Low Risk of Variceal Bleeding in Patients With Cirrhosis After Variceal Screening Stratified by Liver/Spleen Stiffness

Abstract

We previously demonstrated the possible noninferiority of a screening strategy for varices guided by liver and spleen stiffness measurement (LSSM) compared to universal endoscopic screening in detecting clinically significant varices in patients with cirrhosis. We now report the long‐term outcome of the patients recruited in this trial for incident variceal bleeding and other hepatic events. This was a prospective follow‐up study of a noninferiority, open‐label, randomized controlled trial (NCT02024347) of 548 adult patients with known chronic liver diseases, radiological evidence of liver cirrhosis, and compensated liver function. The primary outcome of this prospective study was incident variceal bleeding confirmed with upper endoscopy. Between October 2013 and June 2016, 548 patients were randomized to an LSSM arm (n = 274) and a conventional arm (n = 274). Patients in both study arms were predominantly middle‐aged men (mean age 59 years, male 68.9%) with viral hepatitis–related cirrhosis (85%). Upper endoscopy examination was performed in 127 (46.4%) patients in the LSSM arm and 263 (96.0%) in the conventional arm. During the follow‐up period of 41.3 ± 12.6 months, 12/274 patients in the LSSM arm (4.4%) and 11/274 in the conventional arm (4.0%) developed incident variceal bleeding (log‐rank test P = 0.724). The incident rates of hepatic events were also similar in both arms (P = 0.327). Conclusions: Patients with liver cirrhosis who had undergone LSSM‐guided variceal screening were at similarly low risk of incident variceal bleeding in the future; patients with cirrhosis may first have LSSM measured to save up to half of the upper endoscopy examinations.

East Asia expert opinion on treatment initiation for chronic hepatitis B

“…According to the EASL clinical practice guideline, 3 31 The severity of fibrosis, as determined by histology and non-invasive tests, is highly predictive of HCC, portal hypertension, cirrhotic complications and liver-related mortality. [32][33][34][35][36] Therefore, current regional guidelines support anti-viral treatment in patients with significant fibrosis. [2][3][4] Traditionally, liver biopsy is the primary means to diagnose sig- Liver stiffness may be increased in CHB patients with mild to moderate ALT elevation, prompting some clinicians to adjust the optimal cut-offs according to the ALT level.…”

Peculiarities of Cirrhosis due to Nonalcoholic Steatohepatitis (NASH)

“…28 Recent prospective data have also highlighted the utility of liver-to-spleen stiffness measurements using TE (n ¼ 274) for variceal screening in compensated cirrhosis compared with conventional endoscopy (n ¼ 274). 29 In doing so, the group from Hong Kong highlighted that the number of screening endoscopies could be reduced by 50% using liver-tospleen stiffness measurements. However, as 85% of the cohort had viral hepatitis this would require further validation in patients with NASH cirrhosis.…”

Reply:

“…We would like to express our gratitude to Dr. Lo for his insightful comments on our study . We fully acknowledge the role of endoscopic examinations in addition to variceal screening, such as to detect other upper gastrointestinal pathologies (e.g., peptic ulcer, portal hypertensive gastrolatry, etc.)…”