The correlation between liver stiffness (LS), measured by ultrasonic transient elastometry (FibroScan), and the presence and severity of esophageal varices (EV) in patients with viral cirrhosis of the liver has not been well documented to date. The study described here investigated the value of using FibroScan to predict EV. Patients with cirrhosis (200 patients: 167 cases caused by hepatitis B virus and 33 cases caused by hepatitis C virus) underwent both upper gastrointestinal endoscopy and FibroScan. Demographic, clinical, biochemical and endoscopic data and FibroScan-obtained LS parameters were collected. The mean LS value in patients with EV (33.2 kPa) was significantly higher than the mean LS value in patients without EV (18.6 kPa) (p < 0.05). The mean LS value in patients with grade 2 and 3 EV (38.3 kPa) was significantly higher than that in patients with grade 1 EV (24.8 kPa) (p < 0.05). Overall, FibroScan was 86.4% sensitive and 72.2% specific in predicting the presence of EV, with an area under the receiver operating characteristic curve (AUROC) of 0.84. The sensitivity and specificity for the patients with grade 2 or 3 EV were 84% and 73% (AUROC = 0.86). When FibroScan was combined with platelet count, the overall sensitivity and specificity of prediction increased to 84% and 80% (AUROC = 0.88), respectively, and 84% and 75% (AUROC = 0.89), respectively, in patients with grade 2 and 3 EV. FibroScan alone or combined with platelet count might predict the presence and severity of EV in patients with hepatitis B or C-related viral cirrhosis.
AIMS: Non-invasive methods are required to diagnose presence and grading of esophageal varices in patients with hepatic cirrhosis and in this respect we have evaluated the role of transient elastography and abdominal ultrasound parameters.
MATERIAL AND METHODS: Cirrhotic patients were prospectively evaluated by transient elastography and Doppler ultrasound for diagnosis of presence and grading of esophageal varices, the results being compared with the findings of the esophagogastroduodenoscopy.
RESULTS: Sixty patients with hepatic cirrhosis were analysed. The parameters that reached statistical significance for diagnosis of esophageal varices were: liver stiffness (LSM) > 15 kPa, hemodynamic liver index (PVr1) >/= 0.66, portal vascular resistance (PVR) > 17.66 and splenoportal index (SPI) > 4.77. The only parameter that reached statistical power for the diagnosis of large esophageal varices was LSM at a cut-off value of 28.8 kPa.
CONCLUSIONS: Assessment of LSM in patients with liver cirrhosis can predict both the presence of esophageal varices and of large esophageal varices. The PVr1, PVR and SPI Doppler indexes can be used to diagnose the presence of esophageal varices but have no role in the prediction of large esophageal varices. Further studies are required to confirm these results and offer a stronger clinical significance.
Liver transient elastography (L-TE) is a reliable, noninvasive predictor of disease severity in chronic liver disease of viral aetiology (CLD). Owing to the relationships among severity of CLD, portal hypertension and spleen involvement, the assessment of splenic stiffness (S-TE) may have an added value in staging CLD. Of 132 CLD patients of viral aetiology, 48 with myeloproliferative disorders (MD) and 64 healthy volunteers (HV), were concurrently investigated by both L-TE and S-TE. Liver disease severity was staged by liver biopsy (LB; Metavir) taken concurrently with TE examination and upper gastrointestinal tract endoscopy for gastro-oesophageal varices. The S-TE inter-observer agreement was analysed by an intra-class correlation coefficient (ICC); L-TE and S-TE accuracy was evaluated by receiver operating characteristic (ROC) curve analysis. Logistic regression analysis assessed the independent effect of L-TE and S-TE as predictors of hepatic fibrosis stage. S-TE failed in 22 CLD (16.6%), 12 (25%) MD and 12 (18%) HV. In the three groups, the ICC was 0.89 (0.84-0.92), 0.90 (0.85-0.94) and 0.86(0.80-0.91), respectively. In the CLD group, L-TE and S-TE independently predicted significant fibrosis (OR 5.2 and 4.6) and cirrhosis (OR 7.8 and 9.1), but at variance from L-TE, S-TE was independent from liver necroinflammation and steatosis. The NPV of S-TE for gastro-oesophageal varices was 100% using a 48 kPa cut-off. In CLD, spleen stiffness alone or in combination with hepatic stiffness can be reliably and reproducibly assessed by TE with the added value of improving the noninvasive diagnosis of severe liver disease and excluding the presence of oesophageal varices.
