Liver and spleen stiffness measurement using the new FibroScan module for prediction of esophageal varices and monitoring response to beta blockers in portal hypertension

Abstract

Background

This study aimed to assess the clinical use of the new FibroScan module for measurement of liver and spleen stiffness (LS and SS), comparing their usefulness in prediction of esophageal varices (EV) in patients with portal hypertension (PH) and their clinical value for monitoring response to non-selective beta blockers (NSBB) treatment in these cases. The study included 120 patients with compensated cirrhosis and PH, in addition to 30 healthy comparable controls. Based on gastrointestinal endoscopy, patients were classified into three groups: 48 without EV, 42 with small EV, and 30 with large varices needing treatment. Then, abdominal ultrasound and assessment of LS and SS using new FibroScan 630 Expert module were done for both patients and controls. Group 3 patients were then initiated on NSBB (propranolol), and follow-up of these parameters was done after 3 months.

Results

LS and SS were significantly increased in cirrhotic patients compared to controls and were positively correlated with ultrasonography parameters (spleen length and portal vein diameter). Moreover, they were significantly higher in patients with varices than in those without varices (compared to other noninvasive parameters), correlating with varices severity, and significantly decreased with NSBB treatment, especially SS.

Conclusion

Screening of cirrhotic patients for development of EV by elastography (LS and especially SS) using the new FibroScan machine seems to be an optimal method in clinical practice and superior to other noninvasive tests in the diagnosis, assessment of severity, and follow-up of response to treatment in these patients.

Background

Portal hypertension (PH) is one of the most important consequences of chronic liver disease and cirrhosis [1]. It is considered when the hepatic venous pressure gradient (HVPG) rises to a level that the body cannot compensate for, resulting in complications such as ascites, variceal bleeding, and hepatic encephalopathy.

The gold standards to assess PH in cirrhotic patients are direct measurement of HVPG using angiographic techniques as well as upper gastrointestinal endoscopy to assess for the presence and grade of esophageal varices (EV), which are both invasive tests [2]. In addition, the monitoring of response to therapy by non-selective beta blockers (NSBB) in these cases is dependent mainly on HVPG measurement [3].

On the other hand, ultrasound elastography was suggested to be a noninvasive alternative for assessment of PH and prediction of EV by measuring liver stiffness (LS) and/or spleen stiffness (SS). Some of the studies found LS to be more accurate than SS for the diagnosis of clinically significant portal hypertension (CSPH), while other data show that SS may be a superior marker in diagnosing both clinically significant and severe PH. This controversy was attributed to many factors, like the presence of obesity, ascites, and the method of elastography used [4].

Recently, in 2020, Echosens introduced the FibroScan 630 Expert machine, which is a high-performance elastography engine that can be used to assess LS by vibration-controlled transient elastography (VCTE) and so diagnose and monitor liver health and portal hypertension. In addition, it offers a new spleen stiffness measurement (SS by VCTE based on a 100 Hz shear wave frequency) for risk stratification of patients with advanced chronic liver disease [5].

So, the aim of this study was to assess the clinical use of the new FibroScan Echosens Expert 630 elastography for measurement of LS and SS, comparing their usefulness in prediction of EV in PH patients and their clinical value for monitoring response to beta blocker treatment in these cases.

Methods

This study was designed as an observational cross-sectional study followed by an experimental study. A total of 120 patients with compensated cirrhosis referred from the gastroenterology clinic of our institute between October 2023 and May 2024 were chosen by convenience sampling method for this interventional diagnostic study. In addition, 30 healthy comparable subjects attending the Radiology Department for minor radiological causes were chosen as a control group.

The confirmed diagnosis of cirrhosis was established based on a combination of results from the clinical examination, laboratory blood tests, abdominal ultrasound, and upper gastrointestinal endoscopy. Patients with decompensated cirrhosis (as evaluated by the presence of ascites or hepatic encephalopathy), previous or current variceal bleeding, or current treatment with beta blockers were excluded from the study.

All patients and controls were informed about the study and gave written consent forms after being explained that they would not be exposed to any harm or risk and that confidentiality would be ensured. The study protocol fulfilled the ethical guidelines of our institute, and official permission was obtained from the Radio Diagnosis Department of Ain Shams University Hospitals.

