Utility of Non Invasive Tests to detect any varices in patients with compensated advanced chronic liver disease

Background and Aims: Baveno-VII recommends treatment of clinically significant portal hypertension (CSPH) in patients with compensated advanced chronic liver disease (cACLD). Apart from hepatic venous pressure gradient, the presence of esophageal varices (EVs) irrespective of their size remains the most definitive evidence of CSPH. While non-invasive tools (NITs) accurately detect patients who have varices needing treatment (VNTs), we evaluated if these tools can be used to triage patients with regard to the risk of having any EVs. Methods: Patients with reliable liver stiffness measurement (LSM), blood parameters, and esophago-gastroduodenoscopy were included from a large prospectively recruited multinational cohort of cACLD of different aetiologies. Performance of Baveno-VI (LSM > 20kPa or platelet < 150,000/mm3), expanded Baveno-VI criteria (LSM > 25kPa or platelet < 110,000/mm3) and was assessed to detect VNTs as well as any EVs. This performance was compared with a recently given Baveno VII-based criteria (LSM > 15 kPa and platelet < 150000/mm3) for detecting possible CSPH to evaluate its utility to detect any EVs. Result: Patients with cACLD (N=1200) of predominantly viral etiology (Hepatitis B virus:269, hepatitis C virus: 564, non-alcoholic fatty liver disease: 145, alcoholic liver disease: 130, autoimmune hepatitis: 28, and others: 64) were included. Any esophageal varices (EVs) and VNTs were present in 514 (42.8%) and 70(5.8%) patients respectively. BavenoVI expanded BavenoVI and BavenoVII based on possible CSPH criteria missed 29/514 (5.6%), 115/514 (22.4%), 19/514 (3.7%) patients with any EVs respectively whereas they misclassified 517/686 (75.4%), 211/686(30.8%) and 598/686 (87.4%) patients with no EVs as high risk for harboring EVs. Baveno-VI expanded Baveno-VI and possible CSPH criteria missed 3/70 (4.3%) and 15/70 (21.4%) and 0/70 (0%) VNTs respectively. Conclusion: Both original Baveno-VI-based VNTs detection criteria and Baveno-VII-based possible CSPH detection criteria are highly sensitive but not specific to detect any EVs in patients with cACLD.