Open access peer-reviewed chapter

Elastography for the Evaluation of Portal Hypertension

Written By

Roxana Șirli, Iulia Rațiu and Ioan Sporea

Submitted: 20 December 2021 Reviewed: 03 January 2022 Published: 01 March 2022

DOI: 10.5772/intechopen.102444

From the Edited Volume

Elastography - Applications in Clinical Medicine

Edited by Dana Stoian and Alina Popescu

Chapter metrics overview

193 Chapter Downloads

View Full Metrics


Liver cirrhosis, regardless of its etiology, is an important health problem with a chronic evolution, characterized by the possibility of developing several important complications. The best management of these patients implies the correct and early diagnosis of the disease and of its complications. A major complication of cirrhosis is portal hypertension. The reference method for its diagnosis is the direct measurement of hepatic vein portal gradient, an invasive procedure. In the last years, several noninvasive techniques for the evaluation of liver fibrosis were developed, such as biological tests and elastographic methods. Ultrasound-based and MRI-based elastographic techniques have been assessed as predictive tools for the presence and severity of portal hypertension. This paper reviews published data regarding the value of ultrasound and MRI-based elastography (liver, spleen, or both) for the evaluation of portal hypertension.


  • portal hypertension
  • clinically significant portal hypertension (CSPH)
  • elastography
  • liver stiffness
  • spleen stiffness

1. Introduction

The prevalence of chronic hepatopathies in daily practice is increasing due to their multiple causes, such as chronic viral infections, alcoholic or non-alcoholic steatohepatitis, cholestatic or autoimmune chronic liver disease. Evaluation of such patients is important for therapeutical decisions, follow-up, and for prognosis assessment.

One main complication of advanced chronic liver disease is portal hypertension (PHT), and the exact evaluation of this entity is crucial for further steps. The direct measurement of hepatic vein portal gradient (HVPG) is the “gold standard” for portal hypertension assessment, but this procedure is invasive, and it is not available in all centers of hepatology. Upper endoscopy for the evaluation of possible esophageal varices or portal gastropathy is a surrogate used in daily practice. Ultrasound and other imaging methods that can reveal collateral circulation in the abdomen can be used to suggest portal hypertension.

Elastography techniques developed in the last 10–15 years mainly evaluate liver stiffness as a marker of fibrosis severity and, lately of portal hypertension. More recently, spleen stiffness was used for the assessment of liver disease severity and evaluation of portal hypertension. Ultrasound-based elastography techniques are the most used in practice, but some studies also evaluated magnetic resonance elastography (MR-E).


2. Portal hypertension: definition and standard method of diagnosis

The main consequence of fibrosis during chronic liver disease, regardless of the etiology, is a perturbation of the sinusoidal blood flow in the liver that leads to increased pressure in the portal venous system, namely portal hypertension (PHT). Additionally, as a compensatory reaction, splanchnic vasodilatation further aggravates the PHT, this mechanism contributing 25–30% to the portal vein pressure [1].

The standard method to diagnose PHT is by measurement of the hepatic venous pressure gradient (HVPG). It is an invasive method that implies catheterization with a balloon catheter of one of the hepatic veins, via the jugular or via a cubital vein. The balloon catheter, with a pressure transducer at the tip, is inflated as to totally occlude the hepatic outflow, thus measuring the wedge hepatic venous pressure (WHVP) [2]. With the balloon deflated free hepatic venous pressure (FHVP) is measured. The hepatic venous pressure gradient (HVPG) is calculated as the difference between WHVP and FHVP [3].

Normal values of HVPG are ≤5 mmHg. As liver injury and fibrosis progress, the HVPG increases progressively. HVPG between 5 and 10 mmHg represents subclinical PHT while HVPG ≥10 mmHg represents the threshold from where PHT-related complications may occur and thus is known as clinically significant PHT (CSPH) [3, 4].

Upper endoscopy is the standard diagnostic method for the presence and severity of esophageal varices (EV), the most visible and severe consequence of PHT. To diagnose clinically significant EV (large-grade 2, or 3 EV), a screening program with periodic upper digestive endoscopy should be implemented. However, it is an invasive procedure and numerous endoscopies are performed in patients with advanced liver disease without finding EV, thus raising questions regarding cost-efficiency and patients’ acceptance.

Considering the invasiveness of these methods, their availability, and also patients’ acceptance, effective noninvasive methods are needed to assess the presence and progression of PHT, as well as the occurrence of EV and their bleeding risk [5].


3. Ultrasound-based elastographic techniques in the liver

According to international guidelines [6, 7], elastography techniques can be classified into Strain Elastography (used mostly for breast, thyroid, and prostate) and Shear Waves Elastography (SWE). In SWE, an external impulse generates shear waves inside the examined organ. The shear waves speed is subsequently measured by ultrasound. Based on the type of external impulse and measurement technique of the shear-waves speed, SWE elastography is subdivided into Transient Elastography (mechanic external impulse); Point SWE (pSWE)—in which an Acoustic Radiation Force Impulse (ARFI) is used as stimulus and the shear-waves speed is measured in a point; and real-time elastography which includes 2D-SWE and 3D-SWE (ARFI used as a stimulus, the shear-waves speed is measured in an area of interest and, in the same time, a color-coded elastogram is generated) [6, 7]. It must be noted that cut-off values proposed for various stages of fibrosis are system-specific.