A full history and a physical examination were performed by the referring gastroenterologist clinician with measurements of body weight, height, body mass index (BMI), and blood pressure. Then, laboratory tests (hemogram, hepatic panel, serum albumin, etc.) followed by upper gastrointestinal endoscopy were done for all patients.

According to endoscopy results and esophageal varices evaluation, patients were classified into three groups, depending on the expanded Baveno VI criteria [6]. Group 1 included patients with no EV; group 2 included patients with low-risk EV (varices that had a thickness of less than 5 mm); and group 3 included patients with varices needing treatment (VNT): either large EV that had a thickness of more than 5 mm or varices displaying any signs of high risk of bleeding: red wales or cherry red spots). The patients in group 3 were then initiated on NSBB (propranolol) treatment according to the standard protocol by the referring gastroenterologist clinician (started by 20 mg orally twice a day and increased by 20 mg twice a day in steps every 3 days until maximum tolerated dose (or dose of 160 mg/day), with a target of 25% reduction in the resting heart rate, provided that the heart rate is ≥ 55 beats per minute and systolic pressure ≥ 90 mmHg, and follow-up was done after 3 months.

Depending on the clinical, laboratory, and radiological evaluations, we have measured some noninvasive indices for the patients that were suggested to evaluate the prognosis of liver cirrhosis, such as the Child–Pugh score [7], in addition to assessing the degree of liver fibrosis and predicting the presence and severity of EV as platelet count (× 10⁹/L)/splenic length (mm) ratio (PSR) and aspartate aminotransferase (IU/L)/platelet (× 10⁹/L) ratio index (APRI) [8].

Radiologic interventions

A radiological study was done for all 150 participants (120 cirrhotic patients and 30 healthy controls) within a maximum of 72 h from the previous laboratory and endoscopy evaluation of the patients and repeated for group 3 after 3 months of treatment with NSBB. This included abdominal ultrasound (highlighting the spleen length (SPL), portal vein diameter (PVD), as well as the existence of ascites, followed by liver and splenic stiffness elastography performed by a radiologist of at least 5 years of experience in elastography technique and blinded to the endoscopy results.

For elastography technique, the FibroScan Echosens 630 Expert (France) was used, which offers improved ergonomics, embedded ultrasound guidance system, intuitive user interface, touchscreen, advanced keyboard and an integrated barcode reader. FibroScan Echosens 630 Expert allowed VCTE examination for stiffness elastography through dedicated modules for both liver and spleen, based on 50 (for LS) and 100 (for SS) Hz shear wave frequencies coupled with an ultrasound localization system for these organs [5]. The study was performed in the early morning, while the participants had fasted for at least 4 h before the examination for proper results. The patients were positioned supine with maximum abduction of the corresponding arm (right for the liver and left for the spleen) and were asked to hold their breath for 5 s. The probe was positioned in the corresponding intercostal spaces and correctly visualized by ultrasound to take the measurement sites of each organ. Two separate sets of measurements for the liver and spleen (LS and SS) were carried out, respectively. Each set of measurements was repeated at least ten times, and the mean value was chosen for analysis. The quantitative stiffness values were calculated in kPa.

Statistical analysis

The Statistical Program for Social Science (SPSS) version 21 was used for the statistical analysis.

Results

The age, sex, and BMI were matched in the patients and control groups, while both ultrasonography (SPL and PVD) and elastography (LS and SS) parameters were significantly increased in cirrhotic patients compared to the controls (12.45 ± 1.51 versus 9.60 ± 0.85 cm for SPL, 10.48 ± 1.54 versus 9.60 ± 1.59 mm for PVD, 25.14 ± 9.84 versus 4.80 ± 1.05 kPa for LS, and 45.43 ± 12.13 versus 16.20 ± 1.91 kPa for SS).

On correlating liver and spleen stiffness with other parameters in cirrhotic patients, weak positive correlations were found between either LS or SS and BMI, but strong positive correlations were detected with other parameters, namely SPL and PVD, and also between liver and spleen stiffness (p > 0.01).