OBJECTIVE: To investigate reliability of FibroScan (FS) in diagnosing size of oesophageal varices (OV) in patients with liver cirrhosis.
METHODS: A total of 260 patients with liver cirrhosis were enrolled in the study. All patients underwent endoscopy to assess OV stage and FS to measure liver stiffness. Receiver operating characteristic (ROC) curves were generated to evaluate the diagnostic reliability of FS.
RESULTS: The FS values according to OV stage were 20.9 ± 10.3 kPa for patients without OV, 32.2 ± 13.5 kPa for patients with mild OV, 45.6 ± 18.3 kPa for patients with moderate OV, and 55.1 ± 15.6 kPa for patients with severe OV. Significant differences were found among the groups (P < 0.001) as well as between any two groups (t=6.574, 10.533, 13.247, 4.719, 7.072 and 2.171, P less than 0.05 respectively). ROC curves of FS for the diagnoses of patients with various OV stages showed the following:with vs. without OV, 0.824 (95% CI:77.5% to 87.4%); less than moderate vs. more than moderate OV, 0.849 (95% CI:79.6% to 90.2%); and less than severe vs. severe OV, 0.871 (95% CI:81.1% to 93.0%); the corresponding FS cut-off values were 22.8 kPa, 30.6 kPa, and 34.6 kPa.
CONCLUSION: Liver stiffness measurement by FibroScan allows prediction of the oesophageal varices stage in patients with liver cirrhosis.
BACKGROUND & AIMS: Detecting portal hypertension (PH) before the development of varices is important for prognosis and for designing interventional studies. None of the available strategies is used in practice. We evaluated a sequential screening-diagnostic strategy based on clinical data and transient elastography (TE) to detect PH in asymptomatic outpatients with liver disease.
METHODS: Consecutive patients with chronic liver disease and no previous diagnosis of PH were screened by TE. Patients with liver stiffness (LS) ⩾ 13.6 kPa were further evaluated by endoscopy and hepatic venous pressure gradient (HVPG). For analysis, patients were classified in 3 groups: group A, platelets ⩾ 150,000/mm(3), normal abdominal ultrasound; group B, platelets <150,000/mm(3), normal ultrasound; group C, platelets <150,000/mm(3), abnormal ultrasound (splenomegaly, nodular liver surface).
RESULTS: 250 patients were evaluated (69% group A, 20% group B, 11% group C). In 9% elastography was non-valid. LS ⩾ 13.6 was found in 54 patients (8% A, 43% B, and 81% C, p<0.001). Endoscopy was performed in 49 of these: 20% had small varices, 0% high-risk varices. No patients from group A had varices, and 90% with varices belonged to group C. HVPG was obtained in 40 patients: 93% had PH (HVPG >5 mmHg) and 65% clinically significant PH (CSPH, HVPG ⩾ 10). Only 3 patients, all from group A, had HVPG <5. All patients from groups B and C with LS ⩾ 13.6 had PH. The LS 25 cut-off was excellent at ruling-in CSPH.
CONCLUSIONS: A simple strategy based on routine clinical data and TE could be useful to detect early PH among asymptomatic patients with chronic liver disease.
BACKGROUND: Acoustic radiation force impulse imaging (ARFI) is a new method of liver stiffness measurement (LSM). The aim was to compare ARFI, transient elastography (TE) and AST to platelet ratio index (APRI) for the noninvasive diagnosis of clinically significant portal hypertension (CSPH, hepatic venous pressure gradient; HVPG ≥ 10 mmHg) and esophageal varices (EV).
