Buechter Matthias, Kahraman Alisan, Manka Paul, Gerken Guido, Jochum Christoph, Canbay Ali, Dechêne Alexander
Department of Gastroenterology and Hepatology, University Hospital Essen, Essen, Germany.
Digestion. 2016;94(3):138-144. doi: 10.1159/000450704. Epub 2016 Oct 19.
BACKGROUND/AIMS: Portal hypertension (PH) is a common complication of chronic liver disease and results in esophageal and gastric variceal bleeding, which is associated with a high mortality rate. Measurement of the hepatic venous pressure gradient (HVPG) is considered the gold standard for diagnosing PH and estimating the risk of varices and bleeding. In contrast, upper gastrointestinal (GI) endoscopy (UGE) can reliably demonstrate the presence of varices and bleeding. Both measures are invasive, and HVPG is mainly restricted to tertiary centers. Therefore, the development of noninvasive methods of assessing the severity of PH and the risk of variceal bleeding is warranted.
We retrospectively examined the correlation of spleen stiffness (SSM) and liver stiffness measurements (LSM) with the incidence of variceal bleeding among 143 patients who underwent combined liver and spleen elastography between 2013 and 2015.
For 19 of 103 patients (16.8%), upper GI variceal bleeding was diagnosed and treated endoscopically. The median SSM of all patients was 35.3 kilopascals (kPa); the median LSM, 11.7 kPa. Patients with previous bleeding episodes had significantly higher SSM (75.0 kPa) and LSM (37.3 kPa) than those without a history of bleeding (SSM, 30.6 kPa; LSM, 8.2 kPa; p < 0.0001). Seventy-five patients (66.4%) underwent UGE in addition to SSM and LSM: 25 with no esophageal varices (EVs; SSM, 29.5 kPa; LSM, 11.4 kPa), 16 with EV grade 1 (SSM, 35.9 kPa; LSM, 33.4 kPa), 21 with EV grade 2 (SSM, 67.8 kPa; LSM, 27.0 kPa) and 13 with EV grade 3 (SSM, 75.0 kPa; LSM, 26.3 kPa). No statistically significant differences were found between respective grades of EV but were found between the presence and absence of varices. At a calculated cutoff level of 42.6 kPa (with application of 95% CI), SSM had sensitivity of 89% and specificity of 64% in determining the risk of bleeding, with a negative predictive value (NPV) of 0.97 (LSM sensitivity, 84%; LSM specificity, 80%; LSM NPV, 0.96 at LSM cutoff level of 20.8 kPa). When LSM (cutoff level, 20.8 kPa) and SSM (cutoff level, 42.6 kPa) were combined, the NPV was 1 (sensitivity, 100%; specificity, 55%).
SSM and LSM as determined by FibroScan (a noninvasive method of detecting PH) is positively correlated with upper GI variceal bleeding (optimal SSM cutoff level, 42.6 kPa; optimal LSM cutoff level, 20.8 kPa). No patients with both SSM and LSM below cutoff levels had a history of bleeding complications.
背景/目的：门静脉高压（PH）是慢性肝病的常见并发症，可导致食管和胃静脉曲张出血，其死亡率很高。肝静脉压力梯度（HVPG）测量被认为是诊断PH以及评估静脉曲张和出血风险的金标准。相比之下，上消化道（GI）内镜检查（UGE）能够可靠地显示静脉曲张和出血的存在。这两种方法都是侵入性的，并且HVPG主要局限于三级中心。因此，有必要开发评估PH严重程度和静脉曲张出血风险的非侵入性方法。
我们回顾性研究了2013年至2015年间接受肝脏和脾脏联合弹性成像检查的143例患者中脾脏硬度（SSM）和肝脏硬度测量值（LSM）与静脉曲张出血发生率之间的相关性。
103例患者中有19例（16.8%）经内镜诊断并治疗了上消化道静脉曲张出血。所有患者的SSM中位数为35.3千帕（kPa）；LSM中位数为11.7 kPa。有既往出血史的患者的SSM（75.0 kPa）和LSM（37.3 kPa）显著高于无出血史的患者（SSM，30.6 kPa；LSM，8.2 kPa；p<0.0001）。75例患者（66.4%）除进行SSM和LSM检查外还接受了UGE检查：25例无食管静脉曲张（EVs）（SSM，29.5 kPa；LSM，11.4 kPa），16例为1级EV（SSM，35.9 kPa；LSM，33.4 kPa），21例为2级EV（SSM，67.8 kPa；LSM，27.0 kPa），13例为3级EV（SSM，75.0 kPa；LSM，26.3 kPa）。各等级EV之间未发现统计学上的显著差异，但有静脉曲张和无静脉曲张之间存在差异。在计算的截断水平为42.6 kPa（应用95%CI）时，SSM在确定出血风险方面的敏感性为89%，特异性为64%，阴性预测值（NPV）为0.97（LSM敏感性为84%；LSM特异性为80%；在LSM截断水平为20.8 kPa时LSM的NPV为0.96）。当LSM（截断水平为20.8 kPa）和SSM（截断水平为42.6 kPa）联合使用时，NPV为1（敏感性为100%；特异性为55%）。
通过FibroScan（一种检测PH的非侵入性方法）测定的SSM和LSM与上消化道静脉曲张出血呈正相关（最佳SSM截断水平为42.6 kPa；最佳LSM截断水平为20.8 kPa）。SSM和LSM均低于截断水平的患者无出血并发症史。
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