3.1 Transient elastography (TE)

Transient Elastography was the first elastographic method developed for the evaluation of liver stiffness (LS) [8] and it is not integrated into a standard ultrasound system. It uses a FibroScan device (Echosens, Paris, France) that includes a special ultrasound probe (3.5 MHz for the standard M probe) integrated into a piston that “punches” the body surface. The “punch” generates shear waves that propagate into the liver. Their velocity is measured by pulse-echo ultrasound acquisition and is proportional to LS, increasing in parallel with LS. Increased BMI decreases the feasibility, an inconvenience partially solved by using an XL probe. The FibroScan device displays Young’s modulus, expressed in kilopascals (kPa), which is proportional to the shear-wave velocity [6, 7, 9, 10].

Several published meta-analyses have demonstrated that LS measurement by TE is a reliable method for diagnosing cirrhosis, with a pooled sensitivity ranging from 84.4 to 87% and a pooled specificity ranging from 91 to 94.69% [11, 12]. Liver stiffness measured by TE showed a good correlation with HVPG and the presence of EV; as a result, it has been evaluated as a noninvasive tool for portal hypertension quantification. The first studies were performed in rather small numbers of patients. In an Italian study, the AUROC for predicting HVPG ≥10 mmHg was 0.99 with 97% sensitivity (Se), while for predicting HVPG≥12 mmHg the calculated AUROC was 0.92 with 94% Se. The calculated cut-offs were 13.6 kPa for HVPG ≥10 mmHg and 17.6 kPa for HVPG ≥12 mmHg. The cut-off for predicting any EV was 17.6 kPa (AUROC 0.76, Se-90%) [13]. In a French study, TE predicted HVPG ≥10 mmHg with AUROC 0.945 (cut-off 21 kPa) [14]. In a study that followed up 100 patients for 2 years, none of the patients who initially had LS measurements (LSM) values <21.1 kPa (the calculated cut-off) had PHT complications, vs. 47.5% of those with higher values [15].

Finally, a method’s value is demonstrated by meta-analyses. Regarding TE and portal hypertension, a meta-analysis that included 18 studies with more than 3500 patients was published in 2013 [16]. The conclusion was that, due to the low specificity of this method, TE cannot replace upper gastrointestinal endoscopy for EV screening. However, in 2017 another meta-analysis on 11 studies was published [17]. The summary correlation coefficient was 0.783. Summary Se, Sp, and area under the hierarchical summary receiver operating characteristic curve (AUC) were 87.5%, 85.3%, and 0.9 respectively. In summary, LS correlated well with HVPG and had a good diagnostic performance in diagnosing CSPH. Low cut-off values of 13.6–18 kPa were proposed to ensure a good sensitivity for screening purposes.

The latest EASL guidelines on noninvasive tests for the evaluation of liver disease severity and prognosis proposed an algorithm for risk stratification in compensated advanced chronic liver disease (cACLD) using the Baveno VI criteria [4, 18]: patients with LSM <20 kPa and PLT >150 × 109/L should be considered to have a very low risk of having CSPH. These criteria [4] have been well validated for the identification of patients with cACLD who are unlikely to have varices needing treatment and can safely avoid variceal screening endoscopy, while those not meeting these criteria are at an increased risk of clinical decompensation. Numerous studies validated these criteria [19, 20, 21, 22, 23]. However, in the latest update of the EASL and AASLD guidelines on noninvasive tests for liver fibrosis severity, no clear recommendation was given on whether 20 kPa or 25 kPa is better to rule in the risk of clinical decompensation [18, 24]. A very recently published study demonstrated that patients not meeting the Baveno VI criteria were indeed at a significantly higher risk of liver decompensation. More importantly, the patients with LSMs ranging from 20 to 25 kPa, regardless of the platelet count, might be classified as having a medium risk of clinical decompensation, while those with LSM higher than 25 kPa could be classified as having a high risk of clinical decompensation [25].

In a meta-analysis performed exclusively in patients with chronic viral hepatitis, it was suggested that two cut-offs can be used, namely, ≤13.6 kPa to rule out CSPH (pooled Se 96%), and ≥ 22 kPa to rule in CSPH (pooled Sp 94%), thus confirming Baveno VI consensus recommendations [26]. Another systematic review and meta-analysis of 30 studies, including 8469 participants, assessed the accuracy of Baveno VI criteria (LSM <20 kPa and platelet count >150 x 109cells/L) and Expanded Baveno criteria (LSM <25 kPa and platelet count >110 x 109cells/L) to identify high-risk varices (HRVs) in patients with cACLD were published in 2019 [27]. This meta-analysis concluded that the Baveno criteria and expanded criteria can identify patients with HRVs with high sensitivity but with low specificity. The Expanded Baveno criteria reduce the proportion of unnecessary endoscopies, with a higher rate of missed HRVs [27].

3.2 Shear-wave elastography techniques using acoustic radiation force impulse (ARFI)

In this type of elastography, the shear waves are generated into the tissue by acoustic impulses. It is divided into point Shear-Waves elastography (pSWE) and real-time elastography (2D-SWE and 3D-SWE).

3.2.1 Point shear-waves elastography (pSWE)

In pSWE, the shear-waves speed is measured in a small, fixed-size region of interest (ROI), at the focal point of the US beam, the results being expressed either in m/s, or converted into kPa [6, 7]. pSWE technology is used by several vendors, using proprietary techniques implemented on standard US machines. The first one that appeared on the market and was studied the most is Virtual Touch Tissue Quantification (VTQ) by Siemens, followed by ElastPQ from Philips, and later by techniques by Hitachi, Esaote, Samsung, and others.

Several studies demonstrated the value of VTQ elastography to predict cirrhosis when compared to liver biopsy, the cut-offs ranging from 1.55 to 2 m/s and AUROCS ranging from 0.89 to 0.937 [28, 29], with similar performance to TE in diagnosing cirrhosis [30, 31]. These results were confirmed by several meta-analyses [32, 33, 34].