MATERIALS AND METHODS: LSM via ARFI and TE was performed in 88 consecutive patients with cirrhosis prior to HVPG measurement. The mean liver stiffness for ARFI was calculated out of 5 measurements for each lobe.
RESULTS: LSM by TE and ARFI was not successful in 22 (25%) patients and 1 (1 %) patient, respectively, due to ascites or obesity. Both TE (r = 0.765; p < 0.001) and ARFI (r = 0.646; p < 0.001) correlated significantly with HVPG. At the optimal cut-off (16.8 kPa), TE (area under the curve, AUC 0.870) yielded a sensitivity and specificity of 89.7% and 75%, respectively, for predicting CSPH. At the optimal cut-off (2.58 m/s), the sensitivity and specificity for ARFI (AUC 0.855) were 71.4% and 87.5%, respectively. Using an APRI (AUC 0.838), the sensitivity and specificity were 69% and 87.5%, respectively. The AUC for the diagnosis of EV was 0.802 for TE (cut-off: 27.9 kPa), 0.743 for ARFI (cut-off: 2.74 m/s), and 0.805 for APRI (cut-off: 1.90).
CONCLUSION: ARFI shows a higher applicability particularly in obese and ascitic patients. All three investigated methods show a high diagnostic accuracy for CSPH. Notably, APRI performed not significantly different compared to ARFI for the diagnosis of CSPH.
Para evaluar la exactitud de hígado elastografía transitoria (TE), el bazo TE y otras pruebas no invasivas (AAR, la puntuación APRI, recuento de plaquetas, plaquetas cociente / bazo) en la predicción de la presencia y el tamaño de las varices esofágicas en virus compensado la hepatitis C (VHC) cirrosis, se estudiaron 112 pacientes consecutivos con cirrosis compensada VHC que se sometieron a pruebas bioquímicas, endoscopia gastrointestinal, el hígado y el bazo TE TE por Fibroscan (®) (Echosens, París, Francia), utilizando una versión modificada del software con un rango entre 1,5 y 150 kPa. Bazo TE no era fiable en 16 pacientes (14,3%). Entre los 96 pacientes con una medición válida (69,8% hombres, edad media: 63,2 ± 9,5 años), el 43,7% no tenía varices esofágicas, el 29,2% tienen grado 1% y el 27,1% tienen grado 2 o grado 3 varices esofágicas. Los pacientes con valores de 75 kPa por el bazo estándar TE tenían valores medios de bazo modificado TE de 117 kPa (rango: 81,7 a 149,5). La regresión lineal reveló una correlación significativa entre el bazo modificado TE y tamaño várice esofágica (r = 0,501; beta: 0.763, SE: 0,144; p <0,001). En el análisis univariado, las variables asociadas con várices grado 2 / grado 3 esofágicas eran puntuación AAR, la puntuación APRI, plaquetas / relación de bazo, el hígado y el bazo modificado TE TE. En el análisis multivariado, sólo modificado bazo TE (OR: 1,026; IC del 95%: 1,007 a 1,046; p = 0,006) y AAR (OR: 14.725; IC del 95%: 1,928 a 112,459; P = 0,010) se mantuvo asociado independientemente con grado 2 / grado 3 varices esofágicas. Relación de plaquetas / bazo es el mejor predictor de la várices esofágicas área bajo la curva ROC (AUROC: 0.763, de corte: 800, sensibilidad: 74%, especificidad: 70%), mientras que el bazo modificado TE fue más preciso en la predicción de grado 2 / grado 3 varices esofágicas (AUROC: 0.82, de corte: 54,0 kPa, sensibilidad: 80%, especificidad: 70%). La hipertensión portal aumenta la rigidez del bazo, y la medición de bazo modificado TE es una herramienta precisa, no invasiva para predecir la presencia de grandes varices esofágicas en pacientes con cirrosis compensada HCV.
