Spleen stiffness of 40 kPa or less spares endoscopy in portal vein thrombosis without cirrhosis

Design

Retrospective multicentre derivation and validation study

Population

346 patients with chronic non-cirrhotic portal vein thrombosis, 16 centres

Primary outcome

Ruling out high-risk varices with spleen stiffness ≤40 kPa

Effect

NPV 97% (derivation) and 96% (validation); endoscopies spared 41% and 43%; high-risk varices missed 3% and 5%

This retrospective study from 16 VALDIG centres included 346 patients with chronic portal vein thrombosis without cirrhosis who had spleen stiffness measured by transient elastography and an upper endoscopy within two years. It used a derivation cohort of 159 and a validation cohort of 187. Current practice is to scope all such patients to screen for high-risk varices. It was published in September 2026.

Only spleen stiffness remained independently associated with high-risk varices. A cut-off of 40 kPa or less had a negative predictive value of 97% in derivation and 96% in validation. It would have spared 41% and 43% of endoscopies, missing 3% and 5% of high-risk varices.

Liver stiffness is usually normal in these patients, so the rules used in cirrhosis do not apply, and until now every patient needed endoscopy. Non-cirrhotic portal vein thrombosis is not rare in India, including after childhood umbilical sepsis. Spleen stiffness offers a way to cut repeated endoscopies, but it requires a spleen-dedicated elastography probe, which not every centre has.

• Measure spleen stiffness in chronic non-cirrhotic portal vein thrombosis where the equipment exists
• Consider deferring screening endoscopy when spleen stiffness is 40 kPa or less
• Continue to scope patients above 40 kPa or with previous variceal bleeding
• Repeat spleen stiffness at follow-up rather than repeating endoscopy routinely
• Explain the small risk of missed varices to patients

Why it matters

It gives these patients a non-invasive alternative to routine screening endoscopy for the first time.

Don't overread it

The study was retrospective, and endoscopy and elastography were up to two years apart.

The statistics, in plain English

A negative predictive value of 96–97% means that among patients below 40 kPa, only 3–4 in 100 had high-risk varices. The validation cohort, with a lower prevalence of varices, gave similar results, which supports generalisability. Retrospective data with up to two years between tests may misclassify some patients.

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