Copyright ©The Author(s) 2020. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. May 14, 2020; 26(18): 2247-2267
Published online May 14, 2020. doi: 10.3748/wjg.v26.i18.2247
Computed tomography vs liver stiffness measurement and magnetic resonance imaging in evaluating esophageal varices in cirrhotic patients: A systematic review and meta-analysis
Yue Li, Lei Li, Hong-Lei Weng, Roman Liebe, Hui-Guo Ding
Yue Li, Lei Li, Hui-Guo Ding, Department of Gastroenterology and Hepatology, Beijing You’an Hospital Affiliated with Capital Medical University, Beijing 100069, China
Hong-Lei Weng, Department of Medicine II, Section Molecular Hepatology, Medical Faculty Mannheim, Heidelberg University, Mannheim 68167, Germany
Roman Liebe, Department of Medicine II, Saarland University Medical Center, Homburg 66424, Germany
Author contributions: Li Y and Li L contributed equally to collecting the data and writing the manuscript; Ding HG designed the project and was in charge of the manuscript; Weng HL and Liebe R performed the language editing; all authors have read and approved the manuscript.
Supported by the State Key Projects Specialized on Infectious Diseases, No. 2017ZX10203202–004; Beijing Municipal Administration of Hospitals Clinical Medicine Development of Special Funding, No. ZYLX201610; Beijing Municipal Administration of Hospitals’ Ascent Plan, No. DFL20151602; and Digestive Medical Coordinated Development Center of Beijing Hospitals Authority, No. XXT24.
Conflict-of-interest statement: The authors deny any conflict of interest.
PRISMA 2009 Checklist statement: The authors have read the PRISMA 2009 Checklist, and the manuscript was prepared and revised according to the PRISMA 2009 Checklist.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:
Corresponding author: Hui-Guo Ding, MD, PhD, Chief Doctor, Chief Physician, Professor, Department of Gastroenterology and Hepatology, Beijing You’an Hospital affiliated with Capital Medical University, 8 Xitoutiao, Youanmenwai, Fengtai District, Beijing 100069, China.
Received: February 13, 2020
Peer-review started: February 13, 2020
First decision: March 15, 2020
Revised: March 19, 2020
Accepted: April 24, 2020
Article in press: April 24, 2020
Published online: May 14, 2020
Research background

The non-invasive and easy-to-perform diagnostic techniques to predict complications in cirrhotic patients are required in clinical practice. Up to now, the clinical use of liver stiffness measurement (LSM), computed tomography (CT), and magnetic resonance imaging (MRI), as non-invasive diagnostic methods to diagnose esophageal varices (EV) and to predict high-bleeding-risk EV (HREV) in cirrhotic patients, is controversial.

Research motivation

The LSM, CT, and MRI for the diagnosis of EV and prediction of HREV, promising non-invasive diagnostic methods to predict complications in cirrhotic patients, are required in clinical practice. However, the accuracy, sensitivity, and specificity varied in different studies. The overall accuracy, sensitivity, and specificity of LSM, CT, and MRI in the diagnosis of EV and prediction of HREV in cirrhotic patients have not stated.

Research objectives

This is a very important and interesting systematic review and meta-analysis aimed to determine the overall accuracy and sensitivity of three non-invasive methods to diagnose EV and predict the risk of bleeding in patients with liver cirrhosis.

Research methods

We performed literature searches by using selected keywords in PubMed, Embase, Cochrane, CNKI, and Wanfang databases for full-text articles published in English and Chinese. All statistical analyses were conducted using Stata12.0, MetaDisc1.4, and RevMan5.3. Summary sensitivity and specificity, positive likelihood ratio and negative likelihood ratio, diagnostic odds ratio, and the area under the summary receiver operating characteristic curves that evaluated the accuracy of LSM, CT, and MRI as candidates for diagnosing EV and predicting HREV in cirrhotic patients were analyzed. The random-effects model was used to combine effect quantity. 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.

Research results

Overall, 18, 17, and 7 relevant articles on the accuracy of LSM, CT, and MRI in diagnosing EV and predicting HREV were retrieved. CT had higher accuracy than LSM and MRI in diagnosing EV and predicting HREV with areas under the summary receiver operating characteristic curves of 0.91 (95%CI: 0.88-0.93) and 0.94 (95%CI: 0.91-0.96), respectively. The sensitivities of LSM, CT, and MRI in diagnosing EV and predicting HREV were 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), respectively. The specificities were 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 positive likelihood ratios were 2.91, 3.67, and 4.44, and 3.04, 6.90, and 2.83, respectively. The negative likelihood ratios were 0.22, 0.12, and 0.23, and 0.26, 0.14, and 0.28, respectively. The diagnostic odds ratios were 13.01, 30.98, and 19.58, and 11.93, 49.99, and 10.00, respectively. A significant heterogeneity was observed in all analyses (P < 0.05). CT scanner was identified to be the source of heterogeneity. There was no significant difference in diagnostic threshold effects (P > 0.05) or publication bias (P > 0.05). To determine the risk for bleeding of EV using a non-invasive method might have important clinical applications in daily practice. The study gives an overall view of the problem, and for sure does give clinical details which could be useful in making decisions in everyday practice.

Research conclusions

Based on the meta-analysis of observational studies, CT has higher accuracy in evaluating EV and HREV than LSM and MRI in cirrhotic patients. It is suggested that CT, 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.

Research perspectives

The results are very important with significant applications for clinicians in making decisions in daily practice for treatment of cirrhotic patients with portal hypertension. In future, the head-to-head or direct comparisons of these non-invasive methods in the same series of patients are required to confirm the predictive value, especially by using artificial intelligence technique.