Regarding VTQ measurements as a predictor of PHT, the published studies had shown controversial results. In European studies, VTQ had poor results in predicting large EV, with AUROCs 0.596 [35] and 0.580 [36]. A Japanese study had shown much better results: for a cut-off of 2.05 m/s, VTQ had 83% Se, 76% Sp, and an AUROC of 0.89 to predict any grade EV; while a cut-off of 2.39 m/s had 81% Se, 82% Sp and an AUROC of 0.868 to predict HRVs [37].

3.2.2 Real-time shear-wave elastography (2D-SWE and 3D-SWE)

Two-dimensional Shear-Wave Elastography (2D-SWE) also uses Acoustic Radiation Force Impulse technology (ARFI) to generate shear waves into the tissue. As opposed to pSWE, in 2D-SWE multiple ARFI impulses evaluate a large field of view, inside which a ROI can be selected. Thus, tissue elasticity is displayed in a “real-time” color map (elastogram) superimposed on a B-mode image (red for stiff tissues and blue for soft ones), and also a numerical value is displayed. LS measured in the user-adjustable ROI is expressed in kPa or m/s at the operator’s decision [6, 7]. 2D-SWE technology is used by several vendors, using proprietary techniques implemented on standard US machines. The first 2D-SWE that appeared on the market was developed by SuperSonic Imagine and integrated into the Aixplorer™ system, followed by other vendors (General Electric, Canon/Toshiba, Philips, Samsung, etc.).

Liver 2D-SWE has proven to be an accurate method for diagnosing cirrhosis, with AUROCs ranging from 0.94 to 0.98, for cut-off values ranging from 10.4 to 11.7 kPa (lower than those of TE) [38, 39, 40, 41, 42].

There are promising results regarding the predictive value of 2D-SWE for predicting CSPH. Studies evaluating 2D-SWE from Supersonic Imagine (2D-SWE.SSI) reported cut-offs of 15.2 kPa to predict CSPH, with AUROC 0.819 (85.7% Se and 80% Sp) and 15.4 kPa [43], with AUROC 0.948 (Se and Sp > 90%) [44]. Similar good results have been obtained using 2D-SWE from General Electric (2D-SWE.GE) [45].

An individual patient data meta-analysis was published in 2020 regarding the performance of 2D-SWE.SSI to identify CSPH, severe PHT, and large varices in cirrhotic patients, using HVPG and upper endoscopy as reference. The study included data of 519 patients from seven centers. A cut-off of 2D-SWE.SSI < 14 kPa ruled out CSPH with 85% accuracy (summary AUROC (sROC)—0.88, 91% Se and 37% Sp) [46]. 2D-SWE.SSI ≥ 32 kPa ruled in CSPH with 55% accuracy (sROC—0.83, 47% Se, 89% Sp). The authors concluded that LS values by 2D-SWE.SSI below 14 kPa may be used to rule out SCPH, however, 2D-SWE.SSI cannot predict varices needing treatment [46].

The consensus panel on Ultrasound Liver Elastography of the Society of Radiologists proposes a vendor-neutral “rule of four” (5, 9, 13, 17 kPa) regarding LSM by ARFI techniques (pSWE and 2D-SWE) for viral etiologies and NAFLD: LS ≤ 5 kPa (1.3 m/sec) has a high probability of being normal; LS ≤ 9 kPa (1.7 m/sec), in the absence of clinical signs, rules out cACLD; values between 9 kPa (1.7 m/sec) and 13 kPa (2.1 m/sec) are suggestive of cACLD but need further tests for confirmation; LS ≥ 13 kPa (2.1 m/sec) are highly suggestive of cACLD. There is a probability of CSPH with LS ≥ 17 kPa (2.4 m/sec) [47].


4. Ultrasound-based elastographic techniques in the spleen

Portal hypertension leads to splenic congestion, which induces architectural changes in the splenic arteries and veins, resulting in fibrosis and an increase in spleen stiffness (SS). Recently, noninvasive techniques that measure spleen stiffness to identify CSPH are gaining more and more interest [48, 49]. SS can be evaluated through elastography techniques, such as TE and ARFI based technologies (pSWE and 2D-SWE) [6, 7, 50, 51].

4.1 Transient elastography

Since TE is the oldest ultrasound-based elastographic technique, it was the first used to assess SS as a predictor of PHT, based on the idea that splenomegaly is one of the clinical signs of cirrhosis. Several studies found a good correlation between SS and LS by TE in patients with cirrhosis and between SS and the presence of EV or HVPG.

The first study that evaluated SS measurement (SSM) by TE showed that SS values become higher as the liver disease is more advanced, correlating well with LS, the association being stronger (r = 0.587) in patients with varices [52]. The SS value was also higher in patients with EV, the best cut-off to predict the presence of EV was ≥46.4 kPa (AUROC = 0.781, PPV = 93.4%). If LS and SS are combined, using LSM ≥ 19 kPa for high Se and SSM ≥ 55 kPa for high Sp, the diagnostic accuracy increased to 88.5%. In an Italian study on 100 patients with HCV cirrhosis, SS correlated better with HVPG than LS (r2 = 0.78 vs. r2 = 0.7) [53]. For the same specificity, SS has a better sensitivity than LS to rule in the presence of EV and both HVPG >10 mmHg and HVPG >12 mmHg).

