Diagnostic accuracy of spleen stiffness measurement for detecting esophageal varices and high-risk varices: A systematic review and meta-analysis across elastography modalities

A critical secondary effect of portal hypertension associated with chronic liver disease is the formation of esophageal varices, which act as a main trigger for upper gastrointestinal hemorrhage. Endoscopic screening is recommended to identify patients at risk, but it is invasive, costly, and not widely available. Evaluating splenic stiffness has emerged as a potential non-invasive diagnostic option because it reflects splenic congestion associated with portal hypertension rather than intrahepatic fibrosis alone. Several studies have evaluated spleen stiffness measurement (SSM) using different elastography techniques, reporting heterogeneous diagnostic performances. The aim of this study was to assess the diagnostic precision of SSM in identifying esophageal varices and high-risk esophageal varices (HREV), with secondary analyses comparing performance across elastography modalities. A systematic review alongside a diagnostic test accuracy meta-analysis was performed following Preferred Reporting Items for Systematic Reviews and Meta-Analyses of Diagnostic Test Accuracy Studies (PRISMA-DTA) guidelines, registered in the International Prospective Register of Systematic Reviews (PROSPERO) (CRD420251207420). Literature searches were performed in PubMed, Google Scholar, ProQuest, and EBSCOhost. Studies were eligible if spleen stiffness served as the index test and esophagogastroduodenoscopy was utilized as the gold standard. Methodological quality was evaluated using Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2). Key endpoints included combined sensitivity and overall specificity. Subgroup analyses examined differences among elastography modalities. This study included 6,322 patients across 50 distinct studies. Diagnostic accuracy was generally consistent across elastography techniques. When identifying esophageal varices, the overall pooled sensitivity was 0.88 (95% confidence interval (CI): 0.85–0.91), and specificity was 0.76 (95%CI: 0.70–0.82). However, HREV provided a slightly enhanced diagnostic yield, achieving a higher sensitivity of 0.91 (95%CI: 0.89–0.93) but a slightly lower specificity of 0.71 (95%CI: 0.66–0.76). SSM showed intermediate specificity and high sensitivity as a non-invasive HREV rule-out method. Its ability to pinpoint high-risk varices underlines its potential as an effective, non-invasive screening strategy for chronic liver disease.