When comparing laboratory tests in cirrhotic patients with and without varices, there were significantly lower levels of hemoglobin (HB), total leukocyte count (TLC), platelet count, and serum albumin; and higher levels of total serum bilirubin (TSB), aspartate aminotransferase (AST), and international normalized ratio (INR); while alanine aminotransferase (ALT) levels were comparable in both groups. On the other hand, noninvasive scores (Child–Pugh Score, PSR, and APRI), ultrasonography, and elastography parameters were significantly increased (except PSR decreased) in cirrhotic patients with varices compared to those without varices (Table 1 and Fig. 1) and in patients with large varices compared to those with small varices (Fig. 2).

Table 1. Comparison of the demographic characteristics, laboratory, ultrasonography, and elastography parameters of cirrhotic patients with and without esophageal varices

Parameter	Group I (No varices) (n = 48)	Group II & III (With varices) (n = 72)	p value
Age (year)	54.17 ± 11.21	55.46 ± 10.69	˃ 0.05 (NS)
Sex
Male	26	38	˃ 0.05 (NS)
Female	22	34
BMI (kg/m2)	26.44 ± 4.05	26.46 ± 4.16	˃ 0.05 (NS)
Laboratory
HB (gm/dl)	12.78 ± 1.00	11.80 ± 1.33	˃ 0.01 (HS)
TLC (k/ul)	6.10 ± 0.35	5.79 ± 0.85	˃ 0.01 (HS)
Platelet count (k/ul)	176.79 ± 44.66	137.03 ± 31.81	˃ 0.01 (HS)
Albumin (g/dl)	3.66 ± 0.28	3.27 ± 0.28	˃ 0.01 (HS)
TSB (mg/dl)	1.05 ± 0.24	1.63 ± 0.47	˃ 0.01 (HS)
AST (IU/L)	48.00 ± 8.06	52.07 ± 8.94	˃ 0.01 (HS)
ALT (IU/L)	34.50 ± 7.50	35.96 ± 8.93	˃ 0.05 (NS)
INR	1.16 ± 0.15	1.41 ± 0.22	˃ 0.01 (HS)
Noninvasive scores
Child–Pugh score	5.73 ± 0.71	6.61 ± 1.10	˃ 0.01 (HS)
PSR	1623.71 ± 522.45	1072.60 ± 332.37	˃ 0.01 (HS)
APRI	0.74 ± 0.27	1.03 ± 0.41	˃ 0.01 (HS)
Ultrasonography
Spleen length (cm)	11.52 ± 1.17	13.08 ± 1.39	˃ 0.01 (HS)
Portal vein diameter (mm)	9.75 ± 1.16	10.96 ± 1.58	˃ 0.01 (HS)
Elastography
Liver stiffness (kPa)	19.21 ± 4.02	29.10 ± 10.58	˃ 0.01 (HS)
Spleen stiffness (kPa)	36.10 ± 5.46	51.64 ± 11.36	˃ 0.01 (HS)

BMI: body mass index, HB: hemoglobin, TLC: total leukocyte count, TSB: total serum bilirubin, AST: aspartate aminotransferase, ALT: alanine aminotransferase, INR: international normalized ratio, PSR: platelet spleen ratio, APRI: AST/platelet ratio index. p > 0.05: insignificant (NS), and p < 0.01: highly significant (HS)

Fig. 1 [Images not available. See PDF.]

Comparison of liver and spleen stiffness (LS and SS in KPa) between group 1 (no varices) and both group 2 and 3 (with varices)

Fig. 2 [Images not available. See PDF.]

Comparison of liver and spleen stiffness (LS and SS in KPa) between group 2 (small varices) and group 3 (large varices)

On comparing the three groups of cirrhotic patients diagnosed by endoscopy study (group 1 with no varices, group 2 with small varices, and group 3 with large varices, needing treatment) by one-way analysis of variance (ANOVA), we found significant differences between the 3 groups as regards all laboratory tests (except ALT), noninvasive scores, ultrasonography, and elastography parameters. A tendency toward increasing both LS and SS levels was observed with increasing severity of varices (Table 2 and Figs. 3, 4, 5). In addition, patients with esophageal varices (either small or large) had significantly higher average liver and spleen elastography values than those with no varices (p < 0.01), while those with varices needing treatment had an even greater difference versus patients with no or small varices (p < 0.01).

