TOPLINE

A spleen stiffness reading of 40 kPa or lower reliably identified patients with chronic portal vein thrombosis (PVT) but no cirrhosis who could safely skip screening endoscopy for high-risk, bleeding-prone varices. This simple, noninvasive spleen stiffness test could have spared more than 40% of screening endoscopies while missing high-risk varices in 5% or fewer cases.

METHODOLOGY

• While liver and spleen stiffness measurements have long guided variceal risk stratification in cirrhosis, liver stiffness cutoffs validated in cirrhosis cannot be applied to noncirrhotic PVT, where values run much lower. Clinicians have therefore relied on endoscopy alone: a first screening within 6 months of the acute clot, and if no varices are found, repeat endoscopy at 12 months and every 2 years thereafter.
• Researchers conducted a retrospective study across 16 centers in Europe, Russia, and India to determine whether spleen stiffness measurement by vibration-controlled transient elastography could reliably rule out high-risk varices — defined as large varices, small varices with red markings, or varices that had already undergone preventive banding or glue injection — in patients with chronic noncirrhotic PVT.
• The spleen stiffness cutoff was first identified in a derivation cohort of 159 patients (median age at PVT diagnosis, 49 years; 62% men) and then tested in an independent validation cohort of 187 patients from other centers (median age at PVT diagnosis, 53 years; 55% men).
• All patients had chronic PVT confirmed by imaging, with cirrhosis ruled out using liver stiffness measurement, imaging features, or biopsy. 
• Each patient underwent spleen stiffness measurement and upper endoscopy within 2 years of one another, allowing researchers to test how well the spleen stiffness cutoff predicted actual endoscopy findings.

TAKEAWAY

• High-risk varices were found in more than 40% of patients in the derivation cohort and in more than 30% in the validation cohort.
• Spleen stiffness was the only variable independently associated with high-risk varices in both cohorts (P < .001), with median values more than twice as high in patients with these varices than in those without (derivation cohort: 75 vs 32.1 kPa; validation cohort: 75 vs 35.0 kPa).
• Using a spleen stiffness cutoff of 40 kPa, the test correctly flagged 97% of patients with high-risk varices in the derivation cohort and 95% in the validation cohort, with a negative predictive value above 95% in both groups.
• Using the 40-kPa cutoff, 41% of endoscopies in the derivation cohort and 43% in the validation cohort could have been avoided, while missing high-risk varices in 3% and 5% of cases, respectively.

IN PRACTICE

"Surveillance using SSM [spleen stiffness measurement] by VCTE [vibration-controlled transient elastography] could therefore contribute, at an individual level, to spare a large number of screening endoscopies over a lifetime, thus improving the quality of life of these young patients," the authors wrote.

SOURCE

The study was led by Lucile Moga, MD, Service d'Hépatologie, AP-HP, Hôpital Beaujon, DMU DIGEST, Centre de Référence des Maladies Vasculaires du Foie, in Clichy, France. It was published online in the Journal of Hepatology.

LIMITATIONS

Researchers did not apply a newer quality standard recommending at least 15 measurements for patients with very high spleen stiffness (> 75 kPa), as it was published after most patients had already been tested. Only a few patients needed the XL probe for spleen stiffness measurement, limiting certainty about how well the test performs with that probe. Some patients may also have had porto-sinusoidal vascular disorder, which is harder to rule out than cirrhosis.

DISCLOSURES

The study was supported by COST Action EURO-VALDI-NET and multiple research grants. Several authors reported advisory roles, consulting fees, speaker fees, travel support, or research support from several pharmaceutical companies. 

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.