EV and high-risk features was 81 % and 92 %, respectively. Among HCC patients, the NPV for EV and high-risk features was 80 % and 64 %, respectively. Being on NSBB didn't statistically impact the imaging detection of EV. Imaging was a better predictor of high-risk EGD findings than Child-Turcotte-Pugh scores.

CONCLUSIONS

Our results suggest that imaging can effectively rule out the presence of EV and high-risk features during EGD, even in patients with HCC and/or receiving NSBB.

Microwave ablation versus laparoscopic resection for hepatocellular carcinoma in patients with clinically significant portal hypertension: a propensity score-matched study of postoperative liver decompensation

OBJECTIVES

The study of postoperative liver decompensation after microwave ablation (MWA) for hepatocellular carcinoma (HCC) in patients with clinically significant portal hypertension (CSPH) is still lacking. The purpose of the present study was to compare the postoperative liver decompensation after MWA and laparoscopic resection (LR) for HCC in patients with CSPH.

METHODS

The present retrospective study enrolled 222 HCC patients with CSPH who underwent MWA (n = 67) or LR (n = 155). Postoperative liver decompensation, complications, postoperative hospital stays, and overall survival were analyzed. Factors associated with postoperative liver decompensation were identified.

RESULTS

After propensity score matching, the postoperative liver decompensation rate was significantly lower in the MWA group than that in the LR group (15.5% versus 32.8%, p = 0.030). The multivariable regression analysis identified that type of treatment (MWA vs. LR, odds ratio [OR] 0.44; 95% confidence interval [CI], 0.21-0.91; p = 0.026) and Child-Pugh B (OR, 2.86; 95% CI, 1.24-6.61; p = 0.014) were independent predictors for postoperative liver decompensation. The rate of complications for patients in the MWA group was significantly lower than that in the LR group (p < 0.001). And MWA showed shorter postoperative hospital stays than LR (3 days vs. 6 days, p < 0.001). Overall survival rate between the two groups was not significantly different (p = 0.163).

CONCLUSION

Compared with laparoscopic resection, microwave ablation has a lower rate of postoperative liver decompensation and might be a better option for HCC patients with CSPH.

CLINICAL RELEVANCE STATEMENT

Microwave ablation exhibited a lower incidence of postoperative liver decompensation in comparison to laparoscopic resection, thereby conferring greater advantages to hepatocellular carcinoma patients with clinically significant portal hypertension.

KEY POINTS

•Postoperative liver decompensation rate after microwave ablation was lower than that of laparoscopic resection for hepatocellular carcinoma in patients with clinically significant portal hypertension. •Microwave ablation showed shorter postoperative hospital stays than laparoscopic resection. •Microwave ablation had fewer complications than laparoscopic resection.

Hepatic artery diameter predicts bleeding risk after gastroesophageal varices treatment: a contrast-enhanced CT study

OBJECTIVE

Portal hypertension leads to hepatic artery dilatation and a higher risk of bleeding. We tried to identify the bleeding risk after gastroesophageal varices (GOV) treatment using hepatic artery diameter of contrast-enhanced CT.

METHODS

Retrospective retrieval of 258 patients with cirrhosis who underwent contrast-enhanced CT from January 2022 to May 2023 and endoscopy within one month thereafter at Hainan Affiliated Hospital of Hainan Medical University. Cirrhotic patients before GOV treatment were used as the test cohort (n = 199), and cirrhotic patients after GOV treatment were used as the validation cohort (n = 59). The grading and bleeding risk was classified according to the endoscopic findings. Arterial-phase images of contrast-enhanced CT were used for coronal reconstruction, and the midpoint diameter of the hepatic artery was measured on coronal images. The optimal cutoff value for identifying bleeding risk was analyzed and calculated in the test cohort, and its diagnostic performance was evaluated in the validation cohort.

RESULTS

In the test cohort, hepatic artery diameters were significantly higher in high-risk GOV than in low-risk GOV [4.69 (4.31, 5.56) vs. 3.10 (2.59, 3.77), P < 0.001]. With a hepatic artery diameter cutoff value of 4.06 mm, the optimal area under the operating characteristic curve was 0.940 (95% confidence interval: 0.908-0.972), with a sensitivity of 0.887, a specificity of 0.892, a positive predictive value of 0.904, and a negative predictive value of 0.874 for identifying bleeding risk in the test cohort, while in the validation cohort, the sensitivity was 0.885, specificity was 0.939, positive predictive value was 0.920, and negative predictive value was 0.912.

CONCLUSION

Hepatic artery diameter has high diagnostic performance in identifying bleeding risk after GOV treatment.

HCC portal hypertension imaging score derived from CT predicts re-bleeding and mortality after acute variceal bleeding

BACKGROUND/PURPOSE

Risk factors for re-bleeding and death after acute variceal bleeding (AVB) in cirrhotic HCC patients are not fully understood.We aimed to (1) explore how the combination of high-risk esophageal varices, HCC status, and portal vein tumor thrombus (i.e., HCC Portal Hypertension Imaging Score [HCCPHTIS]) helps predict increased risk of variceal re-bleeding and mortality; (2) assess predictability and reproducibility of the identified variceal re-bleeding rules.

METHODS

This prospective study included 195 HCC patients with first-time AVB and liver cirrhosis, and conducted multivariable Cox regression analysis and Kaplan-Meier analysis. Receiver operating characteristic curve analysis was calculated to find the optimal sensitivity, specificity, and cutoff values of the variables. The reproducibility of the results obtained was verified in a different but related group of patients.