In another study on 498 patients, the authors developed a prediction model combining SS with Baveno VI criteria, useful to rule out HRVs, that could make it possible to avoid a significantly larger number of unnecessary upper endoscopies as compared to Baveno VI criteria only. Applying the newly identified SSM cut-off (≤46 kPa) to exclude HRVs, or Baveno VI criteria, 35.8 and 21.7% of patients in the internal validation cohort could have avoided upper digestive endoscopy, with only 2% of HRVs being missed with either model. By combining SSM with Baveno VI criteria an additional 22.5% endoscopies could be avoided, reaching a final value of 43.8% spared EGDs, with <5% missed HRVs [54]. Results were confirmed in a prospective external validation cohort, as the combined Baveno VI and SSM ≤46 kPa model would have safely spared 37.4% endoscopies, as compared to 16.5% when using the Baveno VI criteria alone, with 0 HRVs missed [54].

Initial studies regarding SSM were made using the standard FibroScan® device (SSM@50 Hz), with a ceiling threshold of 75 kPa, which could lead to underestimating EV severity. Therefore, EchoSens developed a novel spleen dedicated FibroScan® (SSM@100 Hz), in which the vibrator has a higher frequency (100 Hz) than the standard machine (50 Hz). In a study comparing the two techniques, Stefanescu et al. found out that valid measurements could be obtained in a significantly higher proportion by patients by SSM@100 Hz than by SSM@50 Hz (92.5% vs. 76.0%, p < 0.001) [55]. The accuracy of SSM@100 Hz to predict the presence of EV (AUC = 0.728) and HRVs (AUC = 0.756) was higher than that of other noninvasive tests, including LSM. The proportion of spared endoscopies using Baveno VI criteria (8.1%) significantly increased if combined with SSM@50 Hz (26.5%) or SSM@100 Hz (38.9%, p < 0.001 vs. others). The proportions of missed HRVs were 0% for Baveno VI criteria and 4.7% for combinations [55].

4.2 Shear-wave elastography techniques using acoustic radiation force impulse (ARFI)

4.2.1 Point shear-waves elastography

There are several studies that evaluated VTQ for the assessment of SS, alone [35, 56, 57] or in comparison with TE [58]. Studies considering HVPG as a reference for evaluating SSM performance revealed a remarkable accuracy of SSM in predicting CSPH [59, 60]. A study published in 2019 found out that VTQ is an excellent method of predicting HRVs. Patients with EV of any grade had significantly higher average SS values as compared to those without EVs (3.37 m/s vs. 2.79 m/s, p < 0.001), while patients with HRVs had even higher SS values (3.96 m/s vs. 2.93 m/s, p < 0.001) [61].

4.2.2 Real time shear-wave Elastography

A prospective multicentric study evaluated LS and SS by 2D-SWE.SSI as predictor of CSPH considering HVPG as a reference in 158 subjects, with valid measurements obtained in 109 patients [62]. LS > 29.5 kPa and SS > 35.6 kPa were able to “rule-in” CSPH, with a specificity >92%. LS ≤ 16.0 kPa and SS ≤ 21.7 kPa were able to “rule-out” CSPH. Patients with a LS >38.0 kPa had a substantial risk of having CSPH. In patients with LS ≤ 38.0 kPa, a SS >27.9 kPa ruled in CSPH. This algorithm has 89.2% Se and 91.4% Sp to rule-in CSPH [62].

A recent study evaluated SSM by 2D-SWE.GE to predict the presence of HRVs and compared it to VTQ (a pSWE technique). The optimal SS cut-off value by 2D-SWE was 13.2 kPa (AUROC–0.84), while for VTQ it was 2.91 m/s (AUROC–0.90), with no significant performance difference between the two techniques (p = 0.1606) [63].

A meta-analysis published in 2016, including 12 studies (5 regarding SSM by TE, 5 SSM by pSWE, and 2 SSM by strain elastography) evaluated SS as a predictor of the presence of EV. SS detected the presence of any EV with 78% Se, 76% Sp, 3.4 positive likelihood ratio (LR), 0.2 negative LR, and a diagnostic odds ratio (DOR) of 19.3 [64]. In a subsequent meta-analysis of nine studies, SS predicted the presence HRVs with 81% Se, 66% Sp, 2.5 positive LR, 0.2 negative LR, and 12.6 DOR [64].

A meta-analysis published in 2018, including 9 studies (3 regarding SSM by TE, 2 SSM by pSWE, and 4 SSM by 2D-SWE) showed a good correlation between SS and HVPG, the summary correlation coefficient was 0.72 [65]. In detection of CSPH, the sensitivity, specificity, AUC and DOR were: 88%, 84%, 0.92 and 38 respectively; while for severe PHT they were 92%, 79%, 0.79 and 41 respectively [65].


5. Magnetic resonance elastography (MRE)

The predictive value of MRE for liver fibrosis severity was evaluated by several meta-analyses, which found diagnostic accuracies higher than 90% for the diagnosis of advanced fibrosis and cirrhosis [66, 67, 68]. Among its advantages are that it is evaluating the whole liver at the same time, the possibility of steatosis quantification and also of possible focal liver lesions, as well as the fact that the presence of obesity does not decrease feasibility or accuracy [18]. The main limitations of MRE include its prohibitive costs, limited availability, and the need for specialized infrastructure, equipment, and considerable need for radiological expertise.

A preliminary study on 34 patients regarding the value of liver MRE to predict PHT evaluated by HVPG shoved a significant but weak correlation of LS with HVPG (r = 0.478, p = 0.016). ROC analysis provided significant AUROCs for LS to predict PHT (0.809), and CSPH (0.742) [69]. In another study on 263 patients, LS and SS by MRE were evaluated as predictors of the presence of EV. SS was higher in patients with EV and, in multivariate analysis, there was a significant association of SS with EV, but not of LS and EV. The AUROC of MRE-SS for EV was 0.853. A cut-off value of 9.53 kPa had 84.4% Se and 73.7% Sp to predict EV [70]. Similar satisfactory results have been obtained by two other studies [71, 72].