OBJECTIVE: To investigate the clinical value of FibroScan transient elastography for assessing portal hypertension in liver cirrhosis patients by determining the relationship between the liver or spleen stiffness measurement with the imaging parameters of esophageal varices, portal vein width, spleen volume, and splenic vein width.
METHODS: A total of 259 patients with liver cirrhosis underwent FibroScan measurement, ultrasound, computed tomography and routine blood analyses. One-hundred-and-one of those patients also underwent endoscopy to diagnose esophageal varices. Receiver operating characteristic (ROC) curves were generated and the areas under the curves (AUCs) were calculated to assess the accuracy of the FibroScan liver and spleen stiffness measurements to predict esophageal varices. Pearson's correlation analysis was used to assess the relationship between clinical features.
RESULTS: The median liver and spleen stiffness of the cirrhotic patients were 24.27 kPa and 44.64 kPa, respectively. Liver and spleen stiffness increased in conjunction with increases in Child-Pugh score. Liver stiffness was positively correlated with spleen stiffness (P less than 0.05). Liver and spleen stiffness were positively correlated with esophageal varices, portal vein width, spleen thickness, spleen volume, and splenic vein width. The correlation of spleen stiffness was higher than that of liver stiffness. Spleen stiffness was also negatively correlated with white blood cell count and platelet count. Liver and spleen stiffness also increased in conjunction with increased severity of esophageal varices. The AUC of spleen stiffness was higher than that of liver stiffness for predicting esophageal varices (0.804 vs. 0.737). The optimal cut-off level of spleen stiffness was 44.5 kPa (sensitivity: 88%; specificity: 68%). The estimated prevalence of esophageal varices was 97.87% and the optimized cut-off level of liver stiffness was 18.0 kPa.
CONCLUSION: FibroScan appears to be a clinically valuable non-invasive method to assess portal hypertension in cirrhotic patients. Both liver and spleen stiffness measurements correlated with portal hypertension but the spleen stiffness measurement may be of higher clinical value.
BACKGROUND AND AIM: Liver stiffness measured by transient elastgraphy correlates with Hepatic vein pressure gradient, liver Stiffness value of 21 kpa predicts significant portal hypertension. Aim is to predict esophageal varices presence by fibroscan and possible grading by degree of liver stiffness in HCV related cirrhotic patients.
MATERIAL AND METHODS: Thirty two HCV related cirrhotic patients were recruited, age > 18 years, BMI< 35, no history of: upper GI bleeding, hepatocellular carcinoma, abdominal collaterals, ascites. Patients underwent clinical examination, laboratory investigations, abdominal ultrasonography, upper endoscopy and fibroscan. They divided into (Group I= no varices, Group II =small varices (Grade 1 & 2), Group III = large varices (Grade 3 & 4).
RESULTS: Age is higher in Group III than I & II (55+6.6 vs 49.5+4.7 & 48.9+4.7, p-value 0.04) respectively, Groups were gender & BMI matched, fibroscan values in Group I vs II & III were 27 Vs 49.4, p value 0.01, cutoff 29.7 Kpa (sensitivity 95% & specificity 67%) while its value in Group II vs III were 38.4 vs 60.4, p value 0.002, cutoff 38.2 Kpa (sensitivity 100% & specificity77.3%). Platelet count, splenic size, platelet count/splenic size in Group I vs II & III were 107.166 vs 72.900, 13.8 vs 15.4, 803.6 vs 478, p value 0.01, 0.008, 0.005, cutoff 80.000, 14.5, 545, sensitivity & specificity (85%&75%, 75%&75%, 85%&84%) respectively. On multivariate analysis fibroscan (OR 1.113; p=0.005) & platelet count/splenic size (OR 0.995; p=0.012) were positive predictors of esophageal varices presence.
CONCLUSION: Fibroscan is a good non-invasive method to predict esophageal varices presence & possible grading with high sensitivity.