Table 2. Comparison of the demographic characteristics, clinical, laboratory, ultrasonography, and elastography parameters of cirrhotic patients with different grades of esophageal varices

Parameter	Group I (No varices) (n = 48)	Group II (Small varices) (n = 42)	Group III (Large varices) (n = 30)	p value
Age (year)	54.17 ± 11.21	55.79 ± 10.80	55 ± 10.69	˃ 0.05 (NS)
Sex
Male	26	22	16	˃ 0.05 (NS)
Female	22	20	14
BMI (kg/m2)	26.44 ± 4.05	26.53 ± 4.28	26.37 ± 4.06	˃ 0.05 (NS)
Laboratory
HB (gm/dl)	12.78 ± 1.00	12.45 ± 1.12	10.88 ± 1.04	˃ 0.01 (HS)
TLC (k/ul)	6.10 ± 0.35	5.88 ± 0.89	5.67 ± 0.79	˃ 0.05 (S)
Platelet count (k/ul)	176.79 ± 44.66	148.55 ± 29.47	120.9 ± 28.09	˃ 0.01 (HS)
Albumin (g/dl)	3.66 ± 0.28	3.38 ± 0.24	3.10 ± 0.26	˃ 0.01 (HS)
TSB (mg/dl)	1.05 ± 0.24	1.40 ± 0.38	1.95 ± 0.39	˃ 0.01 (HS)
AST (IU/L)	48.00 ± 8.06	50.62 ± 8.93	54.10 ± 8.70	˃ 0.05 (S)
ALT (IU/L)	34.50 ± 7.50	35.00 ± 9.78	37.30 ± 7.53	˃ 0.05 (NS)
INR	1.16 ± 0.15	1.30 ± 0.18	1.45 ± 0.17	˃ 0.01 (HS)
Noninvasive scores
Child–Pugh Score	5.73 ± 0.71	6.12 ± 0.89	7.30 ± 0.99	˃ 0.01 (HS)
PSR	1623.71 ± 522.45	1216.43 ± 311.5	878.03 ± 249.17	˃ 0.01 (HS)
APRI	0.74 ± 0.27	0.90 ± 0.28	1.22 ± 0.49	˃ 0.01 (HS)
Ultrasonography
Spleen length (cm)	11.52 ± 1.17	12.41 ± 1.14	14.00 ± 11.17	˃ 0.01 (HS)
Portal vein diameter (mm)	9.75 ± 1.16	10.41 ± 1.33	11.73 ± 1.60	˃ 0.01 (HS)
Elastography
Liver stiffness (kPa)	19.21 ± 4.02	23.88 ± 6.28	36.40 ± 11.11	˃ 0.01 (HS)
Spleen stiffness (kPa)	36.10 ± 5.46	45.60 ± 8.51	60.10 ± 9.31	˃ 0.01 (HS)

BMI: body mass index, HB: hemoglobin, TLC: total leukocyte count, TSB: total serum bilirubin, AST: aspartate aminotransferase, ALT: alanine aminotransferase, INR: international normalized ratio, PSR: platelet spleen ratio, APRI: AST/platelet ratio index. p > 0.05: insignificant, p < 0.05: significant, p < 0.01: highly significant

Fig. 3 [Images not available. See PDF.]

A male patient 52-year-old with no varices A. FibroScan for liver stiffness revealed kPa = 21.4 B. FibroScan for splenic stiffness revealed Kpa = 39.2

Fig. 4 [Images not available. See PDF.]

A male patient 59-year-old with small varices A. FibroScan for liver stiffness revealed kPa = 25.5 B. FibroScan for splenic stiffness revealed Kpa = 51.6

Fig. 5 [Images not available. See PDF.]