In a recently published meta-analysis, LS and SS by MRE were evaluated as predictors of PHT. Fourteen studies were included (12 evaluating LS and 8 evaluating SS). The pooled and weighted Se, Sp, and AUROC for LS were 83%, 80% and 0.88 respectively, while for SS they were 79%, 90% and 0.92 respectively [73]. The conclusion of this meta-analysis was that SS may be more specific and accurate than LS for detecting PHT.


6. Conclusions

Numerous studies on the diagnostic performance of elastography-based methods to predict the presence of CSPH have been published, mostly reporting data on liver and spleen stiffness measurements by means of TE, pSWE, and 2D-SWE, which represent promising tools for portal hypertension screening.

According to international guidelines, patients with NASH cirrhosis and those with viral etiology who have LS by TE ≥20–25 kPa should be considered at elevated risk of having endoscopic signs of PH. Patients with LS by TE < 20 kPa and with a platelet count >150 x 109cells/L have a very low risk of having varices requiring treatment and can avoid screening endoscopy.

Patients with LS values evaluated by pSWE and 2D-SWE higher than 17 kPa (2.4 m/sec) are likely to have CSPH.

Spleen stiffness using TE, pSWE or 2D-SWE can be used for PH evaluation.


  1. 1. Bosch J, Berzigotti A, Garcia-Pagan JC, Abraldes JG. The management of portal hypertension: Rational basis, available treatments and future options. Journal of Hepatology. 2008;48(Suppl 1):S68-S92
  2. 2. Perello A, Escorsell A, Bru C, Gilabert R, Moitinho E, Garcia-Pagan JC, et al. Wedged hepatic venous pressure adequately reflects portal pressure in hepatitis C virus-related cirrhosis. Hepatology. 1999;30(6):1393-1397
  3. 3. Bosch J, Abraldes JG, Berzigotti A, Garcia-Pagan JC. The clinical use of HVPG measurements in chronic liver disease. Nature Reviews. Gastroenterology & Hepatology. 2009;6(10):573-582
  4. 4. de Franchis R, Baveno VIF. Expanding consensus in portal hypertension: Report of the Baveno VI consensus workshop: Stratifying risk and individualizing care for portal hypertension. Journal of Hepatology. 2015;63(3):743-752
  5. 5. Bari K, Garcia-Tsao G. Treatment of portal hypertension. World Journal of Gastroenterology. 2012;18(11):1166-1175
  6. 6. Bamber J, Cosgrove D, Dietrich CF, Fromageau J, Bojunga J, Calliada F, et al. EFSUMB guidelines and recommendations on the clinical use of ultrasound elastography. Part 1: Basic principles and technology. Ultraschall in der Medizin—European Journal of Ultrasound. 2013;34(2):169-184
  7. 7. Shiina T, Nightingale KR, Palmeri ML, Hall TJ, Bamber JC, Barr RG, et al. WFUMB guidelines and recommendations for clinical use of ultrasound elastography: Part 1: Basic principles and terminology. Ultrasound in Medicine & Biology. 2015;41(5):1126-1147
  8. 8. Sandrin L, Fourquet B, Hasquenoph JM, Yon S, Fournier C, Mal F, et al. Transient elastography: A new noninvasive method for assessment of hepatic fibrosis. Ultrasound in Medicine & Biology. 2003;29(12):1705-1713
  9. 9. Cosgrove D, Piscaglia F, Bamber J, Bojunga J, Correas JM, Gilja OH, et al. EFSUMB guidelines and recommendations on the clinical use of ultrasound elastography. Part 2: Clinical applications. Ultraschall in der Medizin—European Journal of Ultrasound. 2013;34(3):238-253
  10. 10. Sporea I, Bota S, Saftoiu A, Sirli R, Gradinaru-Tascau O, Popescu A, et al. Romanian national guidelines and practical recommendations on liver elastography. Medical Ultrasonography. 2014;16(2):123-138
  11. 11. Stebbing J, Farouk L, Panos G, Anderson M, Jiao LR, Mandalia S, et al. A meta-analysis of transient elastography for the detection of hepatic fibrosis. Journal of Clinical Gastroenterology. 2010;44(3):214-219
  12. 12. Talwalkar JA, Kurtz DM, Schoenleber SJ, West CP, Montori VM. Ultrasound-based transient elastography for the detection of hepatic fibrosis: Systematic review and meta-analysis. Clinical Gastroenterology and Hepatology. 2007;5(10):1214-1220
  13. 13. Vizzutti F, Arena U, Romanelli RG, Rega L, Foschi M, Colagrande S, et al. Liver stiffness measurement predicts severe portal hypertension in patients with HCV-related cirrhosis. Hepatology. 2007;45(5):1290-1297
  14. 14. Bureau C, Metivier S, Peron JM, Selves J, Robic MA, Gourraud PA, et al. Transient elastography accurately predicts presence of significant portal hypertension in patients with chronic liver disease. Alimentary Pharmacology & Therapeutics. 2008;27(12):1261-1268
  15. 15. Robic MA, Procopet B, Metivier S, Peron JM, Selves J, Vinel JP, et al. Liver stiffness accurately predicts portal hypertension related complications in patients with chronic liver disease: A prospective study. Journal of Hepatology. 2011;55(5):1017-1024
  16. 16. Shi KQ, Fan YC, Pan ZZ, Lin XF, Liu WY, Chen YP, et al. Transient elastography: A meta-analysis of diagnostic accuracy in evaluation of portal hypertension in chronic liver disease. Liver International. 2013;33(1):62-71
