A non-invasive nomogram for high-risk esophageal varices in cirrhosis without transient elastography: development and internal validation
TL;DR
A simple nomogram based on routine clinical and ultrasonographic variables stratified HREV risk and outperformed established biochemical scores and is proposed for prioritising endoscopy where transient elastography is unavailable, rather than as a substitute for Baveno-based rule-out strategies.
Abstract
Background Gastroesophageal varices (GOV) and variceal hemorrhage are major life-threatening complications of cirrhosis. Although esophagogastroduodenoscopy (EGD) remains the diagnostic gold standard, its invasiveness, cost, and limited patient adherence underscore the need for reliable non-invasive risk-stratification tools. We aimed to identify independent predictors of high-risk esophageal varices (HREV) and develop and validate a simple, cost-effective nomogram integrating routinely available clinical and ultrasonographic parameters. Methods In this retrospective cohort study, we enrolled 575 cirrhotic patients hospitalized between January 2010 and December 2019. All participants underwent contemporaneous EGD and abdominal color Doppler ultrasonography during the same hospitalization. A nomogram was constructed based on independent predictors identified by multivariate analysis. Model performance was evaluated using the area under the receiver operating characteristic curve (AUROC), calibration curves, decision-curve analysis (DCA), and compared with established non-invasive scores (APRI, AAR, FIB-4, PC/SD) and with each individual predictor; the training-derived threshold was fixed and applied unchanged to the validation cohort. Results Endoscopy identified HREV in 71.8% (413/575) of patients. Multivariate analysis revealed six independent predictors: male sex, hemoglobin (HGB), platelet count (PLT), right liver thickness (RLT), portal vein diameter (PVD), and spleen diameter (SD). The developed nomogram demonstrated satisfactory discrimination, with AUROCs of 0.803 (95% CI: 0.755–0.850) in the training cohort and 0.807 (95% CI: 0.734–0.880) in the validation cohort, outperforming the biochemical scores APRI and AAR, and significantly improving risk reclassification over both FIB-4 and the platelet count-to-spleen diameter (PC/SD) ratio (NRI and IDI, all P < 0.05). It also outperformed each single component in the training cohort (spleen diameter alone, 0.742; P = 0.003) but not in validation (P = 0.061); at the fixed threshold of 0.770 the negative predictive value was 48.2%. Calibration and DCA confirmed satisfactory predictive accuracy and clinical utility. Conclusions A simple nomogram based on routine clinical and ultrasonographic variables stratified HREV risk and outperformed established biochemical scores. Its negative predictive value in this high-prevalence cohort was insufficient to defer endoscopy safely; the nomogram is therefore proposed for prioritising endoscopy where transient elastography is unavailable, rather than as a substitute for Baveno-based rule-out strategies. External validation in lower-prevalence populations is required.