A male patient 62-year-old with large varices A. FibroScan for liver stiffness revealed kPa = 32.4 B. FibroScan for splenic stiffness revealed Kpa = 65.3

For LS, AUROC values were good for the detection of any degree of esophageal varices (AUROC = 0.815, 95% CI = 0.740–0.889, p < 0.001) and for distinguishing patients with VNT from those with no or small varices (AUROC = 0. 886, 95% CI = 0. 821–0.951, p < 0.001). Cutoff values for prediction of EV were 20.5 kPa (sensitivity 81.9% and specificity 66.7%) and 28.5 kPa for large varices (sensitivity 70% and specificity 87.8%). On the other hand, SS was excellent for both detection of any degree of esophageal varices (AUROC = 0.888, 95% CI = 0. 832–0.945, p < 0.001) and for distinguishing patients with VNT (AUROC = 0. 929, 95% CI = 0. 882–0.976, p < 0.001) (Fig. 6), with cutoff values for prediction of EV of 36.5 kPa (sensitivity 93.1% and specificity 64.6%) and 47.5 kPa for large varices (sensitivity 90% and specificity 77.8%).

Fig. 6 [Images not available. See PDF.]

Comparison of ROC curves for liver and spleen stiffness: (A) patients with varices (small and large) versus no varices group; (B) large varices group versus no and small varices groups

Compared with the other noninvasive scoring, ultrasonography parameters, and liver elastography, the spleen stiffness, as shown in the multivariate analysis and ROC curves, was the best parameter for predicting the presence of EV in general and for large varices needing treatment specifically (Table 3).

Table 3. Comparison of the noninvasive scoring, ultrasonography, and elastography parameters for prediction of the presence of any esophageal varices and for large varices

Parameter	Prediction of any esophageal varices AUROC (95% CI)	Prediction of large varices AUROC (95% CI)
Child–Pugh Score	0.729 (0.641–0.818)	0.843 (0.764–0.921)
PSR	0.193 (0.114–0.271)	0.133 (0.066–0.201)
APRI	0.732 (0.640–0.823)	0.771 (0.677–0.865)
Spleen length	0.798 (0.719–0.876)	0.880 (0.817–0.943)
Portal vein diameter	0.716 (0.625–0.808)	0.790 (0.703–0.877)
Liver stiffness	0.815 (0.740–0.889)	0.886 (0.821–0.951)
Spleen stiffness	0.888 (0.832–0.945)	0.929 (0.882–0.976)

AUROC: area under the receiver operating curve, CI: confidence interval, PSR: platelet spleen ratio, APRI: AST/platelet ratio index

Reassessment of the noninvasive scoring, ultrasonography, and elastography parameters in group 3 patients with VNT after receiving NSBB (propranolol) for 3 months showed non-significant changes in the three noninvasive scores studied and in splenic length, while PVD was significantly decreased post-treatment in comparison to pre-treatment measurement (p < 0.05). Also, a significant decrease in LS post-treatment compared to pre-treatment measurements (35.30 ± 10.76 versus 36.40 ± 11.11 kPa) was found (p < 0.05). On the other hand, SS showed a highly significant decrease in post-treatment compared to pre-treatment measurements (56.80 ± 8.93 versus 60.10 ± 9.31 kPa, p < 0.01) (Table 4). It is worthy of mention that no serious adverse events were noted after taking NSBB treatment during this 3-month follow-up period.

Table 4. Comparison of the noninvasive scoring, ultrasonography, and elastography parameters of 30 cirrhotic patients with varices needing treatment, pre- and post-therapy with B blockers

Parameter	Pre-treatment	Post-treatment	P value
Child–Pugh score	7.30 ± 0.99	7.17 ± 0.99	˃ 0.05 (NS)
PSR	878.03 ± 249.17	898.10 ± 203.85	˃ 0.05 (NS)
APRI	1.22 ± 0.49	1.14 ± 0.30	˃ 0.05 (NS)
Spleen length	14.00 ± 1.17	13.95 ± 1.20	˃ 0.05 (NS)
Portal vein diameter	11.73 ± 1.60	11.40 ± 1.40	˃ 0.05 (S)
Liver stiffness	36.40 ± 11.11	35.30 ± 10.76	˃ 0.05 (S)
Spleen stiffness	60.10 ± 9.31	56.80 ± 8.93	˃ 0.01 (HS)

AUROC: area under the receiver operating curve, CI: confidence interval, PSR: platelet spleen ratio, APRI: AST/platelet ratio index. p > 0.05: insignificant, p < 0.05: significant, p < 0.01: highly significant

Discussion

In the present study, we tried to assess the clinical use of the new FibroScan Echosens Expert 630 elastography for measurement of LS and SS and compare their usefulness in prediction of EV in patients with portal hypertension. In addition, we attempted to evaluate the role of these parameters in monitoring the response to beta blocker treatment in these cases. We have found that both ultrasonography (SPL and PVD) and elastography (LS and SS) parameters were significantly increased in cirrhotic patients compared to the controls, with strong positive correlations between either LS or SS and both SPL and PVD and between LS and SS, which is consistent with previous studies [1, 9].