  17. 17. You MW, Kim KW, Pyo J, Huh J, Kim HJ, Lee SJ, et al. A Meta-analysis for the diagnostic performance of transient Elastography for clinically significant portal hypertension. Ultrasound in Medicine & Biology. 2017;43(1):59-68
  18. 18. European Association for the Study of the Liver. EASL clinical practice guidelines on non-invasive tests for evaluation of liver disease severity and prognosis. Journal of Hepatology. 2021;75(3):659-689
  19. 19. Nawalerspanya S, Sripongpun P, Chamroonkul N, Kongkamol C, Piratvisuth T. Validation of original, expanded Baveno VI, and stepwise & platelet-MELD criteria to rule out varices needing treatment in compensated cirrhosis from various etiologies. Annals of Hepatology. 2020;19(2):209-213
  20. 20. Perazzo H, Fernandes FF, Castro Filho EC, Perez RM. Points to be considered when using transient elastography for diagnosis of portal hypertension according to the Baveno’s VI consensus. Journal of Hepatology. 2015;63(4):1048-1049
  21. 21. Thabut D, Bureau C, Layese R, Bourcier V, Hammouche M, Cagnot C, et al. Validation of Baveno VI criteria for screening and surveillance of esophageal Varices in patients with compensated cirrhosis and a sustained response to antiviral therapy. Gastroenterology. 2019;156(4):997-1009e5
  22. 22. Bae J, Sinn DH, Kang W, Gwak GY, Choi MS, Paik YH, et al. Validation of the Baveno VI and the expanded Baveno VI criteria to identify patients who could avoid screening endoscopy. Liver International. 2018;38(8):1442-1448
  23. 23. Maurice JB, Brodkin E, Arnold F, Navaratnam A, Paine H, Khawar S, et al. Validation of the Baveno VI criteria to identify low risk cirrhotic patients not requiring endoscopic surveillance for varices. Journal of Hepatology. 2016;65(5):899-905
  24. 24. Qi X, Berzigotti A, Cardenas A, Sarin SK. Emerging non-invasive approaches for diagnosis and monitoring of portal hypertension. The Lancet Gastroenterology & Hepatology. 2018;3(10):708-719
  25. 25. Liu Y, Liu C, Li J, Kim TH, Enomoto H, Qi X. Risk stratification of decompensation using liver stiffness and platelet counts in compensated advanced chronic liver disease (CHESS2102). Journal of Hepatology. 2022;76(1):248-250
  26. 26. Song J, Ma Z, Huang J, Liu S, Luo Y, Lu Q, et al. Comparison of three cut-offs to diagnose clinically significant portal hypertension by liver stiffness in chronic viral liver diseases: A meta-analysis. European Radiology. 2018;28(12):5221-5230
  27. 27. Stafylidou M, Paschos P, Katsoula A, Malandris K, Ioakim K, Bekiari E, et al. Performance of Baveno VI and Expanded Baveno VI criteria for excluding high-risk Varices in patients with chronic liver diseases: A systematic review and Meta-analysis. Clinical Gastroenterology and Hepatology. 2019;17(9):1744-55e11
  28. 28. Lupsor M, Badea R, Stefanescu H, Sparchez Z, Branda H, Serban A, et al. Performance of a new elastographic method (ARFI technology) compared to unidimensional transient elastography in the noninvasive assessment of chronic hepatitis C. Preliminary results. Journal of Gastrointestinal and Liver Diseases. 2009;18(3):303-310
  29. 29. Sporea I, Sirli R, Bota S, Fierbinteanu-Braticevici C, Petrisor A, Badea R, et al. Is ARFI elastography reliable for predicting fibrosis severity in chronic HCV hepatitis? World Journal of Radiology. 2011;3(7):188-193
  30. 30. Rizzo L, Calvaruso V, Cacopardo B, Alessi N, Attanasio M, Petta S, et al. Comparison of transient elastography and acoustic radiation force impulse for non-invasive staging of liver fibrosis in patients with chronic hepatitis C. The American Journal of Gastroenterology. 2011;106(12):2112-2120
  31. 31. Sporea I, Badea R, Sirli R, Lupsor M, Popescu A, Danila M, et al. How efficient is acoustic radiation force impulse elastography for the evaluation of liver stiffness? Hepatitis Monthly. 2011;11(7):532-538
  32. 32. Bota S, Herkner H, Sporea I, Salzl P, Sirli R, Neghina AM, et al. Meta-analysis: ARFI elastography versus transient elastography for the evaluation of liver fibrosis. Liver International. 2013;33(8):1138-1147
  33. 33. Friedrich-Rust M, Nierhoff J, Lupsor M, Sporea I, Fierbinteanu-Braticevici C, Strobel D, et al. Performance of acoustic radiation force impulse imaging for the staging of liver fibrosis: A pooled meta-analysis. Journal of Viral Hepatitis. 2012;19(2):e212-e219
  34. 34. Nierhoff J, Chavez Ortiz AA, Herrmann E, Zeuzem S, Friedrich-Rust M. The efficiency of acoustic radiation force impulse imaging for the staging of liver fibrosis: A meta-analysis. European Radiology. 2013;23(11):3040-3053
  35. 35. Bota S, Sporea I, Sirli R, Focsa M, Popescu A, Danila M, et al. Can ARFI elastography predict the presence of significant esophageal varices in newly diagnosed cirrhotic patients? Annals of Hepatology. 2012;11(4):519-525
  36. 36. Vermehren J, Polta A, Zimmermann O, Herrmann E, Poynard T, Hofmann WP, et al. Comparison of acoustic radiation force impulse imaging with transient elastography for the detection of complications in patients with cirrhosis. Liver International. 2012;32(5):852-858
