Spleen stiffness ≤40 kPa rules out high-risk varices in non-cirrhotic portal vein thrombosis

Design

Retrospective multicentre derivation and validation study

Population

346 patients with chronic portal vein thrombosis without cirrhosis

Primary outcome

Performance of spleen stiffness to rule out high-risk varices

Effect

≤40 kPa: 41–43% endoscopies spared, 3–5% HRV missed, NPV 96–97%

In compensated cirrhosis, spleen stiffness can already spare screening endoscopy, but every patient with chronic portal vein thrombosis without cirrhosis is currently advised to have endoscopy. This retrospective study from 16 VALDIG centres in the Journal of Hepatology tested spleen stiffness by vibration-controlled transient elastography in 346 such patients, split into derivation (159) and validation (187) cohorts.

High-risk varices were present in 43% and 32%. On multivariable analysis, only spleen stiffness remained independently associated with them. A cut-off of 40 kPa or less would have spared 41% of endoscopies in the derivation cohort with 3% of high-risk varices missed (NPV 97%), and 43% in the validation cohort with 5% missed (NPV 96%).

Liver stiffness is usually low in these patients, so cirrhosis cut-offs do not work. Spleen stiffness offers a rule-out that could spare repeated endoscopies over a lifetime, particularly in young patients. It is retrospective, with up to two years between elastography and endoscopy, and needs the spleen-specific probe. Current guidance still recommends endoscopy in this group, so treat this as grounds for discussion with your unit rather than an immediate change.

• In non-cirrhotic chronic portal vein thrombosis, spleen stiffness ≤40 kPa identified patients with ≤5% probability of high-risk varices.
• Do not apply cirrhosis liver-stiffness cut-offs to these patients.
• Where spleen elastography is available, consider it to prioritise who needs endoscopy first.
• Keep endoscopy for patients above 40 kPa or with myeloproliferative neoplasm, ascites or prior bleeding.

Why it matters

It could free many young patients from lifelong surveillance endoscopy.

Don't overread it

This retrospective study has not yet changed guidance, which still recommends endoscopy in all such patients.

The statistics, in plain English

A negative predictive value of 96–97% means that of patients below 40 kPa, about 3–4 in 100 still had high-risk varices. Whether that miss rate is acceptable is a clinical judgement.

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