Retrospective Study
Copyright ©The Author(s) 2019. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. Jan 21, 2019; 25(3): 367-377
Published online Jan 21, 2019. doi: 10.3748/wjg.v25.i3.367
Predicting gastroesophageal varices through spleen magnetic resonance elastography in pediatric liver fibrosis
Haesung Yoon, Hyun Joo Shin, Myung-Joon Kim, Seok Joo Han, Hong Koh, Seung Kim, Mi-Jung Lee
Haesung Yoon, Hyun Joo Shin, Myung-Joon Kim, Mi-Jung Lee, Department of Radiology, Severance Hospital, Severance Pediatric Liver Disease Research Group, Research Institute of Radiological Science, Yonsei University College of Medicine, Seoul 03722, South Korea
Seok Joo Han, Department of Surgery, Severance Hospital, Severance Pediatric Liver Disease Research Group, Yonsei University College of Medicine, Seoul 03722, South Korea
Hong Koh, Seung Kim, Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Severance Children’s Hospital, Severance Pediatric Liver Disease Research Group, Yonsei University College of Medicine, Seoul 03722, South Korea
Author contributions: Yoon H and Lee MJ designed the research; Yoon H, Shin HJ and Lee MJ performed the research and wrote the manuscript; Yoon H, Shin HJ and Lee MJ analyzed the data; Kim MJ, Han SJ, Koh H and Kim S contributed analytic tools; Yoon H, Shin HJ, Kim MJ, Han SJ, Koh H, Kim S and Lee MJ revised and approved the final version.
Institutional review board statement: This study was reviewed and approved by the local ethics committee of the Severance Hospital, Yonsei University.
Informed consent statement: Because of the retrospective and anonymous character of this study, the need for informed consent was waived by the institutional review board.
Conflict-of-interest statement: All authors declare no conflicts-of-interest related to this article.
Data sharing statement: No additional data are available.
Open-Access: This is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Corresponding author: Mi-Jung Lee, MD, PhD, Assistant Professor, Department of Radiology, Severance Hospital, Severance Pediatric Liver Disease Research Group, Research Institute of Radiological Science, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul 03722, South Korea. mjl1213@yuhs.ac
Telephone: +82-2-22287400 Fax: +82-2-3933035
Received: November 14, 2018
Peer-review started: November 14, 2018
First decision: December 5, 2018
Revised: December 12, 2018
Accepted: December 21, 2018
Article in press: December 21, 2018
Published online: January 21, 2019
Processing time: 68 Days and 20.3 Hours
Abstract
BACKGROUND

A recent retrospective study confirmed that hepatic stiffness and splenic stiffness measured with magnetic resonance elastography (MRE) are strongly associated with the presence of esophageal varices. In addition, strong correlations have been reported between splenic stiffness values measured with MRE and hepatic venous pressure gradients in animal models. However, most studies have been conducted on adult populations, and previous pediatric MRE studies have only demonstrated the feasibility of MRE in pediatric populations, while the actual clinical application of spleen MRE has been limited.

AIM

To assess the utility of splenic stiffness measurements by MRE to predict gastroesophageal varices in children.

METHODS

We retrospectively reviewed abdominal MRE images taken on a 3T system in pediatric patients. Patients who had undergone Kasai operations for biliary atresia were selected for the Kasai group, and patients with normal livers and spleens were selected for the control group. Two-dimensional spin-echo echo-planar MRE acquisition centered on the liver, with a pneumatic driver at 60 Hz and a low amplitude, was performed to obtain hepatic and splenic stiffness values. Laboratory results for aspartate aminotransferase to platelet ratio index (APRI) were evaluated within six months of MRE, and the normalized spleen size ratio was determined with the upper normal size limit. All Kasai group patients underwent gastroesophageal endoscopy during routine follow-up. The Mann-Whitney U test, Kendall's tau b correlation and diagnostic performance analysis using the area under the curve (AUC) were performed for statistical analysis.

RESULTS

The median spleen MRE value was 5.5 kPa in the control group (n = 9, age 9-18 years, range 4.7-6.4 kPa) and 8.6 kPa in the Kasai group (n = 22, age 4-18 years, range 5.0-17.8 kPa). In the Kasai group, the APRI, spleen size ratio and spleen MRE values were higher in patients with portal hypertension (n = 11) than in patients without (n = 11) (all P < 0.001) and in patients with gastroesophageal varices (n = 6) than in patients without (n = 16) (all P < 0.05), even though their liver MRE values were not different. The APRI (τ = 0.477, P = 0.007), spleen size ratio (τ = 0.401, P = 0.024) and spleen MRE values (τ = 0.426, P = 0.016) also correlated with varices grades. The AUC in predicting gastroesophageal varices was 0.844 at a cut-off of 0.65 (100% sensitivity and 75% specificity) for the APRI, and 0.844 at a cut-off of 9.9 kPa (83.3% sensitivity and 81.3% specificity) for spleen MRE values.

CONCLUSION

At a cut-off of 9.9 kPa, spleen MRE values predicted gastroesophageal varices as well as the APRI and spleen size ratio in biliary atresia patients after the Kasai operation. However, liver MRE values were not useful for this purpose.

Keywords: Biliary atresia; Magnetic resonance elastography; Kasai operation; Splenic stiffness; Portal hypertension

Core tip: Non-invasive monitoring of portal hypertension is important in children with hepatic fibrosis. Spleen magnetic resonance elastography (MRE) values predicted gastroesophageal varices at a cut-off of 9.9 kPa in biliary atresia patients after the Kasai operation, and the diagnostic performance was comparable to that of the aspartate aminotransferase to platelet ratio index and the spleen size ratio. However, liver MRE values did not differ in patients with and without portal hypertension or gastroesophageal varices.