As regards laboratory tests in cirrhotic patients with and without varices, Kim et al. [10] found lower platelet counts and albumin, higher bilirubin levels, and prolonged prothrombin time in patients with varices compared to those without varices. For noninvasive scores, lower PSR, a higher Child–Pugh Score, and equivalent APRI were found in their patients with and without varices, which matched our results except for the higher APRI in our study, which could be attributed to higher levels of AST in cirrhotic patients with varices. In addition, Colecchia et al. [11] found that the SPL, LS, and SS were significantly higher in patients with varices compared to those without varices, which supports our results.

On comparing cirrhotic patients with no EV, small EV, and large EV groups together, significant differences were found in laboratory, ultrasonography, and elastography parameters in previous studies [12, 13], as was noted in the present study. They also reported a tendency toward increasing both LS and SS levels with increasing severity of varices [2], which is emphasized by our finding that patients with EV (either small or large) had significantly higher average LS and SS values than those with no varices, while those with VNT had an even greater difference versus patients with no or small varices.

For studying the diagnostic performance of the noninvasive scores, ultrasonography, and elastography parameters for the detection of any degree of EV and for distinguishing patients with VNT from those with no or small varices, we compare the AUROC values for each parameter, which indicated that SS was the best one, followed by LS, and then other parameters in both domains. Cutoff values of LS for prediction of EV were 20.5 kPa (sensitivity 81.9% and specificity 66.7%) and 28.5 kPa for large varices (sensitivity 70% and specificity 87.8%), while those for SS were 36.5 kPa (sensitivity 93.1% and specificity 64.6%) and 47.5 kPa (sensitivity 90% and specificity 77.8%), respectively.

Actually, previous studies showed more or less equivalent cutoff values for prediction of EV and VNT; the larger the size of varices, the higher the risk of bleeding [2]. Both LS and SS correlate well with HVPG, with thresholds of LS > 20–25 kPa and SS > 40–45 kPa indicating a high likelihood of CSPH that can lead to EV [1]. Saad et al. [12] suggested a cutoff value of LS for prediction of EV of 29.7 kPa (sensitivity 95% and specificity 67%) and for predicting large varices of 38.2 kPa (sensitivity 100% and specificity 77.3%), which are higher than our results, while Sporea et al. [13] suggested a cutoff value of ˃ 29.5 kPa for predicting significant EV (sensitivity 77.5% and specificity 96.9%), which is comparable to our findings. Also, Pu et al. in a meta-analysis on the accuracy of LS for detection of EV in cirrhotic patients with a threshold of > 20 kPa for the presence of EV and > 30 kPa for large varices concluded that FibroScan could be considered a better noninvasive test for EV and significant EV in different histological stages and aetiologies of hepatic cirrhosis [14].

Regarding SS measurement, initially a value of 56 kPa was suggested to be associated with CSPH and correlate well with HVPG [1]. Also, Al-Dahshan reported that SS at 50.4 kPa was the best cutoff value for prediction of varices with a sensitivity of 81.2% and specificity of 73.2% [9]. However, as evidence has accumulated, it appears that lower thresholds of ≤ 41–46 kPa are able to rule out the presence of CSPH and high-risk varices [1, 11], as was found in our results.

The discrepancy in cutoff values found in different studies may be related to the different demographics and characteristics of the patients, the aetiology of liver cirrhosis, as well as the type of FibroScan machines used [13, 15]. These high AUROC values for LS and specifically SS, with higher sensitivity and specificity of cut values detected in our study with the use of a new spleen-dedicated module (100 Hz) machine, contradict the previous belief that transient elastography could be a valuable tool in the diagnosis of cirrhosis but cannot replace endoscopy for variceal screening [16, 17].