RESULTS

56 patients (28.7%) had re-bleeding within 6 weeks; HCCPHTIS was an independent risk factor for variceal re-bleeding after AVB (Odd ratio, 2.330; 95% confidence interval: 1.728-3.142, p < 0.001). The positive predictive value of HCCPHTIS cut off value > 3 was 66.2%, sensitivity 83.9%, and specificity 82.3%. HCCPHTIS area under the curve was higher than Child-Pugh score (89% vs. 75%, p < 0.001). 74(37.9%) death occurred within 6 weeks; HCCPHTIS > 4 was associated with increased risk of death within 6 weeks after AVB (p < 0.001).

CONCLUSION

HCCPHTIS > 3 is a strong predictor of variceal re-bleeding within the first 6 weeks. However, patients with HCCPHTIS > 4 were at increased risk of death within 6 weeks.

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

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

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

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

The role of computed tomography for the prediction of esophageal variceal bleeding: Current status and future perspectives

Esophageal variceal bleeding (EVB) is one of the most common and severe complications related to portal hypertension (PH). Despite marked advances in its management during the last three decades, EVB is still associated with significant morbidity and mortality. The risk of first EVB is related to the severity of both PH and liver disease, and to the size and endoscopic appearance of esophageal varices. Indeed, hepatic venous pressure gradient (HVPG) and esophagogastroduodenoscopy (EGD) are currently recognized as the “gold standard” and the diagnostic reference standard for the prediction of EVB, respectively. However, HVPG is an invasive, expensive, and technically complex procedure, not widely available in clinical practice, whereas EGD is mainly limited by its invasive nature. In this scenario, computed tomography (CT) has been recently proposed as a promising modality for the non-invasive prediction of EVB. Although CT is only a diagnostic modality, thus being not capable of supplanting EGD or HVPG in providing therapeutic and physiological data, it could potentially assist liver disease scores, HVPG, and EGD in a more effective prediction of EVB. However, to date, evidence concerning the role of CT in this setting is still lacking. Our review aimed to summarize and discuss the current evidence concerning the role of CT in predicting the risk of EVB.

Predicting the risk of early bleeding following endoscopic variceal ligation in cirrhotic patients with computed tomography

BACKGROUND

Life-threatening bleeding following endoscopic variceal ligation (EVL) in patients with cirrhosis rarely can occur. The present study aimed to evaluate the performance of computed tomography (CT) in predicting the risk of early bleeding following EVL in cirrhotic patients.

METHODS

We retrospectively investigated 285 cirrhotic patients who had undergone EVL. EVL was performed for prophylaxis or acute variceal bleeding. The patients were classified into 2 groups: early bleeding (< 14 days after EVL) and non-early bleeding. We compared baseline characteristics including CT findings between the patient groups.

RESULTS

Among the 285 patients who underwent EVL treatment, 19 patients (6.7%) experienced early bleeding. On average, these bleeding occurred 9.3 ± 3.5 days after the EVL, with a range of 3 to 13 days. Patients who experience early bleeding had a higher six-week bleeding-related mortality rate compared to those in the non-early bleeding group (31.6% vs. 10.2%; p = 0.014). There was a correlation between the grade of esophageal varix observed during endoscopy and the diameter of esophageal varix observed on CT (p < 0.001). The diameter of esophageal varix on CT was identified as the only significant predictive factor for early bleeding (p = 0.005).

CONCLUSION

A larger esophageal varix diameter observed on CT is associated with an increased risk of early bleeding after EVL treatment. Early identification of this high-risk group can provide a change of treatment strategies to improve patient outcomes.

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

AIM

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

CT hepatic arterial perfusion index does not allow stratification of the degree of esophageal varices and bleeding risk in cirrhotic patients in Child-Pugh classes A and B

Purpose

To evaluate if the hepatic arterial perfusion index (HPI) in liver parenchyma of cirrhotic patients can serve as a surrogate parameter for stratifying the degree of esophageal varices and related bleeding risks.

Methods

CT image data of sixty-six patients (59 men; mean age 68 years ± 10 years) with liver cirrhosis (Child–Pugh class A (35/66, 53%), B (25/66, 38%), and C (6/66, 9%) who underwent perfusion CT (PCT) for hepatocellular carcinoma (HCC) screening between April 2010 and January 2019 were retrospectively identified. HPI, a parameter calculated by a commercially available CT liver perfusion analysis software that is based on the double maximum slope model, using time attenuation curve to determine perfusion, was correlated with the degree of esophageal varices diagnosed at endoscopy and the number of bleeding events.

Results

Eta correlation coefficient for HPI/presence of esophageal varices was very weak (0.083). Spearman-Rho for HPI/grading of esophageal varices was very weak (0.037 (p = 0.804)). Kendall-Tau-b for HPI/grading of esophageal varices was very weak (0.027 (p = 0.807)). ANOVA and Bonferroni post-hoc-tests showed no significant difference of HPI between different grades of esophageal varices (F (3, 62) = 1.676, p = 0.186). Eta correlation coefficient for HPI/bleeding event was very weak (0.126).

Conclusion

The stratification of the degree of esophageal varices and the related bleeding risk by correlation with the HPI as a surrogate parameter for portal venous hypertension was not possible for patients with liver cirrhosis in Child–Pugh class A and B.

Graphic abstract

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

ADVANCES IN KNOWLEDGE

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

Laparoscopic transgastric necrosectomy in treatment of walled-off pancreatic necrosis with sinistral portal hypertension

Background

Laparoscopic transgastric necrosectomy (LTGN) has been used in treatment of walled-off pancreatic necrosis (WON) for more than a decade. However, the safety and effectiveness of LTGN for WON with sinistral portal hypertension was still unclear.

