Diagnostic Accuracy of Spleen-dedicated 100 Hz Transient Elastography to Predict High-risk Esophageal Varices

Introduction: The Baveno VII consensus suggested different SSM cut-offs to predict High-Risk Esophageal Varices (HREV) and Clinically Significant Portal Hypertension (CSPH) in patients with cirrhosis. Few studies have validated these cut-offs using spleen-dedicated 100 Hz TE. We have assessed the diagnostic performance of SSM in predicting HREV and CSPH using a spleen-dedicated 100 Hz TE and compared it with other noninvasive algorithms. Methods: This is a single-centre prospective study including patients with cirrhosis. Endoscopy, spleen dedicated TE and laboratory investigations were performed for all participants. A new SSM cut-off to rule out HREV was derived from our cohort. Its performance was compared with existing algorithms by determining endoscopy spare rate and HREV miss rate. The cut-offs suggested by the Baveno VII consensus for predicting HREV and CSPH were compared with the new SSM cut-off value. Results: HREV were present in 33 (28.4%) of 116 patients (97 compensated and 19 recompensated cirrhosis). The AUROC of SSM, LSM alone, combination of LSM and platelet count (PC), and combination of LSM, PC, and SSM were 0.849, 0.683, 0.808, and 0.864, respectively. An SSM cut-off value of 35 kPa in compensated cirrhosis had a corresponding sensitivity of 95.6%. On extrapolating this cut-off in the overall cohort, SSM alone spared more endoscopies as compared to the Baveno VI criteria combining LSM and PC (44.8% vs. 21.5%) and had a lower HREV miss rate as compared to the Baveno VII criteria for HREV (6.1% vs. 15.1%). The combination of LSM, PC and SSM narrowed the grey zone of CSPH to 12.9% when the single value of SSM cut-off derived from this study (35 kPa) was used. Conclusions: SSM alone can accurately predict HREV in cirrhosis, and its combination with LSM and PC precisely predicted CSPH, saving a significant number of endoscopies. The SSM cut-off to rule out HREV may vary with etiology.