Recently, in 2021, according to EASL guidelines published by the European Association for the Study of the Liver, LS by TE < 20 kPa and platelet count > 150 G/L (Baveno VI criteria) are validated tools to rule out high-risk varices and avoid endoscopic screening, and SS can be used as an additional tool to refine the risk of high-risk varices in chronic liver diseases [18]. The superiority of SS over LS measurement in the detection of tissue elasticity, in particular, can be related to many factors that affect LS measurements, such as obesity, venous congestion, and mechanical cholestasis of the liver, in addition to local and systemic inflammatory cell infiltrations in the liver more than in the spleen, which is less biased by inflammation than LS [1, 19, 20].

Reassessment of the noninvasive scoring, ultrasonography, and elastography parameters in group 3 patients with large varices needing treatment after receiving NSBB (propranolol) for 3 months showed non-significant changes in the 3 noninvasive scores studied and in SPL, while PVD and LS were significantly decreased post-treatment in comparison to pre-treatment measurement. On the other hand, SS showed a highly significant decrease in post-treatment measurement compared to pre-treatment measurement, which indicates that it is the most sensitive tool for follow-up of the response to treatment for these patients.

In fact, most of the initial studies for measuring response to BB treatment in these patients were dependent on measuring HVPG level [21], and after starting to use elastography techniques (LS mainly and SS later), they found that these parameters correlated with HVPG in the initial diagnosis but were not appropriate for follow-up and monitoring of these cases [3, 22]. However, by using MR elastography, administration of BB was followed by a significantly decreased SS but had no consistent effect on LS [23].

Because SS is a direct and dynamic surrogate of PH that has the potential to assess an improvement in PH as a surrogate marker for clinical outcomes, SS may be a superior tool to LS and other parameters, as shown in our study, for monitoring therapy response in clinical trials [1]. In a recent review article (2023), SS alone or combined with other tests was recommended for predicating decompensating cirrhotic patients and estimating the response to treatment with BB [24–26].

There are some limitations of the current study, which include a lack of comparison of transient elastography with HVPG measurement, a lack of consideration for the aetiology of cirrhosis, which requires a large number of patients in addition to a small number of patients with VNT, and a short period of follow-up of response to treatment.

Conclusions

Screening of cirrhotic patients for the development of esophageal varices by TE (for LS and SS) using the new FibroScan 630 Expert machine seems to be an optimal method in clinical practice and superior to other noninvasive tests in the diagnosis and follow-up of these patients. So, these parameters, especially SS, can assist in the early detection of esophageal varices, the evaluation of their severity, and as prognostic tools in the follow-up of their NSBB treatment response.

Acknowledgements

The authors thank all the study participants for their patience and support.

Author contributions

All authors contributed to the study’s conception and design. Material preparation, data collection, and analysis of results were performed by all authors. The first draft of the manuscript was written by Ahmed Elshimy, and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

Funding

No funds, grants, or other support was received.

Availability of data and materials

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Declarations

Ethical approval and consent to participate

This study was approved by the Research Ethics Committee of the Faculty of Medicine, Ain Shams University in Egypt on 12/10/2023; Reference Number of approval: FWA000017585. FMASU R285/2023. All patients and controls were informed about the study, and written informed consents were obtained from them after explanation that they would not be exposed to any harm or risk and to ensure confidentiality.

Consent for publication

The authors affirm that human research participants provided informed consent for publication of the images in Figures.

Competing interests

The authors have no relevant financial or non-financial interests to disclose.

Abbreviations

AST

Aspartate aminotransferase

APRI

Aspartate aminotransferase/platelet ratio index

BB

Beta blockers

BMI

Body mass index

CSPH

Clinically significant portal hypertension

EV

Esophageal varices

HVPG

Hepatic venous pressure gradient

LS

Liver stiffness

NSBB

Non-selective beta blockers

PSR

Platelet count/splenic length ratio

PH

Portal hypertension

PVD

Portal vein diameter

SPL

Spleen length

SS

Spleen stiffness

SPSS

Statistical Program for Social Science

TE

Transient elastography

VNT

Varices needing treatment

VCTE

Vibration-controlled transient elastography

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References

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