Methods

WON patients with sinistral portal hypertension treated in our department between January 2011 and December 2018 were included and retrospectively analyzed in this study. Patients were divided into two groups according to different surgical approaches, LTNG or laparoscopic assisted trans-lesser sac necrosectomy (LATLSN). Perioperative and long-term outcomes were compared between two groups.

Results

312 cases diagnosed with WON were screened and 53 were finally included in this study. Of the included patients, 21 and 32 cases were received LTGN and LATLSN, respectively. LTGN was associated with significantly lower morbidity than LATLSN (19.0% vs 46.9%, p = 0.04) and similar severe complication (Clavien–Dindo ≥ III) rate (12.5% vs 19.0%, p = 0.70). LTGN did not increase the rate of postoperative hemorrhage (9.5% vs 6.3%, p = 1.00) and mortality (9.5% vs 9.4%, p = 1.00). After 39 (11–108) months follow-up, the recurrence rate of WON and long-term complications were also comparable between groups.

Conclusion

From current data, LTGN was safe and effective in treatment of WON patients with sinistral portal hypertension in terms of short- and long-term outcomes.

Endoscopic Evaluation of Radiologic Distal Esophageal Thickening

GOALS

We aim to determine the incidence of esophagogastroduodenoscopies (EGDs) primarily performed for imaging findings of distal esophageal thickening (DET). We also aim to determine if patients with imaging findings of DET have a higher incidence of cancer, and to evaluate the risk factors associated with findings of malignancy.

BACKGROUND

The growth of diagnostic imaging has led to an increase in incidental findings of DET. This nonspecific finding frequently prompts an EGD for evaluation-many of which demonstrate benign conditions. There may be a misuse of valuable resources.

STUDY

We performed a retrospective chart review of 1080 EGDs from January 2016 to July 2018 at the Veterans Affairs Medical Center, comparing EGDs for the indication of imaging report of DET with EGDs for other indications. Patient demographics, clinical history, imaging, procedure, and pathology reports were collected. Descriptive analysis and biostatistical analysis with χ2, Fisher exact, Wilcoxon rank sum, and Kruskal-Wallis tests were utilized in analyzing the data.

RESULTS

Of the 1080 total endoscopies, 8.2% (n=88) were done specifically because of the imaging findings of DET. Those who had EGDs performed because of DET had a higher percentage of abnormal esophageal findings and of cancer. A history of Barrett's esophagus, tobacco use, and having gastrointestinal symptoms were not significant predictors of abnormal findings or of cancer for EGDs done for DET.

CONCLUSIONS

There may be a role for EGDs performed for radiologic findings of DET. Even those without risk factors for malignancy should have EGDs performed for DET. Radiologists should consider reporting the DET size in order to determine if significant endoscopic findings correlate with wall thickness.

Development and Validation of a Nomogram Based on Perioperative Factors to Predict Post-hepatectomy Liver Failure

BACKGROUND AND AIMS

Post-hepatectomy liver failure (PHLF) is a severe complication and main cause of death in patients undergoing hepatectomy. The aim of this study was to build a predictive model of PHLF in patients undergoing hepatectomy.

METHODS

We retrospectively analyzed patients undergoing hepatectomy at Zhongshan Hospital, Fudan University from July 2015 to June 2018, and randomly divided them into development and internal validation cohorts. External validation was performed in an independent cohort. Least absolute shrinkage and selection operator (commonly referred to as LASSO) logistic regression was applied to identify predictors of PHLF, and multivariate binary logistic regression analysis was performed to establish the predictive model, which was visualized with a nomogram.

RESULTS

A total of 492 eligible patients were analyzed. LASSO and multivariate analysis identified three preoperative variables, total bilirubin (p=0.001), international normalized ratio (p<0.001) and platelet count (p=0.004), and two intraoperative variables, extent of resection (p=0.002) and blood loss (p=0.004), as independent predictors of PHLF. The area under receiver operating characteristic curve (referred to as AUROC) of the predictive model was 0.838 and outperformed the model for end-stage liver disease score, albumin-bilirubin score and platelet-albumin-bilirubin score (AUROCs: 0.723, 0.695 and 0.663, respectively; p<0.001 for all). The optimal cut-off value of the predictive model was 14.7. External validation showed the model could predict PHLF accurately and distinguish high-risk patients.

CONCLUSIONS

PHLF can be accurately predicted by this model in patients undergoing hepatectomy, which may significantly contribute to the postoperative care of these patients.

A novel radiomics-platelet nomogram for the prediction of gastroesophageal varices needing treatment in cirrhotic patients

BACKGROUND AND AIMS

Highly accurate noninvasive methods for predicting gastroesophageal varices needing treatment (VNT) are desired. Radiomics is a newly emerging technology of image analysis. This study aims to develop and validate a novel noninvasive method based on radiomics for predicting VNT in cirrhosis.

METHODS

In this retrospective-prospective study, a total of 245 cirrhotic patients were divided as the training set, internal validation set and external validation set. Radiomics features were extracted from portal-phase computed tomography (CT) images of each patient. A radiomics signature (Rad score) was constructed with the least absolute shrinkage and selection operator algorithm and tenfold cross-validation in the training set. Combined with independent risk factors, a radiomics nomogram was built with a multivariate logistic regression model.

