Computed tomography vs liver stiffness measurement and magnetic resonance imaging in evaluating esophageal varices in cirrhotic patients: A systematic review and meta-analysis

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Meta-Analysis

World J Gastroenterol. May 14, 2020; 26(18): 2247-2267
Published online May 14, 2020. doi: 10.3748/wjg.v26.i18.2247

Table 1 Characteristics of articles using computed tomography imaging to diagnose esophageal varices

Ref.	Study design	Total patients	Mean age (yr)	Male (%)	Etiology (%)	Child-Pugh class (%)	CT scanner	Interval between CT and endoscopy	Presence of EV
Ref.	Study design	Total patients	Mean age (yr)	Male (%)	Etiology (%)	Child-Pugh class (%)	CT scanner	Interval between CT and endoscopy	TP	FP	FN	TN
Cansu et al[33], 2014	Prospective	50	56.8	54	HBV (40.0); HCV (30.0); Biliary (6.0); HBV + HCV (4.0); Alcohol (4.0%); Others (16.0)	A (52.0); B (36.0); C (12.0)	16-slice	Within 4 wk	33	2	0	15
	Prospective	42	56.2	69	HBV (45.2); HCV (23.8); Alcohol (4.8); HBV + HCV (2.4); Biliary (2.4); Others (21.4)	A (38.1); B (31.0); C (31.0)	16-slice	Within 4 wk	25	3	8	6
Deng et al[34], 2016	Retrospective	52	55.4	63.5	Alcohol (30.8); HBV (25.0); HBV + Alcohol (9.6); HCV (3.8); HBV + HCV (1.9); Others (28.9)	A (49.0); B (39.2); C (11.8)	NR	NR	43	2	2	5
Desso-uky et al[35], 2013	Prospective	137	58.7	53.3	HCV (67.9); HBV (19.7); HBV + HCV (10.2); Steatohepatitis (2.2)	A (55); B (31); C (14)	16-slice	Within 24 h	89	1	1	46
Elalfy et al[36], 2016	Retrospective	124	56.5	52	HCV (100)	A (62.9); B (37.1)	16-slice	NR	70	4	4	46
Elkammash et al[37], 2015	NR	112	51.4	68.8	HBV (46); HCV (44); Schisto-somiasis (10)	NR	64-slice	Within 2 wk	97	0	2	13
Elkammash et al[37], 2015	NR	112	51.4	68.8	HBV (46); HCV (44); Schisto-somiasis (10)	NR	64-slice	Within 2 wk	99	0	0	13
Jiang et al[38], 2015	NR	89	57	64	HBV (71.9); Alcohol (11.2); HCV (7.9); Biliary (5.6); Drug (1.1); Unknown (2.3)	NR	64-slice	NR	58	3	8	20
Kim et al[40], 2020	Retrospective	104	59	74	HBV (72.1); HCV (12.5); Alcohol (6.7); Others (8.7)	A (41.3); B (30.8); C (27.9)	16 or 64-slice	Within 4 wk	180	9	8	11
									169	9	19	11
									172	15	16	5
Kim et al[41], 2007	Prospective	90	54.8	72.2	HBV (73.3); HCV (21.1); Alcohol (2.2); Others (3.3)	A (81.1); B (18.9)	16-slice	Within 4 h	50	15	3	22
									47	12	6	25
									46	13	7	24
									46	8	7	29
Kim et al[42], 2007	Retrospective	67	56.2	58.2	HCV (35.8); HBV (22.4); Alcohol (22.4); HBV + HCV (9.0); Others (10.4)	A (23.9); B (37.3); C (38.8)	NR	Within 4 wk	29	6	13	19
Kim et al[42], 2007	Retrospective	67	56.2	58.2		A (23.9); B (37.3); C (38.8)	NR	Within 4 wk	27	3	15	22
Lipp et al[43], 2011	Retrospective	299	55.2	64.9	NR	NR	4 or 16 or 64-slice	Within 12 wk	54	24	7	52
Lipp et al[43], 2011	Retrospective	299	55.2	64.9	NR	NR	4 or 16 or 64-slice	Within 12 wk	41	17	30	77
Moftah et al[44], 2014	NR	54	56.8	74.1	NR	NR	8-slice	NR	48	0	2	4
Perri et al[45], 2008	Retrospective	101	NR	63.4	Viral (21.8); Alcohol (18.8); Biliary (17.8); NASH (14.9); Others (26.7)	A (44.6); B (39.6); C (15.8)	4-slice or higher	2 d¹	73	10	6	12
Perri et al[45], 2008	Retrospective	101	NR	63.4		A (44.6); B (39.6); C (15.8)	4-slice or higher	2 d¹	68	12	11	10
Wu et al[46], 2009	Prospective	50	57.7	60	HBV (76); Autoimmune (2); Others (22)	A (26.0); B (62.0); C (12.0)	16-slice	Within 4 wk	39	3	2	6
Wu et al[46], 2009	Prospective	50	57.7	60	HBV (76); Autoimmune (2); Others (22)	A (26.0); B (62.0); C (12.0)	16-slice	Within 4 wk	40	5	1	4
Yu et al[47], 2011	Retrospective	109	55.9	55	HCV (46.8); Alcohol (17.4); HBV (6.4); Others (29.4)	NR	16 or 64-slice	NR	50	10	12	37
									50	12	12	35
									49	24	13	23
									47	17	15	30
Zhao et al[48], 2016	Retrospective	143	52.39	67.1	HBV (70.6); Alcohol (11.2); Autoimmune (4.9); HCV (3.5); Biliary (3.5); Others (6.3)	A (37.8); B (33.6); C (28.7)	64-slice	3.4 d²	11	3	1	27
Zhao et al[48], 2016	Retrospective	143	52.39	67.1		A (37.8); B (33.6); C (28.7)	64-slice	3.4 d²	2
Zhu et al[49], 2009	Retrospective	127	45.2	75.6	HBV (74.8); Alcohol (10.2); HCV (4.7); Others (10.2)	A (37.8); B (37.0); C (25.2)	4-slice	Within 4 wk	72	15	14	26
Zhu et al[49], 2009	Retrospective	127	45.2	75.6	HBV (74.8); Alcohol (10.2); HCV (4.7); Others (10.2)	A (37.8); B (37.0); C (25.2)	4-slice	Within 4 wk	67	11	19	30

