Design: Retrospective multicentre diagnostic study, derivation and validation cohorts
Population: 346 patients with chronic PVT without cirrhosis, 16 VALDIG centres
Primary outcome: Performance of spleen stiffness ≤40 kPa to rule out high-risk varices
Effect: NPV 97% / 96%; endoscopies spared 41% / 43%; HRV missed 3% / 5%

This retrospective study from 16 VALDIG centres included patients with chronic portal vein thrombosis without cirrhosis who had spleen stiffness measured by transient elastography within two years of an upper endoscopy. There was a derivation cohort of 159 and a validation cohort of 187. It was published in the Journal of Hepatology in September.

High-risk varices were present in 43% and 32%. On multivariable analysis, spleen stiffness was the only independent predictor in both cohorts. A cut-off of 40 kPa or less had 97% sensitivity and 97% negative predictive value in derivation, sparing 41% of endoscopies and missing 3% of high-risk varices. In validation, it spared 43% with 5% missed and 96% NPV.

At present every patient with chronic PVT is scoped, repeatedly. Liver stiffness cut-offs from cirrhosis do not apply because these livers are usually soft. Spleen stiffness offers a validated way to spare many of those endoscopies, especially in young patients who need lifelong surveillance. It needs a spleen-specific probe and operators trained in the technique.

Measure spleen stiffness in chronic non-cirrhotic PVT before screening endoscopy.
If ≤40 kPa, endoscopy can reasonably be deferred, with repeat measurement annually.
If >40 kPa, or ascites or a myeloproliferative neoplasm is present, proceed to endoscopy.
Do not apply liver stiffness cut-offs from cirrhosis to PVT.

Why it matters

It offers the first validated way to avoid routine endoscopy in a group scoped for life.

The statistics, in plain English

A negative predictive value of 96–97% means about 3 to 5 in 100 patients below the cut-off will still have high-risk varices. The study was retrospective, and endoscopy could be up to two years from the stiffness measurement, which may blur the relationship.