RESULTS

The Rad score, consisting of 14 features from the gastroesophageal region and 5 from the splenic hilum region, was effective for VNT classification. The diagnostic performance was further improved by combining the Rad score with platelet counts, achieving an AUC of 0.987 (95% CI 0.969-1.00), 0.973 (95% CI 0.939-1.00) and 0.947 (95% CI 0.876-1.00) in the training set, internal validation set and external validation set, respectively. In efficacy and safety assessment, the radiomics nomogram could spare more than 40% of endoscopic examinations with a low risk of missing VNT (< 5%), and no more than 8.3% of unnecessary endoscopic examinations still be performed.

CONCLUSIONS

In this study, we developed and validated a novel, diagnostic radiomics-based nomogram which is a reliable and noninvasive method to predict VNT in cirrhotic patients.

CLINICAL TRIALS REGISTRATION

NCT04210297.

Varices on computed tomography as predictor of survival after hepatic resection in patients with single hepatocellular carcinoma

BACKGROUND AND AIM

The aim of this study was to evaluate whether presence of varices on computed tomography (CT) could predict treatment outcome for hepatocellular carcinoma patients.

METHODS

We enrolled 241 patients with single hepatocellular carcinoma ≤ 5 cm treated by surgery. With the use of preoperative CT/endoscopy, patients were classified into the following: presence of standard clinically significant portal hypertension (CSPH) surrogate, defined as varices on esophagogastroduodenoscopy and/or thrombocytopenia with splenomegaly (group 1, n = 47); varices on CT without standard CSPH surrogate (group 2, n = 45); and none of both (group 3, n = 149). Development of posthepatectomy liver failure and overall survival (OS) were evaluated for each patient group, and patients were re-classified into two groups according to presence of CT-enhanced CSPH surrogate, defined as standard surrogate and/or varices on CT. Predictive power of each survival model was compared using Harrell's C-index.

RESULTS

Posthepatectomy liver failure rate in group 2 was similar to that in group 1 (53.3% [24/45] vs. 55.3% [26/47]; P = 1.000) but significantly higher than that in group 3 (53.3% [24/45] vs. 28.2% [42/149], P = 0.002). Seven-year OS rates in group 2 were similar to those in group 1 (55.6% vs. 60.8%, P = 0.988) but significantly lower than those in group 3 (55.6% vs. 83.3%, P = 0.001). Presence of standard CSPH surrogate (hazard ratio = 1.89 [1.08-3.30], P = 0.025) and CT-enhanced CSPH surrogate (hazard ratio = 2.60 [1.56-4.39], P < 0.001) were significant predicting factor for OS. However, CT-enhanced CSPH surrogate had significantly higher Harrell's C-index than standard surrogate (0.619 vs. 0.553, P = 0.034).

CONCLUSION

The presence of CT-enhanced CSPH surrogate including varices on CT was the significant predictive of poor OS, providing better predictive power than standard surrogate.

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.

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.

Liver Stiffness Detected by Shear Wave Elastography Predicts Esophageal Varices in Cirrhotic Patients

ABSTRACT

Ultrasound elastography has become a promising noninvasive approach for assessing liver fibrosis. The purpose of this study was to evaluate the diagnosis ability of liver stiffness detected by shear wave elastography (SWE) for predicting the presence of esophageal varices (EVs) in cirrhotic patients. Four hundred sixty-eight cirrhotic patients were enrolled consecutively. Liver stiffness and EVs were detected by SWE and endoscopy, respectively. The baseline characteristics were recorded, and areas under the receiver operating characteristic curves (AUROCs) were used to compare the diagnosis accuracy. Multivariate analysis was used to identify the risk factors for EVs in cirrhosis. The mean liver stiffness was 18.4 kPa with a range of 6.8 to 52.5 kPa. Two hundred seventy-one patients had no EVs (57.9%), 139 patients had F1 EVs (29.7%), and 58 patients had high-risk EVs (12.4%). The optimal cutoff values of SWE for predicting EVs and high-risk varices were 18.5 and 20.4 kPa, respectively. The AUROCs for predicting the incidence of EVs were 0.792 (95% confidence interval [CI], 0.884-0.842), 0.814 (95% CI, 0.658-0.875), and 0.895 (95% CI, 0.813-0.918) for platelet, platelet count-to-spleen diameter ratio, and liver stiffness, respectively. For predicting the presence of high-risk varices, liver stiffness again had the highest AUROC. Multivariate analysis identified liver stiffness and platelet count-to-spleen diameter ratio as independent predictive factors for EVs in cirrhosis. Liver stiffness measured by SWE is an effective diagnostic tool for predicting EVs with greater accuracy, and SWE value is an independent factor for predicting high-risk EVs.

Varices on computed tomography are surrogate of clinically significant portal hypertension and can predict survival in compensated cirrhosis patients

BACKGROUND AND AIM

To investigate prognostic value of varices on computed tomography (CT) and redefine surrogate criteria for clinically significant portal hypertension (CSPH).

METHODS

We retrospectively enrolled 241 patients with compensated cirrhosis who underwent hepatic venous pressure gradient (HVPG) measurement from 2008 to 2013. Using CT and upper endoscopy findings obtained within 3 months from HVPG measurement, patients were classified into three groups: presence of standard surrogate for CSPH, defined as presence of varices on upper endoscopy and/or splenomegaly associated with thrombocytopenia (Group 1, n = 139); varices on CT without standard surrogate for CSPH (Group 2, n = 41); and free from both (Group 3, n = 61). HVPG value and overall survival (OS) rates were compared among three patient groups. Revised surrogate for CSPH was defined as presence of standard surrogate and/or presence of varices on CT (i.e. both Group 1 and Group 2).

