Cholestasis Impacts on Performance of Non Invasive Tests for Ruling out High-Risk Esophageal Varices in Patients with Primary Biliary Cholangitis and Compensated Advanced Chronic Liver Disease

IntroductionNon-invasive tests (NITs) to identify patients with Primary Biliary Cholangitis (PBC) and compensated Advanced Chronic Liver Disease (cACLD) who can avoid esophagogastroduodenoscopy (EGDS) are lacking. Aims of this study were to evaluate the diagnostic performance of NITs to rule out high-risk esophageal varices (HRV) in patients with PBC-related cACLD and to assess the influence of cholestasis on the NITs performance.MethodData of patients with cACLD from 24 centres participating to “Italian PBC registry”, were captured. All PBC patients who performed an EGD for evaluation of signs of portal hypertension were analyzed. Outcome was the presence of HRV at index EGD. RESIST criteria (platelets - PLT >120 × 109/L and serum albumin >3.6 g/dL) were compared with elastography-based criteria (Baveno VI, Expanded Baveno VI, and Baveno VII) in patients with Alkaline Phosphatase (ALP) < or ³ 1.67 ULN. Decision curve analysis (DCA) of NITs were calculated.ResultThe cohort consisted of 250 patients. At EGDS, 137 patients (54.8%) had no varices, 79 (31.6%) had low-risk varices and 34 (13.6%) had HRV. Liver stiffness by Fibroscan was available in 186 patients (74.%). Overall, the proportion of correctly spared endoscopies for HRV was 61.1%, 54.1%, 31.4% and 18.2% for RESIST, Expanded Baveno VI, Baveno VI and Baveno VII criteria, respectively. and RESIST criteria were associated with the lowest rate of missing HRV (2.9%). In patients with ALP ³ 1.67 ULN (101, 40.4%) the rate of missing HRV for Baveno VI and Expandend Baveno VI criteria were 23.8 and 18.9% respectively. In the same category of patients RESIST criteria false negative rate was 6%. DCA demonstrates the highest net benefit of RESIST criteria compared to elastography-based criteria for ruling out HRV both in patients with ALP < or ³ 1.67 ULN (Figure 1).ConclusionCholestasis impacts on NITs ability to rule out HRV in patients with PBC and cACLD. Biochemical-based RESIST criteria demonstrates the highest net benefit compared to elastography-based criteria for ruling out HRV.