Liver stiffness assessment as an alternative to hepatic venous pressure gradient for predicting rebleed after acute variceal bleed: A proof‐of‐concept study

• Published in: JGH open Vol. 5; no. 1; pp. 73 - 80
• Main Authors: Agarwal, Samagra, Sharma, Sanchit, Anand, Abhinav, Gunjan, Deepak, Saraya, Anoop
• Format: Journal Article
• Language: English
• Published: Melbourne Wiley Publishing Asia Pty Ltd 01.01.2021; John Wiley & Sons, Inc; Wiley
• Subjects: cirrhosis; Drug therapy; Endoscopy; Hypertension; liver; Liver cancer; Liver cirrhosis; Original; portal hypertension; Statistical analysis; varices; varices; portal hypertension; liver; cirrhosis
• ISSN: 2397-9070; 2397-9070
• DOI: 10.1002/jgh3.12449

Background and Aim Hepatic venous pressure gradient (HVPG), although an important determinant in predicting rebleeding after an episode of acute variceal bleed (AVB), is seldom utilized in clinical practice. We aimed to study the role of liver stiffness measurement (LSM) after variceal bleeding as a potential noninvasive predictor of rebleed. Methods This was a post hoc analysis of clinical trial of patients undergoing HVPG (postbleed HVPG) and LSM (postbleed LSM) assessment within 3–5 days of index AVB. HVPG response was assessed after 4 weeks of pharmacotherapy. Comparative assessment of long‐term rebleeding rates stratified using postbleed LSM, postbleed HVPG, and HVPG response was performed. Decision curve analysis (DCA) was conducted to identify the most appropriate tool for routine use. Results Long‐term clinical and HVPG response data were available for 48 patients post‐AVB, of whom 45 patients had valid postbleed LSM. Rebleeding occurred in 13 (28%) patients over a median follow‐up of 4 years with no early rebleeds. Postbleed LSM >30 kPa and baseline HVPG >15 mm Hg were optimal cutoffs for identifying patients at high risk of rebleeding. Time‐dependent receiver operating characteristic curves and competing risk analysis accounting for death showed similar discriminative values for all three stratification tools. At usual risk thresholds, HVPG response had maximum benefit on DCA followed by postbleed LSM. On DCA, 50–60 additional HVPGs were required to detect one additional patient at high risk of rebleed. Conclusion Liver stiffness measurement during AVB can potentially be used as an alternative to portal pressure indices in decompensated cirrhosis to identify those at high risk of late‐onset rebleed. Liver stiffness measure during the period of acute variceal bleeding predicted rebleeding comparable to hepatic venous pressure gradient measurement and its subsequent response.