RESULTS

Mean HVPG value in Group 2 was significantly higher than that in Group 3 (10.3 mmHg vs 6.5 mmHg, P < 0.001), but significantly lower than that in Group 1 (10.3 mmHg vs 13.1 mmHg, P < 0.001). Seven-year OS rates in Group 2 was similar to those in Group 1 (57.0% vs 62.7%, P = 0.591), but significantly poorer than those in Group 3 (57.0% vs 84.0%, P = 0.015). The presence of revised surrogate for CSPH was a significant predictive factor for OS (P = 0.025, Hazard ratio = 2.71 [1.14-6.45]) on multivariate analysis whereas standard surrogate for CSPH was not (P = 0.849).

CONCLUSION

The presence of varices on CT was a significant sign for CSPH, predicting poor OS outcome in patients with compensated cirrhosis.

Diagnostic Accuracy of Multidetector Computed Tomography in Detection of Esophageal Varices

Objective

To determine the diagnostic accuracy of multidetector computed tomography (MDCT) in the detection of esophageal varices by taking endoscopy as the reference standard.

Materials and methods

This was a cross-sectional prospective study conducted at the Department of Radiology, Aga Khan University Hospital, (AKUH) Karachi, for the duration of 12 months from August 1, 2014 to July 31, 2015. One hundred ninety-six patients with a suspicion of chronic liver disease/cirrhosis undergoing 64 slice MDCT were enrolled in our study and underwent computed tomography (CT) scanning in the Department of Radiology at AKUH. Biphasic CT was performed with images obtained during the hepatic arterial phase (30-second delay) and the portal venous phase (65-second delay) after the intravenous (IV) injection of 120 mL of nonionic contrast material at a rate of 3.5 mL/s. The presence of esophageal varices was evaluated on MDCT with endoscopy as gold standard. The sensitivity, specificity, negative predictive value and positive predictive value, and accuracy of MDCT were assessed against the gold standard.

Results

Our results yielded an MDCT sensitivity of 98.96%, specificity of 100%, positive predictive value (PPV) of 100%, negative predictive value (NPV) of 66.67%, and diagnostic accuracy of 98.97% for esophageal varices in chronic liver disease (CLD) patients.

Conclusion

The rate of detection of esophageal varices in patients with chronic liver disease on MDCT in our country is comparable to the international data and we advocate that MDCT should be used as a screening tool in patients with chronic liver disease to exclude esophageal varices.

Hepatic resection vs. transarterial chemoembolization for hepatocellular carcinoma beyond the Milan criteria with portal hypertension

OBJECTIVE

To assess the value of hepatic resection by comparing it with transarterial chemoembolization for hepatocellular carcinoma beyond the Milan criteria with clinically relevant portal hypertension.

METHODS

A total of 363 patients and 193 propensity score-matched patients who had hepatocellular carcinoma beyond the Milan criteria with clinically relevant portal hypertension and underwent hepatic resection or transarterial chemoembolization were retrospectively analyzed. The short-term and long-term results were compared.

RESULTS

Postoperative complications and 30-day mortality were similar between the two groups. The hepatic resection provided a survival benefit over TACE at 1, 2, 3, and 5 years. Similar results were observed in the propensity score analysis. Five variables were identified as independent prognostic factors: treatment, AFP, Child-Pugh classification, tumor number and extension of disease in a multivariate analysis of the whole study population. In addition, only the tumor number was identified as an independent risk factor after propensity matching. The subgroup analysis demonstrated that the survival benefit of the hepatic resection can only be derived in a subset of patients with a single tumor.

CONCLUSIONS

In a properly selected group of patients with hepatocellular carcinoma beyond the Milan criteria with clinically relevant portal hypertension, hepatic resection appears to be as safe as TACE and provides a significant survival benefit.

Noninvasive Assessment of Portal Hypertension in Advanced Chronic Liver Disease: An Update

The assessment of portal hypertension is a relevant step in the evaluation of newly diagnosed advanced chronic liver disease (ACLD). The current gold standard includes the invasive evaluation of hepatic venous pressure gradient (HVPG) and endoscopy. However, noninvasive or minimally invasive techniques to assess portal hypertension have been proposed and well established. In the present manuscript, we review clinical studies on the use of noninvasive or minimally invasive techniques to assess portal hypertension in ACLD patients.

Νon-invasive screening for esophageal varices in patients with liver cirrhosis

Esophageal varices are one of the main complications of liver cirrhosis. Upper gastrointestinal endoscopy is the gold standard for the detection of esophageal varices. Many less invasive methods for screening of varices have been investigated and the most recent Baveno VI guidelines suggest that endoscopy is not necessary in patients with liver stiffness <20 kPa and platelets >150,000/μL. A critical review of the literature was performed concerning non-invasive or minimally invasive methods of screening for esophageal varices. Liver and spleen elastography, imaging methods including computed tomography, magnetic resonance imaging and ultrasound, laboratory tests and capsule endoscopy are discussed. The accuracy of each method, and its advantages and limitations compared to endoscopy are analyzed. There are data to support the Baveno VI guidelines, but there is still a lack of large prospective studies and low specificity has been reported for the liver stiffness and platelet count combination. Spleen elastography has shown promising results, as there are data to support its superiority to liver elastography, but it needs further assessment. Computed tomography has shown high diagnostic accuracy and can be part of the diagnostic work up of cirrhotic patients in the future, including screening for varices.

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.

