Spleen stiffness to rule out high-risk varices in advanced chronic liver disease: an individual patient data meta-analysis.

Abstract:

BACKGROUND & AIMS

Management of esophageal varices (EV) is of critical importance in compensated advanced chronic liver disease. We conducted an individual patient data (IPD) meta-analysis to (i) investigate the performance of spleen stiffness measurement (SSM)-based algorithms using vibration-controlled transient elastography (VCTE) to rule out high-risk varices (HRV); (ii) develop a new model for diagnosing any grade EV.

METHODS

We systematically searched databases for studies reporting endoscopy and SSM-VCTE data in adult patients, collecting their IPD. The main outcome was ruling out HRV. The tested algorithms were: i) Baveno-VI criteria, liver stiffness measurement (LSM) <20 kPa and platelet count (PLT) >150x10/L); ii) SSM ≤40 kPa; iii) combined Baveno-SSM criteria ≤40 kPa in patients outside Baveno VI criteria. We developed and internally validated logistic regression models to diagnose any grade EV.

RESULTS

Twenty studies comprising 2257 patients were included, with a summary HRV prevalence of 25%. The Baveno VI algorithm showed 100% (95%-CI:97-100%) sensitivity and 100% (95%-CI:95-100%) NPV; the rate of spared endoscopies was 17% (95%-CI:15-18%). The combined Baveno VI-SSM criteria performed best for ruling out HRV: 97% (95%-CI:94-99%) sensitivity, 98% (95%-CI:96-99%) NPV and rate of spared endoscopies of 35% (95%-CI: 34-38%). These results were robust in all sensitivity analyses, including patients with non-viral etiology (n=637) and studies using the 100 Hz module. We developed new logistic models with excellent accuracy for the diagnosis of EV, but the ability to identify patients at low risk (<10%) of EV was limited.

CONCLUSION

This large, multicenter, international study validated spleen stiffness measurement as an accurate tool to assess high-risk esophageal varices. The combined Baveno-SSM algorithm performed best in ruling out HRV.

IMPACT AND IMPLICATIONS

Spleen stiffness has been recommended to rule out high-risk varices, but the evidence supporting its use is of low-quality. Our individual patient data meta-analysis, which included more than 2200 patients with compensated cirrhosis, showed that spleen stiffness ≤40 kPa can rule out high-risk varices with a very low rate of false negatives. Its combination with Baveno VI criteria was the most efficient triage strategy, doubling the rate of endoscopies that could be safely avoided compared to using the Baveno VI criteria alone. The findings of our study strengthen the level of evidence supporting the use of spleen stiffness as an additional screening tool for high-risk varices.

Copyright © 2026. Published by Elsevier B.V.

Keywords: Baveno, SSM, cirrhosis, elastography, endoscopy, esophageal varices, portal hypertension

References:

Authors

• Agustín Albillos |
• Francesco Azzaroli |
• Giovanni Barbara |
• Renata Bende |
• Annalisa Berzigotti |
• Matthias Buechter |
• Christophe Cassinotto |
• Jinjun Chen |
• Young Seo Cho |
• Antonio Colecchia |
• Agostino Colli |
• Lory S Crocè |
• Elton Dajti |
• Laure Elkrief |
• Maha M Elsabaawy |
• Flavia Fernandes |
• Davide Festi |
• Carmen Fierbinţeanu-Braticevici |
• José Ignacio Fortea |
• Mirella Fraquelli |
• Giovanni Galati |
• Rui Gaspar |
• Ivica Grgurević |
• Masashi Hirooka |
• Maciej K Janik |
• Pik Eu Jason Chang |
• Ekaterina O Liusina |
• Natalie Lucchina |
• Giulia Manni |
• Giovanni Marasco |
• Atsushi Nakajima |
• Fabio Piscaglia |
• Xiaolong Qi |
• Pierre-Emmanuel Rautou |
• Federico Ravaioli |
• Thomas Reiberger |
• Davide Roccarina |
• Giorgio Soardo |
• Horia Stefanescu |
• Grace L H Wong |
• Romanas Zykus |