¹Median.

²Mean. NR: Not reported; HBV: Hepatitis B virus; HCV: Hepatitis C virus; NASH: Nonalcoholic steatohepatitis; CT: Computed tomography; EV: Esophageal varices; TP: True positive; FP: False positive; FN: False negative; TN: True negative.

Table 2 Characteristics of articles using computed tomography imaging to predict HREV

Ref.	Study design	Total patients	Mean age (yr)	Male (%)	Etiology (%)	Child-Pugh class (%)	CT scanner	Cut-off value (mm)	Interval between CT and endoscopy	Presence of HREV
Ref.	Study design	Total patients	Mean age (yr)	Male (%)	Etiology (%)	Child-Pugh class (%)	CT scanner	Cut-off value (mm)	Interval between CT and endoscopy	TP	FP	FN	TN
Deng et al[34], 2016	Retrospective	52	55.4	64	Alcohol (30.8); HBV (25.0); HBV + Alcohol (9.6); HCV (3.8); HBV + HCV (1.9); Others (28.9)	A (49.0); B (39.2); C (11.8)	NR	EVD 3.9	NR	35	4	4	9
Dessouky et al[35], 2013	Prospective	137	58.7	53	HCV (67.9); HBV (19.7); HBV + HCV (10.2); Steato-hepatitis (2.2)	A (55); B (31); C (14)	16-slice	EVD 3.0	Within 24 h	38	0	0	99
Elalfy et al[36], 2016	Retrospective	124	56.5	52	HCV (100)	A (62.9); B (37.1)	16-slice	PVD 12.5	NR	33	49	13	29
Kim et al[39], 2008	Retrospective	110	61	74	HBV (60.9); HCV (29.1) Alcohol (6.4); HBV + HCV (1.8); Others (1.8)	A (63.6); B (26.4); C (10.0)	16-slice	EVD 2.0	8.2 d¹	123	15	9	61
										113	2	19	59
										115	15	17	61
Kim et al[40], 2020	Retrospective	104	59	74	HBV (72.1); HCV (12.5); Alcohol (6.7); Others (8.7)	A (41.3); B (30.8); C (27.9)	16 or 64-slice	EVD 2.0	Within 4 wk	34	3	3	70
										36	10	1	63
										32	4	5	69
Kim et al[41], 2007	Prospective	90	54.8	72	HBV (73.3); HCV (21.1); Alcohol (2.2); Others (3.3)	A (81.1); B (18.9)	16-slice	Grade 2 and Grade 3³	Within 4 h	28	11	2	49
										28	5	2	55
										27	9	3	51
										27	2	3	58
Kim et al[42], 2007	Retrospective	67	56.2	58	HCV (35.8); HBV (22.4); Alcohol (22.4); HBV + HCV (9.0); Others (10.4)	A (23.9); B (37.3); C (38.8)	NR	EVD 3.0	Within 4 wk	11	9	1	46
Kim et al[42], 2007	Retrospective	67	56.2	58		A (23.9); B (37.3); C (38.8)	NR	EVD 3.0	Within 4 wk	11	9	1	46
Lipp et al[43], 2011	Retrospective	299	55.2	65	NR	NR	4 or 16 or 64-slice	EVD 4.0	Within 12 wk	18	11	12	96
Lipp et al[43], 2011	Retrospective	299	55.2	65	NR	NR	4 or 16 or 64-slice	EVD 4.0	Within 12 wk	12	4	22	127
Perri et al[45], 2008	Prospective	101	NR	63	Viral (21.8); Alcohol (18.8); Biliary (17.8); NASH (14.9); Others (26.7)	A (44.6); B (39.6); C (15.8)	4-slice or higher	EVD 5.0	2 d²	23	5	18	55
Perri et al[45], 2008	Prospective	101	NR	63		A (44.6); B (39.6); C (15.8)	4-slice or higher	EVD 5.0	2 d²	27	8	14	52
Yu et al[47], 2011	Retrospective	109	55.9	55	HCV (46.8); Alcohol (17.4); HBV (6.4); Others (29.4)	NR	16 or 64-slice	EVD 2.0	NR	25	24	1	59
										25	18	1	65
										23	41	3	42
										23	17	3	66

¹Mean.