  37. 37. Morishita N, Hiramatsu N, Oze T, Harada N, Yamada R, Miyazaki M, et al. Liver stiffness measurement by acoustic radiation force impulse is useful in predicting the presence of esophageal varices or high-risk esophageal varices among patients with HCV-related cirrhosis. Journal of Gastroenterology. 2014;49(7):1175-1182
  38. 38. Bavu E, Gennisson JL, Couade M, Bercoff J, Mallet V, Fink M, et al. Noninvasive in vivo liver fibrosis evaluation using supersonic shear imaging: A clinical study on 113 hepatitis C virus patients. Ultrasound in Medicine & Biology. 2011;37(9):1361-1373
  39. 39. Ferraioli G, Tinelli C, Dal Bello B, Zicchetti M, Filice G, Filice C, et al. Accuracy of real-time shear wave elastography for assessing liver fibrosis in chronic hepatitis C: A pilot study. Hepatology. 2012;56(6):2125-2133
  40. 40. Leung VY, Shen J, Wong VW, Abrigo J, Wong GL, Chim AM, et al. Quantitative elastography of liver fibrosis and spleen stiffness in chronic hepatitis B carriers: Comparison of shear-wave elastography and transient elastography with liver biopsy correlation. Radiology. 2013;269(3):910-918
  41. 41. Sporea I, Bota S, Gradinaru-Tascau O, Sirli R, Popescu A, Jurchis A. Which are the cut-off values of 2D-shear wave Elastography (2D-SWE) liver stiffness measurements predicting different stages of liver fibrosis, considering transient Elastography (TE) as the reference method? European Journal of Radiology. 2014;83(3):e118-e122
  42. 42. Zeng J, Liu GJ, Huang ZP, Zheng J, Wu T, Zheng RQ, et al. Diagnostic accuracy of two-dimensional shear wave elastography for the non-invasive staging of hepatic fibrosis in chronic hepatitis B: A cohort study with internal validation. European Radiology. 2014;24(10):2572-2581
  43. 43. Kim TY, Jeong WK, Sohn JH, Kim J, Kim MY, Kim Y. Evaluation of portal hypertension by real-time shear wave elastography in cirrhotic patients. Liver International. 2015;35(11):2416-2424
  44. 44. Procopet B, Berzigotti A, Abraldes JG, Turon F, Hernandez-Gea V, Garcia-Pagan JC, et al. Real-time shear-wave elastography: Applicability, reliability and accuracy for clinically significant portal hypertension. Journal of Hepatology. 2015;62(5):1068-1075
  45. 45. Stefanescu H, Rusu C, Lupsor-Platon M, Nicoara Farcau O, Fischer P, Grigoras C, et al. Liver stiffness assessed by ultrasound shear wave Elastography from General Electric accurately predicts clinically significant portal hypertension in patients with advanced chronic liver disease. Ultraschall in der Medizin—European Journal of Ultrasound. 2020;41(5):526-533
  46. 46. Thiele M, Hugger MB, Kim Y, Rautou PE, Elkrief L, Jansen C, et al. 2D shear wave liver elastography by Aixplorer to detect portal hypertension in cirrhosis: An individual patient data meta-analysis. Liver International. 2020;40(6):1435-1446
  47. 47. Barr RG, Wilson SR, Rubens D, Garcia-Tsao G, Ferraioli G. Update to the society of radiologists in ultrasound liver Elastography consensus statement. Radiology. 2020;296(2):263-274
  48. 48. Roccarina D, Rosselli M, Genesca J, Tsochatzis EA. Elastography methods for the non-invasive assessment of portal hypertension. Expert Review of Gastroenterology & Hepatology. 2018;12(2):155-164
  49. 49. Takuma Y, Nouso K, Morimoto Y, Tomokuni J, Sahara A, Takabatake H, et al. Portal hypertension in patients with liver cirrhosis: Diagnostic accuracy of spleen stiffness. Radiology. 2016;279(2):609-619
  50. 50. Ferraioli G, Wong VW, Castera L, Berzigotti A, Sporea I, Dietrich CF, et al. Liver ultrasound elastography: An update to the world federation for ultrasound in medicine and biology guidelines and recommendations. Ultrasound in Medicine & Biology. 2018;44(12):2419-2440
  51. 51. Saftoiu A, Gilja OH, Sidhu PS, Dietrich CF, Cantisani V, Amy D, et al. The EFSUMB guidelines and recommendations for the clinical practice of elastography in non-hepatic applications: Update 2018. Ultraschall in der Medizin—European Journal of Ultrasound. 2019;40(4):425-453
  52. 52. Stefanescu H, Grigorescu M, Lupsor M, Procopet B, Maniu A, Badea R. Spleen stiffness measurement using Fibroscan for the noninvasive assessment of esophageal varices in liver cirrhosis patients. Journal of Gastroenterology and Hepatology. 2011;26(1):164-170
  53. 53. Colecchia A, Montrone L, Scaioli E, Bacchi-Reggiani ML, Colli A, Casazza G, et al. Measurement of spleen stiffness to evaluate portal hypertension and the presence of esophageal varices in patients with HCV-related cirrhosis. Gastroenterology. 2012;143(3):646-654
  54. 54. Colecchia A, Ravaioli F, Marasco G, Colli A, Dajti E, Di Biase AR, et al. A combined model based on spleen stiffness measurement and Baveno VI criteria to rule out high-risk varices in advanced chronic liver disease. Journal of Hepatology. 2018;69(2):308-317
