Published online Nov 27, 2020. doi: 10.4254/wjh.v12.i11.1055
Peer-review started: July 16, 2020
First decision: August 9, 2020
Revised: August 22, 2020
Accepted: October 9, 2020
Article in press: October 9, 2020
Published online: November 27, 2020
Portal hypertension is a major complication of cirrhosis with a significant morbidity and mortality associated with it. Many of those with advanced chronic liver disease have esophageal varices and so, many patients undergo the gold-standard invasive procedures of performing an esophago-gastroduodenoscopy (EGD) or having the hepatic venous pressure gradient measurement taken through interventional radiology. However, both of these methods are invasive and carry a risk of complications.
Current guidelines propose that non-invasive methods can predict the incidence of clinically significant portal hypertension (CSPH). The latest guidelines suggest cirrhosis patients with a liver stiffness measurement < 20 kPa and a platelet count > 150000/μL can avoid screening endoscopy. Nevertheless, new algorithms are still required, as up to 40% of EGDs continue unnecessarily.
The aim of this study was to assess whether spleen stiffness measurement, spleen area and spleen diameter can independently predict CSPH, or in combination with other biochemical or elastography parameters. We also aimed to assess reproducibility of splenic area and diameter measurements.
This was a single-centre prospective cohort study where a total of 50 patients were split into two groups and included in a retrospective analysis: 25 with evidence of CSPH (group 1) and 25 with no evidence of CSPH (group 2). The Philips EPIQ7 [elastography point quantification (ElastPQ)] (Philips Medical Systems, Seattle, United States) was used to record liver stiffness, spleen stiffness, spleen area and spleen diameter measurements for each patient. Univariate, multivariate and one-way random interclass correlation coefficient analyses were performed to assess the diagnostic accuracy of splenic parameters.
Body mass index, alanine aminotransferase, aspartate aminotransferase, γ-glutamyl transpeptidase, alkaline phosphatase, bilirubin, platelet count, albumin, prothrombin time, aspartate aminotransferase-to-platelet-ratio-index (APRI) score, liver stiffness, spleen stiffness, spleen area and spleen diameter were assessed in their ability to predict the presence of CSPH. A univariate analysis showed the best individual predictor of CSPH was platelet count [area under the receiver operating characteristic (AUROC) 0.846, P value < 0.001], followed by spleen area (AUROC 0.828, P value = 0.002) and APRI score (AUROC 0.827, P value < 0.001). A multiple logistic regression model revealed that two combinations independently predict CSPH. The combination with the greatest diagnostic accuracy included a combination of spleen area > 57.9 cm2 and platelet count < 126 × 109 which had 63.2% sensitivity, 100% specificity, 100% positive predictive value (PPV), 61.1% negative predictive value (NPV) (AUROC 0.876, P value < 0.001). An alternative combination of spleen stiffness >29.99 kPa and platelet count < 126 × 109 displayed a similar diagnostic accuracy with 88% sensitivity, 75% specificity, 78.6% PPV, 85.7% NPV (AUROC 0.855, P value < 0.001). Spleen area and spleen diameter demonstrated little inter-operator variability as measured by a one-way random interclass correlation coefficient (spleen area: 0.98, P value < 0.001; spleen diameter: 0.96, P value < 0.001).
Combinations of spleen area and platelet count, or spleen stiffness and platelet count as measured by the ElastPQ may be safe and effective methods to diagnose CSPH. At present this cannot replace the gold standard.
Performing large scale prospective studies with long-term follow-up and are needed to validate our findings.