²Median.

³Grade 2: Varices show beaded appearance; Grade 3: Varices run in oblique course and are tortuous with tumorlike appearance. EVD: Esophageal varices diameter; NR: Not reported; PVD: Portal vein diameter; HBV: Hepatitis B virus; HCV: Hepatitis C virus; NASH: Nonalcoholic steatohepatitis; CT: Computed tomography; HREV: High-bleeding-risk esophageal varices; TP: True positive; FP: False positive; FN: False negative; TN: True negative.

Table 3 Overview of results of meta-analysis

Group	LSM for presence of EV	LSM for presence of HREV	CT for presence of EV	CT for presence of HREV	MRI for presence of EV	MRI for presence of HREV
Diagnostic threshold
Spearman correlation coefficient	0.36	0.21	-0.2	0.12	0.27	0.57
P value	0.19	0.5	0.27	0.58	0.56	0.11
SROC
AUSROC (95%CI)	0.86 (0.83-0.89)	0.85 (0.81-0.88)	0.91 (0.88-0.93)	0.94 (0.91-0.96)	0.86 (0.83-0.89)	0.83 (0.79-0.86)
I²	97.43%	97.13%	97.17%	98.30%	86.41%	91.64%
P value	< 0.01	< 0.01	< 0.01	< 0.01	< 0.01	< 0.01
Sensitivity
Summary sensitivity (95%CI)	0.84 (0.78-0.89)	0.81 (0.75-0.86)	0.91 (0.87-0.94)	0.88 (0.82-0.92)	0.81 (0.76-0.86)	0.80 (0.72-0.86)
I²	82.63%	70.93%	88.46%	87.06%	33.57%	67.03%
P value	< 0.01	< 0.01	< 0.01	< 0.01	0.17	< 0.01
Specificity
Summary specificity (95%CI)	0.71 (0.60-0.80)	0.73 (0.66-0.80)	0.75 (0.68-0.82)	0.87 (0.81-0.92)	0.82 (0.70-0.89)	0.72 (0.62-0.80)
I²	86.56%	91.65%	80.58%	93.26%	74.53%	83.17%
P value	< 0.01	< 0.01	< 0.01	< 0.01	< 0.01	< 0.01
PLR
Summary PLR (95%CI)	2.91 (2.08-4.06)	3.04 (2.38-3.89)	3.67 (2.73-4.94)	6.90 (4.54-10.49)	4.44 (2.74-7.21)	2.83 (2.11-3.80)
I²	82.66%	85.63%	83.81%	91.04%	31.66%	51.94%
P value	< 0.01	< 0.01	< 0.01	< 0.01	0.01	< 0.01
NLR
Summary NLR (95%CI)	0.22 (0.16-0.30)	0.26 (0.19-0.34)	0.12 (0.08-0.18)	0.14 (0.09-0.21)	0.23 (0.18-0.28)	0.28 (0.21-0.38)
I²	79.49%	68.30%	88.94%	91.10%	<0.01%	43.01%
P value	< 0.01	< 0.01	< 0.01	< 0.01	0.53	0.08
Summary DOR (95%CI)	13.01 (7.83-21.64)	11.93 (7.89-18.03)	30.98 (16.02-59.91)	49.99 (25.38-98.43)	19.58 (11.39-33.66)	10.00 (6.63-15.09)

A significant heterogeneity was found in all analyses. There were no threshold effects in all analyses (P > 0.05). CT had the largest area under the summary receiver operating characteristic curves in both of the diagnosis of EV and prediction of HREV. SROC: Summary receiver operating characteristic curves; CT: Computed tomography; EV: Esophageal varices; HREV: High bleeding risk esophageal varices; MRI: Magnetic resonance imaging; LSM: Liver stiffness measurement; PLR: Positive likelihood ratio; NLR: Negative likelihood ratio; DOR: Diagnostic odds ratio; AUSROC: Area under the summary receiver operating characteristic curves.

Citation: Li Y, Li L, Weng HL, Liebe R, Ding HG. Computed tomography vs liver stiffness measurement and magnetic resonance imaging in evaluating esophageal varices in cirrhotic patients: A systematic review and meta-analysis. World J Gastroenterol 2020; 26(18): 2247-2267
URL: https://www.wjgnet.com/1007-9327/full/v26/i18/2247.htm
DOI: https://dx.doi.org/10.3748/wjg.v26.i18.2247