Incidence of insulin resistance and diabetes in patients with portosystemic shunts without liver dysfunction

Objective To investigate the incidence of insulin resistance (IR) and diabetes in patients with chronic hepatic schistosomiasis japonica (HSJ) and portosystemic shunts (PSS). Methods Pre- and post-contrasted computed tomography images obtained from patients with HSJ and control subjects were reviewed by two radiologists who identified and graded any shunting vessels. Anthropometric measurements, hepatic enzymes, lipid profile, blood levels of albumin, glucose, insulin and homeostasis model assessment (HOMA-2) index of all participants were also assessed. Results Fifty-two patients with HSJ and 30 control subjects were involved in the study. The coronary, short gastric and perisplenic veins were the most common shunting vessels. There were no significant differences between patients and controls in terms of body mass index or liver function. The degree of shunting vessels, blood glucose, oral glucose tolerance test_120/0, insulin, HOMA-2 index, glycosylated haemoglobin, cholesterol, high- and low-density lipoprotein, and C-reactive protein were significantly higher in the patients with IR. A positive correlation was found between the degree of the shunting vessels and the HOMA-2 index. Conclusions Patients with chronic HSJ and PSS without liver dysfunction had a high incidence of IR and diabetes. The study showed that PSS and IR are related and therefore patients with PSS should be screened for IR and vice versa.

Multidetector computed tomography versus platelet/spleen diameter ratio as methods for the detection of gastroesophageal varices

BACKGROUND

All patients with liver cirrhosis should undergo screening endoscopy, but there are limitations and this approach places a heavy burden upon endoscopy units. The aim of this study was to compare multidetector computed tomography (MDCT) and the platelet/spleen diameter ratio as non-invasive methods for the detection of gastroesophageal varices.

METHODS

The study included 38 cirrhotics who underwent upper gastrointestinal (GI) endoscopy and MDCT within one month. Two radiologists reviewed the scans, in order to determine the presence and the size of varices. Blood tests and measurement of the spleen maximum diameter were also carried out and the platelet/spleen diameter ratio was calculated. Endoscopy was considered the gold standard and the results of the two methods were compared to it.

RESULTS

Varices were detected by upper GI endoscopy in 24 of 38 patients. The mean sensitivity and specificity of MDCT for the two observers was 86.1% and 57.1% respectively. In patients with large varices (>5 mm), the sensitivity was 100% (4/4). Using 909 as a cut-off value of the platelet/spleen diameter ratio this method yielded a sensitivity of 56.5% and a specificity of 35.7%. The difference in sensitivity and specificity between the two methods was statistically significant P<0.05.

CONCLUSION

MDCT was accurate for the detection of gastroesophageal varices, especially those with clinically significant size (>5 mm), and superior to platelet/spleen diameter ratio. MDCT could replace, in selected patients, upper GI endoscopy as a method for detecting gastroesophageal varices in cirrhotic patients.

The role of liver stiffness measurement in the evaluation of liver function and esophageal varices in cirrhotic patients

OBJECTIVE

We aimed to evaluate the efficacy of liver stiffness measurement (LSM) in predicting the presence and severity of esophageal varices (EV) and investigating its association with liver function (LF) in patients with liver cirrhosis.

METHODS

Medical records of 90 cirrhotic patients who underwent LSM by transient elastography were retrospectively reviewed. The relationship between LSM and the presence and severity of EV was evaluated by esophagogastroduodenoscopy (EGD) and multislice spiral computed tomography (MSCT). Another 25 healthy individuals were included as controls.

RESULTS

LSM was significantly associated with the Child-Pugh score in cirrhotic patients, with the highest LSM in those with Child-Pugh C. Patients with clinically decompensated cirrhosis had a higher LSM than those with compensated cirrhosis (36.75 ± 16.54 kPa vs 17.65 ± 10.87 kPa, P < 0.01). However, there was no significant difference in LSM value between patients with severe EV and those with no or non-severe EV determined by endoscopy (28.18 ± 17.44 kPa vs 31.00 ± 18.44 kPa) or MSCT (29.71 ± 18.39 kPa vs 24.90 ± 14.80 kPa). The diagnostic value of LSM for predicting severe EV was low in unselected cirrhotic patients. The presence of EV examined by EGD and MSCT was similar to each other.

CONCLUSIONS

LSM could be used to evaluate the progression of liver cirrhosis continuously. However, its role in assessing EV grades in advanced cirrhosis needs further confirmation. MSCT can assess EV accurately and may serve as an alternative to endoscopy in the assessment of portal hypertension.

Primary prophylaxis of variceal bleeding

Gastroesophageal varices are present in almost half of patients with cirrhosis at the time of initial diagnosis. Variceal bleeding occurs in 25% to 35% of patients with cirrhosis. Effective and timely care can prevent variceal bleeding (primary prophylaxis). For example, clinical studies demonstrate that both beta-blockers and endoscopic variceal ligation are effective in preventing a first episode of variceal bleeding. The major challenge is to screen patients in a timely manner and institute a form of therapy that has the highest chance of success in terms of patient compliance and effectiveness.

Invasive and noninvasive methods to diagnose portal hypertension and esophageal varices

Assessing the presence of clinically significant portal hypertension and esophageal varices is clinically important in cirrhosis. The reference standard techniques to assess the presence of portal hypertension and varices are the measurement of the hepatic vein pressure gradient and esophagogastroduodenoscopy, respectively. Some newer methods have shown a good performance, but none has been proven precise enough to replace hepatic vein pressure gradient measurement or esophagogastroduodenoscopy for the diagnosis of portal hypertension or the presence and grade of esophageal varices.