OBJECTIVES: Screening for esophageal varices (EV) is recommended in patients with cirrhosis. Noninvasive tests had shown varying sensitivity (Se) and specificity (Sp) for predicting EV. Splenomegaly is a common finding in liver cirrhosis because of portal and splenic congestion. These changes can be quantified by transient elastography; hence, the aim of this study was to investigate the utility of spleen stiffness (SS) in evaluating EV in comparison with other noninvasive tests.
METHODS: We measured SS and liver stiffness (LS) by using FibroScan in 200 consecutive cirrhotic patients who met the inclusion criteria. Patients were also assessed by hepatic venous pressure gradient (HVPG), upper gastrointestinal endoscopy, LS-spleen diameter to platelet ratio score (LSPS), and platelet count to spleen diameter ratio (PSR).
RESULTS: Of 200 patients enrolled, 174 patients had valid LS and SS measurement, and 124 (71%) patients had EV (small, n=46 and large n=78). There was a significant difference in median LS (51.4 vs. 23.9 kPa, P=0.001), SS (54 vs. 32 kPa, P=0.001), LSPS (6.1 vs. 2.5, P=0.001), and PSR (812 vs. 1,165, P=0.001) between patients with EV and those without EV. LS ≥27.3 kPa had an Se of 91%, Sp of 72%, positive predictive value (PPV) of 89%, negative predictive value (NPV) of 76%, and a diagnostic accuracy of 86% in predicting EV. LSPS ≥3.09 had Se and Sp of 89% and 76%, respectively, and a PSR cutoff value of 909 or less had Se of 64%, Sp of 76%, and diagnostic accuracy of 68% in predicting EV. SS ≥40.8 kPa had Se (94%), Sp (76%), PPV (91%), NPV (84%), and diagnostic accuracy of 86% for predicting EV. SS was significantly higher in patients who had large varices (56 vs. 49 kPa, P=0.001) and variceal bleed (58 vs. 50.2 kPa, P=0.001). Combining LS+SS (27.3+40.8 kPa) had Se of 90%, Sp 90%, PPV 96%, NPV 79%, and a diagnostic accuracy of 90%. HVPG (n=52) showed significant correlation with SS (r=0.433, P=0.001), LSPS (r=0.335, P=0.01), and PSR (r=-0.270, P=0.05), but not with LS (r=0.178, P=0.20).
CONCLUSIONS: Measurement of SS can be used for noninvasive assessment of EV and can differentiate large vs. small varices and nonbleeder vs. bleeder.
The correlation between liver stiffness (LS), measured by ultrasonic transient elastometry (FibroScan), and the presence and severity of esophageal varices (EV) in patients with viral cirrhosis of the liver has not been well documented to date. The study described here investigated the value of using FibroScan to predict EV. Patients with cirrhosis (200 patients: 167 cases caused by hepatitis B virus and 33 cases caused by hepatitis C virus) underwent both upper gastrointestinal endoscopy and FibroScan. Demographic, clinical, biochemical and endoscopic data and FibroScan-obtained LS parameters were collected. The mean LS value in patients with EV (33.2 kPa) was significantly higher than the mean LS value in patients without EV (18.6 kPa) (p < 0.05). The mean LS value in patients with grade 2 and 3 EV (38.3 kPa) was significantly higher than that in patients with grade 1 EV (24.8 kPa) (p < 0.05). Overall, FibroScan was 86.4% sensitive and 72.2% specific in predicting the presence of EV, with an area under the receiver operating characteristic curve (AUROC) of 0.84. The sensitivity and specificity for the patients with grade 2 or 3 EV were 84% and 73% (AUROC = 0.86). When FibroScan was combined with platelet count, the overall sensitivity and specificity of prediction increased to 84% and 80% (AUROC = 0.88), respectively, and 84% and 75% (AUROC = 0.89), respectively, in patients with grade 2 and 3 EV. FibroScan alone or combined with platelet count might predict the presence and severity of EV in patients with hepatitis B or C-related viral cirrhosis.
