The role of spleen elastometry in the non-invasive assessment of portal hypertension in liver cirrhosis

Background. Portal hypertension (PH) is one of the leading complications of liver cirrhosis (LC) and determines the risk of developing esophageal varices (EV). Measurement of the hepatic venous pressure gradient is considered a standard indicator of PH; however, this method is invasive and has limited availability. In recent years, spleen elastometry has become a promising non-invasive method for assessing the severity of PH in patients with LC.
Objective: To study the diagnostic value of spleen elastometry in patients with PH associated with LC in the compensation stage and to evaluate the correlation between spleen stiffness (SS) parameters and clinical and instrumental PH features.
Materials and methods. A prospective cross-sectional study included 44 patients (26 male and 18 female individuals) with PH associated with LC and the development of grade 1–2 EVs. All participants underwent liver transient elastography using a FibroScan 502 Touch (Probe M) device and spleen elastometry using a BIOSS ANGIODIN-Sono/P-Ultra ultrasound system. The average age of the participants was 50 (44–60) years. According to the Child–Pugh scale, 26 patients (59.1%) were classified as class A cirrhosis and 18 patients (40.9%) as class B. Esophageal varices (EV) of grade 1 were detected in 20 (45.5%) patients and grade 2 in 24 (54.5%) patients. Spleen size (longitudinal and transverse), liver stiffness (LS) and SS, platelet levels, albumin, international normalized ratio (INR), and EV grade (based on esophagogastroduodenoscopy) were assessed.
Results. In the overall sample, the median SS of the group was 60.5 (IQR 48.0–69.0) kPa, LS – 30.6 (IQR 27.1–48.9) kPa. SS was higher in grade 2 EV than in grade 1 EV: 65.0 (IQR 61.3–69.9) vs. 50.0 (IQR 43.0–62.0) kPa (p = 0.008). The results of determination of SS in patients with LC class A and class B according to Child–Pugh were statistically insignificant (p = 0.48). Correlation analysis revealed a moderate correlation between spleen stiffness and platelet count (ρ = -0.46; p = 0.002), as well as an association with spleen length (ρ = 0.41; p = 0.006), spleen structure (ρ = 0.44; p = 0.003), and the grade of EV (ρ = 0.39; p = 0.009). Correlation between SS and LS, albumin, INR, and Child–Pugh LC class was weak and non-significant. ROC analysis for predicting grade 2 EV using SS parameters yielded the following results: area under the curve (AUC) = 0.74, cutoff value – 58 kPa (sensitivity 75%, specificity 70%).
Conclusion. SS was significantly higher in patients with grade 2 EV comparatively to grade 1 EV, while its association with Child–Pugh cirrhosis class was not found. A spleen stiffness cutoff of 58 kPa allows for a moderate differentiation (AUC = 0.74) of grade 2 EV, which can be used for risk stratification and endoscopic screening planning. Compared with LS measurements, spleen elastometry data better reflects portal hypertension severity, making this method a potential additional noninvasive tool in the management of patients with LC.

For citation: Alaeddine T, Ngameni YM, Tarasova OI. The role of spleen elastometry in the non-invasive assessment of portal hypertension in liver cirrhosis. Therapy (Moscow). 2026;12(5S):44–50.
https://dx.doi.org/10.18565/therapy.2026.5-s5.44-50

INTRODUCTION

Cirrhosis is the end stage of many chronic liver diseases and is characterized by progressive fibrosis, disruption of the hepatic architecture, and the development of portal hypertension (PH). PH is responsible for most complications of cirrhosis, marks the transition from compensated to decompensated disease, and is a major cause of death and the need for liver transplantation. Increased intrahepatic vascular resistance is a key factor in the pathogenesis of PH.

At the time of diagnosis, esophageal varices (EV) are detected in 50–60% of patients with decompensated cirrhosis [1]. EV are often the first clinical manifestation of PH and represent a major clinical problem because of both their high prevalence and the risk of rupture and bleeding.

The current medical literature provides extensive data on the major causes of cirrhosis and the prevalence of EV among affected patients. A systematic review of the global epidemiology of alcohol-associated liver disease published in 2026 reported 2023 estimates of 3.15 million prevalent cases of alcohol-associated cirrhosis and an annual incidence of 419,429 cases [2]. The global prevalence of compensated cirrhosis due to alcohol-associated liver disease (ALD) has been estimated at 23.6 million cases, whereas the prevalence of decompensated cirrhosis has been estimated at 2.46 million cases [3]. A 2023 study published in PLOS ONE reported that variceal bleeding was present in 18.5% of patients with alcohol-associated cirrhosis at the time of diagnosis [4].

According to a large systematic review published in 2022, 42% of patients with cirrhosis worldwide have hepatitis B virus (HBV) infection, while 21% have hepatitis C virus (HCV) infection [5]. Globally, age-standardized incidence and mortality rates for HBV- and HCV-related cirrhosis have declined since 1990, largely because of vaccination programs and advances in antiviral therapy [6]. Several studies have demonstrated an association between viral hepatitis and the risk of variceal bleeding. For example, in a retrospective study of 329 patients with chronic HBV infection, the prevalence of variceal bleeding at the time of initial diagnosis was 3.7%, with men being at higher risk than women (5.6% vs 1.4%) [7]. A systematic review and meta-analysis published in Gastroenterology Research and Practice in 2017 found that the prevalence of EV among patients with cirrhosis of viral etiology was 34.2%, while large varices requiring active treatment or prophylaxis accounted for 28.9% [8].

The burden of cirrhosis caused by metabolic dysfunction-associated steatotic liver disease (MASLD), formerly known as nonalcoholic fatty liver disease (NAFLD), is increasing rapidly, and the prevalence of MASLD-related cirrhosis is expected to rise substantially in the coming years. In a cohort study of US veterans, the age-standardized incidence of MASLD-related cirrhosis increased by 37.4% between 2010 and 2021, from 1.39 to 1.91 cases per 1,000 patients [9]. Variceal bleeding is present in 10% of patients with MASLD at the time cirrhosis is diagnosed. In addition, the 5-year cumulative incidence of a first episode of cirrhosis decompensation, including variceal bleeding, has been reported to reach 30.7% in patients with clinically significant PH, defined as a hepatic venous pressure gradient (HVPG) ≥10 mm Hg, and 9.4% in those without clinically significant PH [4, 10].

Bleeding from EV is associated with a high risk of death, ranging from 10% to 20% [11]. Mortality associated with the first bleeding episode ranges from 12% to 44% [12]. Overall, bleeding occurs in approximately one-third of patients with cirrhosis and varices, and a substantial proportion of these episodes may be fatal.

Measurement of the hepatic venous pressure gradient (HVPG) is the gold standard for assessing PH and stratifying the risk of variceal bleeding; however, the procedure is invasive and not widely available [13]. In 2025, alternative diagnostic techniques, such as endoscopic ultrasound-guided portal pressure gradient measurement (EUS-PPG), began to be introduced into routine clinical practice [14]. To avoid performing endoscopy in all patients with suspected PH, other noninvasive methods of assessing the risk and severity of PH have been proposed, including liver and spleen stiffness measurements [15].

Liver stiffness measurement (LSM) by transient elastography (TE) is recommended as a safer and more accessible alternative to liver biopsy and as a method for diagnosing liver fibrosis and cirrhosis [16]. When used to diagnose PH, TE-based LSM has shown area under the receiver operating characteristic curve (AUROC) values ranging from 0.90 to 0.99 at cutoff values of 8.74–26.6 kPa. A liver st...

T. Alaeddinе, Y.M. Ngameni, O.I. Tarasova