Diagnostic performance of CT esophagography in patients with suspected esophageal rupture

Esophageal rupture is a surgical catastrophe. The gold standard for diagnosing is iodine, water-soluble contrast medium esophagography. CT esophagography has shown promising results. This study aimed to assess the diagnostic performance of CT esophagography in patients with a suspicion of esophageal rupture. This prospective study assessed the performance of a diagnostic test and was approved by local IRB committee. Patients who presented with a clinical suspicion of esophageal rupture were included. CT esophagography findings were described by the emergency radiologist. Clinical outcomes (presence or absence of esophageal rupture) were reported by surgeons. The operative characteristics were calculated. A final predictive scale for rupture was built. A total of 64 patients were recruited (age 26.5 years, 90 % male, 82 % trauma). Sensitivity, specificity, and positive and negative likelihood ratios (LRs) were 77.7 % (95 % confidence interval (CI) 45-100), 94.3 % (87.2-100), 14 (9.81-19.9), and 0.24 (0.05-1.22), respectively. The final model for predicting rupture included five variables: age (odds ratio (OR) 1.03; 95 % CI, 0.95-1.11; p=0.04), leakage of contrast media into the mediastinum or pleural space (OR 10.0; 95 % CI, 0.64-156.9; p=0.10), extraluminal air or fluid collections (OR 43.1; 95 % CI, 1.52-1217.3; p=0.027), esophageal wall thickening (OR 10.1; 95 % CI, 0.50-202.8; p=0.12), and left pneumothorax or pleural effusion (OR 6.5; 95 % CI, 0.31-132.7; p=0.2). The overall agreement was 0.40 (95 % CI, 0.09-0.72) for the predictive model. The model sensitivity was 50.0 %, and the specificity was 98.4 %. CT esophagography shows a good diagnostic performance in patients with a suspected esophageal rupture.

Diagnostic performance of CT esophagography in patients with suspected esophageal rupture

Esophageal rupture is a surgical catastrophe. The gold standard for diagnosing is iodine, water-soluble contrast medium esophagography. CT esophagography has shown promising results. This study aimed to assess the diagnostic performance of CT esophagography in patients with a suspicion of esophageal rupture. This prospective study assessed the performance of a diagnostic test and was approved by local IRB committee. Patients who presented with a clinical suspicion of esophageal rupture were included. CT esophagography findings were described by the emergency radiologist. Clinical outcomes (presence or absence of esophageal rupture) were reported by surgeons. The operative characteristics were calculated. A final predictive scale for rupture was built. A total of 64 patients were recruited (age 26.5 years, 90 % male, 82 % trauma). Sensitivity, specificity, and positive and negative likelihood ratios (LRs) were 77.7 % (95 % confidence interval (CI) 45-100), 94.3 % (87.2-100), 14 (9.81-19.9), and 0.24 (0.05-1.22), respectively. The final model for predicting rupture included five variables: age (odds ratio (OR) 1.03; 95 % CI, 0.95-1.11; p=0.04), leakage of contrast media into the mediastinum or pleural space (OR 10.0; 95 % CI, 0.64-156.9; p=0.10), extraluminal air or fluid collections (OR 43.1; 95 % CI, 1.52-1217.3; p=0.027), esophageal wall thickening (OR 10.1; 95 % CI, 0.50-202.8; p=0.12), and left pneumothorax or pleural effusion (OR 6.5; 95 % CI, 0.31-132.7; p=0.2). The overall agreement was 0.40 (95 % CI, 0.09-0.72) for the predictive model. The model sensitivity was 50.0 %, and the specificity was 98.4 %. CT esophagography shows a good diagnostic performance in patients with a suspected esophageal rupture.

Diagnostic performance of using effervescent powder for detection and grading of esophageal varices by multi-detector computed tomography

PURPOSE

To investigate the effect of using effervescent powder (EP) on the efficacy of multi-detector computed tomography (MDCT) in detection and grading of esophageal varices in cirrhotic patients by considering endoscopy as the gold standard.

MATERIALS AND METHODS

Ninety-two cirrhotic patients undergoing biphasic liver MDCT followed by upper gastrointestinal endoscopy within 4 weeks of MDCT were prospectively evaluated. The patients were divided into two groups before MDCT. The first group (n=50) received effervescent powder (EP) before and during MDCT procedure and the second group did not receive (n=42). The presence, size and grade of the esophageal varices were evaluated. MDCT findings were compared with endoscopic results. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and accuracy of MDCT with EP and without EP were calculated and compared. Correlations between the grades of the varices for each group based on MDCT imaging and endoscopic grading were also evaluated.

RESULTS

The sensitivity, specificity, accuracy, PPV, and NPV of MDCT were 100%, 88%, 96%, 94%, and 100%, respectively, in the EP group, whereas they were 76%, 67%, 74%, 89%, and 43%, respectively, in the non-EP group. Correlations between the grades of the esophageal varices on MDCT and endoscopy were significant in both groups (r=0.94, p<0.001 for EP group and r=0.70, p<0.001 for non-EP group).

CONCLUSION

During periodic CT scanning of cirrhotic patients, use of EP increases the success rate of MDCT for detection and grading of esophageal varices.

Usefulness of MR elastography for predicting esophageal varices in cirrhotic patients

PURPOSE

To evaluate the usefulness of magnetic resonance elastography (MRE) as a noninvasive tool for predicting esophageal varices and identifying high-risk varices.

