In compensated cirrhosis, spleen stiffness of 40 kPa or below on vibration-controlled transient elastography is already accepted as sufficient to skip screening endoscopy. Patients with chronic portal vein thrombosis and no cirrhosis have been excluded from that logic, and guidelines still require endoscopy in all of them — largely because their liver stiffness is normal, so the cirrhosis cut-offs cannot be borrowed. This VALDIG study asked whether spleen stiffness works where liver stiffness does not.
Across 16 centres, 346 patients with chronic portal vein thrombosis without cirrhosis who had endoscopy within two years of elastography were split into derivation (159 patients, 43% with high-risk varices) and validation (187 patients, 32%) cohorts. On multivariable analysis, spleen stiffness was the only variable that remained associated with high-risk varices in both cohorts — myeloproliferative neoplasm, ascites, haemoglobin, bilirubin, albumin, splenomegaly, collaterals and liver stiffness all fell away.
A cut-off of 40 kPa or below gave 97% sensitivity in the derivation cohort, sparing 41% of endoscopies while missing 3% of high-risk varices, with a 97% negative predictive value. In validation, it spared 43% of endoscopies, missed 5%, and gave a 96% negative predictive value.
That is a genuinely useful result in a group who are typically young, face decades of surveillance, and accumulate the cumulative risk and cost of repeated endoscopy and sedation. Chronic portal vein thrombosis without cirrhosis is also relatively more common in India than in Western series, particularly in younger patients, which makes lifelong endoscopic surveillance a substantial burden.
Two honest caveats. This is retrospective, with endoscopy and elastography performed up to two years apart — a long window during which varices can develop. And a 4 to 5% miss rate is not zero: the trade is fewer procedures against a small number of unrecognised high-risk varices. That trade is the same one already accepted in compensated cirrhosis, so the principle is established; what is new is applying it to this population. The practical requirement is access to transient elastography with a spleen-specific module, which is not universal.
- In chronic portal vein thrombosis without cirrhosis, spleen stiffness at or below 40 kPa can defer screening endoscopy.
- Do not use liver stiffness cut-offs in this group — liver stiffness is normal and carries no information.
- Expect to spare roughly 4 in 10 endoscopies while missing 3 to 5% of high-risk varices.
- Repeat spleen stiffness annually rather than treating one measurement as permanent clearance.
- Requires transient elastography with a spleen-specific module; endoscope everyone where that is unavailable.
The statistics, in plain English
Negative predictive value is the number that matters for a rule-out test: 96 to 97% means that of patients told they can skip endoscopy, about one in 25 nonetheless has high-risk varices. Whether that is acceptable depends on the consequence, and here it is a delay in starting prophylaxis rather than an immediate harm. Note that negative predictive value depends on how common the condition is — with 32 to 43% prevalence in these cohorts, applying the rule in a lower-risk population would give an even better negative predictive value, and in a higher-risk one, worse. The split into derivation and validation cohorts is what makes this credible: the cut-off was tested on patients not used to derive it.
Read the rest in the app
You have read your two free briefings this month. The app carries all 27 specialties, every morning, free — and this finding is waiting in it.
Scan to keep reading on your phone. No account needed to start.
Tomorrow morning, before your first patient
One edition a day for gastroenterology & hepatology, written by the desk, every claim tied to its paper. Six minutes.
Get the app — free