  55. 55. Stefanescu H, Marasco G, Cales P, Fraquelli M, Rosselli M, Ganne-Carrie N, et al. A novel spleen-dedicated stiffness measurement by FibroScan(R) improves the screening of high-risk oesophageal varices. Liver International. 2020;40(1):175-185
  56. 56. Park J, Kwon H, Cho J, Oh J, Lee S, Han S, et al. Is the spleen stiffness value acquired using acoustic radiation force impulse (ARFI) technology predictive of the presence of esophageal varices in patients with cirrhosis of various etiologies? Medical Ultrasonography. 2016;18(1):11-17
  57. 57. Rizzo L, Attanasio M, Pinzone MR, Berretta M, Malaguarnera M, Morra A, et al. A new sampling method for spleen stiffness measurement based on quantitative acoustic radiation force impulse elastography for noninvasive assessment of esophageal varices in newly diagnosed HCV-related cirrhosis. BioMed Research International. 2014;2014:365982
  58. 58. Kim HY, Jin EH, Kim W, Lee JY, Woo H, Oh S, et al. The role of spleen stiffness in determining the severity and bleeding risk of esophageal varices in cirrhotic patients. Medicine (Baltimore). 2015;94(24):e1031
  59. 59. Takuma Y, Nouso K, Morimoto Y, Tomokuni J, Sahara A, Toshikuni N, et al. Measurement of spleen stiffness by acoustic radiation force impulse imaging identifies cirrhotic patients with esophageal varices. Gastroenterology. 2013;144(1):92-101e2
  60. 60. Attia D, Schoenemeier B, Rodt T, Negm AA, Lenzen H, Lankisch TO, et al. Evaluation of liver and spleen stiffness with acoustic radiation force impulse quantification Elastography for diagnosing clinically significant portal hypertension. Ultraschall in der Medizin—European Journal of Ultrasound. 2015;36(6):603-610
  61. 61. Fierbinteanu-Braticevici C, Tribus L, Peagu R, Petrisor A, Baicus C, Cretoiu D, et al. Spleen stiffness as predictor of esophageal varices in cirrhosis of different etiologies. Scientific Reports. 2019;9(1):16190
  62. 62. Jansen C, Bogs C, Verlinden W, Thiele M, Moller P, Gortzen J, et al. Shear-wave elastography of the liver and spleen identifies clinically significant portal hypertension: A prospective multicentre study. Liver International. 2017;37(3):396-405
  63. 63. Fofiu R, Bende F, Popescu A, Sirli R, Lupusoru R, Ghiuchici AM, et al. Spleen and liver stiffness for predicting high-risk Varices in patients with compensated liver cirrhosis. Ultrasound in Medicine & Biology. 2021;47(1):76-83
  64. 64. Singh S, Eaton JE, Murad MH, Tanaka H, Iijima H, Talwalkar JA. Accuracy of spleen stiffness measurement in detection of esophageal varices in patients with chronic liver disease: Systematic review and meta-analysis. Clinical Gastroenterology and Hepatology. 2014;12(6):935-45e4
  65. 65. Song J, Huang J, Huang H, Liu S, Luo Y. Performance of spleen stiffness measurement in prediction of clinical significant portal hypertension: A meta-analysis. Clinics and Research in Hepatology and Gastroenterology. 2018;42(3):216-226
  66. 66. Wang QB, Zhu H, Liu HL, Zhang B. Performance of magnetic resonance elastography and diffusion-weighted imaging for the staging of hepatic fibrosis: A meta-analysis. Hepatology. 2012;56(1):239-247
  67. 67. Singh S, Venkatesh SK, Wang Z, Miller FH, Motosugi U, Low RN, et al. Diagnostic performance of magnetic resonance elastography in staging liver fibrosis: A systematic review and meta-analysis of individual participant data. Clinical Gastroenterology and Hepatology. 2015;13(3):440-51e6
  68. 68. Friedrich-Rust M, Poynard T, Castera L. Critical comparison of elastography methods to assess chronic liver disease. Nature Reviews Gastroenterology & Hepatology. 2016;13(7):402-411
  69. 69. Wagner M, Hectors S, Bane O, Gordic S, Kennedy P, Besa C, et al. Noninvasive prediction of portal pressure with MR elastography and DCE-MRI of the liver and spleen: Preliminary results. Journal of Magnetic Resonance Imaging. 2018;48(4):1091-1103
  70. 70. Jhang ZE, Wu KL, Chen CB, Chen YL, Lin PY, Chou CT. Diagnostic value of spleen stiffness by magnetic resonance elastography for prediction of esophageal varices in cirrhotic patients. Abdominal Radiology (NY). 2021;46(2):526-533
  71. 71. Abe H, Midorikawa Y, Matsumoto N, Moriyama M, Shibutani K, Okada M, et al. Prediction of esophageal varices by liver and spleen MR elastography. European Radiology. 2019;29(12):6611-6619
  72. 72. Hoffman DH, Ayoola A, Nickel D, Han F, Chandarana H, Babb J, et al. MR elastography, T1 and T2 relaxometry of liver: Role in noninvasive assessment of liver function and portal hypertension. Abdominal Radiology (NY). 2020;45(9):2680-2687
  73. 73. Singh R, Wilson MP, Katlariwala P, Murad MH, McInnes MDF, Low G. Accuracy of liver and spleen stiffness on magnetic resonance elastography for detecting portal hypertension: A systematic review and meta-analysis. European Journal of Gastroenterology & Hepatology. 2021;32(2):237-245

Written By

Roxana Șirli, Iulia Rațiu and Ioan Sporea

Submitted: 20 December 2021 Reviewed: 03 January 2022 Published: 01 March 2022