MATERIALS AND METHODS

In all, 126 patients with liver cirrhosis, and who underwent both MRI including MRE of the liver as well as upper gastrointestinal endoscopy for variceal screening within 1 month before or after the MRI, were included in this study. The relationship between the liver stiffness values measured by MRE and the degree of esophageal varices was assessed using Spearman's correlation analysis. In addition, the diagnostic performance of MRE for predicting the presence of varices or high-risk varices (grade≥II) was evaluated using the receiver-operating characteristics (ROC) curves.

RESULTS

The mean stiffness values of liver parenchyma measured on MRE were well correlated with the grade of esophageal varices (r=0.63). In addition, the MRE-based liver stiffness values were significantly lower in the lower-risk group than in the higher-risk group (P<0.0001). The area under the ROC curve values of MRE for predicting the presence of varices or high-risk varices (grade≥II) were 0.859 and 0.810, respectively. Using a liver stiffness cutoff value of 5.803 kPa, the sensitivity, specificity, positive predictive value, and negative predictive value for predicting high-grade (≥II) esophageal varices were 96%, 60%, 36%, and 98%, respectively.

CONCLUSION

The MRE-based liver stiffness value may be useful for noninvasively predicting esophageal varices and identifying high-risk varices in cirrhotic patients.

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

BACKGROUND AND STUDY AIMS

Variceal bleeding is a frequent and life-threatening complication of portal hypertension. The aim of this study was to evaluate multidetector computed tomographic (MDCT) oesophagography as an alternative to endoscopy for screening oesophageal varices (EVs) and predicting bleeding risk.

PATIENTS AND METHODS

A total of 137 cirrhotic patients underwent MDCT followed by endoscopy and EVs were graded independently. The screening ability of CT for EV was evaluated by comparing the grades of EV at CT and at endoscopy. Prediction of bleeding risk by CT was determined by correlating the CT variceal grades, diameters and palisade vein dilatation with the endoscopic red colour (RC) sign. Extra-oesophageal findings were assessed by CT. Patients' acceptance for both examinations were compared.

RESULTS

At endoscopy, 47 (34%) patients had grade 0 EV, 52 (38%) patients had grade 1 EV, 29 (21%) patients had grade 2 EV and nine (7%) patients had grade 3 EV. The sensitivity, specificity, positive and negative predictive values and accuracy of CT oesophagography for defining EV in all grades were 99%, 98%, 99%, 98% and 99%, respectively. The MDCT variceal grades, diameters and palisade vein dilatation were correlated with the severity of the RC sign. Important extra-oesophageal findings were determined by CT only. The acceptance of patients for CT oesophagography was significantly more than that for endoscopy (p<0.001).

CONCLUSION

MDCT is a reliable, preliminary or adjunctive method that can be used for routine screening for EVs and the prediction of variceal bleeding.

High-risk esophageal varices in patients treated with locoregional therapy for hepatocellular carcinoma: Assessment with liver computed tomography

AIM: To assess the diagnostic performance of follow-up liver computed tomography (CT) for the detection of high-risk esophageal varices in patients treated with locoregional therapy for hepatocellular carcinoma (HCC).

METHODS: We prospectively enrolled 100 patients with cirrhosis who underwent transcatheter arterial chemoembolization, radiofrequency ablation or both procedures for HCCs. All patients underwent upper endoscopy and subsequently liver CT. Three radiologists independently evaluated the presence of high-risk esophageal varices with transverse images alone and with three orthogonal multiplanar reformation (MPR) images, respectively. With endoscopic grading as the reference standard, diagnostic performance was assessed by using receiver operating characteristic (ROC) curve analysis.

RESULTS: The diagnostic performances (areas under the ROC curve) of three observers with transverse images alone were 0.947 ± 0.031, 0.969 ± 0.024, and 0.916 ± 0.038, respectively. The mean sensitivity, specificity, positive predicative value (PPV), and negative predicative value (NPV) with transverse images alone were 90.1%, 86.39%, 70.9%, and 95.9%, respectively. The diagnostic performances, mean sensitivity, specificity, PPV, and NPV with three orthogonal MPR images (0.965 ± 0.025, 0.959 ± 0.027, 0.938 ± 0.033, 91.4%, 89.5%, 76.3%, and 96.6%, respectively) were not superior to corresponding values with transverse images alone (P > 0.05), except for the mean specificity (P = 0.039).

CONCLUSION: Our results showed excellent diagnostic performance, sensitivity and NPV to detect high-risk esophageal varices on follow-up liver CT after locoregional therapy for HCC.

Platelet count/spleen diameter ratio for non-invasive diagnosis of oesophageal varices: is it useful in compensated cirrhosis?

AIM

To assess the diagnostic accuracy of the platelet count/spleen diameter ratio for identification of oesophageal varices and/or hypertensive gastropathy in patients with compensated cirrhosis.

METHODS

Platelet count/spleen diameter ratio was calculated in 87 consecutive patients with compensated cirrhosis. A new cut-off with the highest sensitivity and specificity for the presence/absence of oesophageal varices and/or hypertensive gastropathy was identified. Performance of the platelet count/spleen diameter ratio considering previously reported cut-off values were then tested in our population.

RESULTS

A platelet count/spleen diameter ratio <936.4 had the best sensitivity and specificity for the diagnosis of oesophageal varices and for all endoscopic findings of portal hypertension. A value lower than 936.4 allowed identification of 64.5% of patients with oesophageal varices and 66.7% of patients with any sign of portal hypertension; a value higher than 936.4 excluded oesophageal varices in 64.3% of patients and any sign of portal hypertension in 68.6% of patients.

CONCLUSIONS

In patients with compensated cirrhosis, the platelet count/spleen diameter ratio is not a useful parameter to avoid unnecessary upper endoscopy, independently of the cut-off.