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An index based on deep learning–measured spleen volume on CT for the assessment of high-risk varix in B-viral compensated cirrhosis



Deep learning enables an automated liver and spleen volume measurements on CT. The purpose of this study was to develop an index combining liver and spleen volumes and clinical factors for detecting high-risk varices in B-viral compensated cirrhosis.


This retrospective study included 419 patients with B-viral compensated cirrhosis who underwent endoscopy and CT from 2007 to 2008 (derivation cohort, n = 239) and from 2009 to 2010 (validation cohort, n = 180). The liver and spleen volumes were measured on CT images using a deep learning algorithm. Multivariable logistic regression analysis of the derivation cohort developed an index to detect endoscopically confirmed high-risk varix. The cumulative 5-year risk of varix bleeding was evaluated with patients stratified by their index values.


The index of spleen volume-to-platelet ratio was devised from the derivation cohort. In the validation cohort, the cutoff index value for balanced sensitivity and specificity (> 3.78) resulted in the sensitivity of 69.4% and the specificity of 78.5% for detecting high-risk varix, and the cutoff index value for high sensitivity (> 1.63) detected all high-risk varices. The index stratified all patients into the low (index value ≤ 1.63; n = 118), intermediate (n = 162), and high (index value > 3.78; n = 139) risk groups with cumulative 5-year incidences of varix bleeding of 0%, 1.0%, and 12.0%, respectively (p < .001).


The spleen volume-to-platelet ratio obtained using deep learning–based CT analysis is useful to detect high-risk varices and to assess the risk of varix bleeding.

Key Points

• The criterion of spleen volume to platelet > 1.63 detected all high-risk varices in the validation cohort, while the absence of visible varix did not exclude all high-risk varices.

• Visual varix grade ≥ 2 detected high-risk varix with a high specificity (96.5–100%).

• Combining spleen volume-to-platelet ratio ≤ 1.63 and visual varix grade of 0 identified low-risk patients who had no high-risk varix and varix bleeding on 5-year follow-up.

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Area under the ROC curve


Limit of agreement


Likelihood ratio


Negative predictive value


Positive predictive value


Receiver operating characteristics

Spleen vol/platelet:

Spleen volume-to-platelet ratio


  1. D’Amico G, Morabito A, D’Amico M et al (2018) Clinical states of cirrhosis and competing risks. J Hepatol 68:563–576

    Article  Google Scholar 

  2. Garcia-Tsao G, Abraldes JG, Berzigotti A, Bosch J (2017) Portal hypertensive bleeding in cirrhosis: risk stratification, diagnosis, and management: 2016 practice guidance by the American Association for the Study of Liver Diseases. Hepatology 65:310–335

    Article  Google Scholar 

  3. de Franchis R, Baveno VIF (2015) Expanding consensus in portal hypertension: report of the Baveno VI consensus workshop: stratifying risk and individualizing care for portal hypertension. J Hepatol 63:743–752

    Article  Google Scholar 

  4. Zhang C, Thabut D, Kamath PS, Shah VH (2011) Oesophageal varices in cirrhotic patients: from variceal screening to primary prophylaxis of the first oesophageal variceal bleeding. Liver Int 31:108–119

    Article  CAS  Google Scholar 

  5. de Franchis R, Pascal JP, Ancona E et al (1992) Definitions, methodology and therapeutic strategies in portal hypertension. A consensus development workshop, Baveno, Lake Maggiore, Italy, April 5 and 6, 1990. J Hepatol 15:256–261

    Article  Google Scholar 

  6. Berzigotti A, Seijo S, Arena U et al (2013) Elastography, spleen size, and platelet count identify portal hypertension in patients with compensated cirrhosis. Gastroenterology 144:102–111 e101

    Article  Google Scholar 

  7. Takuma Y, Morimoto Y, Takabatake H et al (2017) Measurement of spleen stiffness with acoustic radiation force impulse imaging predicts mortality and hepatic decompensation in patients with liver cirrhosis. Clin Gastroenterol Hepatol 15:1782–1790 e1784

    Article  Google Scholar 

  8. Giannini E, Botta F, Borro P et al (2003) Platelet count/spleen diameter ratio: proposal and validation of a non-invasive parameter to predict the presence of oesophageal varices in patients with liver cirrhosis. Gut 52:1200–1205

    Article  CAS  Google Scholar 

  9. Thabut D, Trabut JB, Massard J et al (2006) Non-invasive diagnosis of large oesophageal varices with FibroTest in patients with cirrhosis: a preliminary retrospective study. Liver Int 26:271–278

    Article  Google Scholar 

  10. Vizzutti F, Arena U, Romanelli RG et al (2007) Liver stiffness measurement predicts severe portal hypertension in patients with HCV-related cirrhosis. Hepatology 45:1290–1297

    Article  Google Scholar 

  11. Kim H, Choi D, Gwak GY et al (2009) Evaluation of esophageal varices on liver computed tomography: receiver operating characteristic analyses of the performance of radiologists and endoscopists. J Gastroenterol Hepatol 24:1534–1540

    Article  Google Scholar 

  12. Wong GL, Liang LY, Kwok R et al (2019) Low risk of variceal bleeding in patients with cirrhosis after variceal screening stratified by liver/spleen stiffness. Hepatology 70:971–981

    Article  Google Scholar 

  13. Abe H, Midorikawa Y, Matsumoto N et al (2019) Prediction of esophageal varices by liver and spleen MR elastography. Eur Radiol 29:6611–6619

    Article  Google Scholar 

  14. Kim BK, Han KH, Park JY et al (2010) A liver stiffness measurement-based, noninvasive prediction model for high-risk esophageal varices in B-viral liver cirrhosis. Am J Gastroenterol 105:1382–1390

    Article  Google Scholar 

  15. Iranmanesh P, Vazquez O, Terraz S et al (2014) Accurate computed tomography-based portal pressure assessment in patients with hepatocellular carcinoma. J Hepatol 60:969–974

    Article  Google Scholar 

  16. Perri RE, Chiorean MV, Fidler JL et al (2008) A prospective evaluation of computerized tomographic (CT) scanning as a screening modality for esophageal varices. Hepatology 47:1587–1594

    Article  Google Scholar 

  17. Yu NC, Margolis D, Hsu M, Raman SS, Lu DS (2011) Detection and grading of esophageal varices on liver CT: comparison of standard and thin-section multiplanar reconstructions in diagnostic accuracy. AJR Am J Roentgenol 197:643–649

    Article  Google Scholar 

  18. Yan SP, Wu H, Wang GC, Chen Y, Zhang CQ, Zhu Q (2015) A new model combining the liver/spleen volume ratio and classification of varices predicts HVPG in hepatitis B patients with cirrhosis. Eur J Gastroenterol Hepatol 27:335–343

    Article  Google Scholar 

  19. Son JH, Lee SS, Lee Y et al (2020) Assessment of liver fibrosis severity using computed tomography-based liver and spleen volumetric indices in patients with chronic liver disease. Eur Radiol.

  20. Park HJ, Park B, Lee SS (2020) Radiomics and deep learning: hepatic applications. Korean J Radiol 21:387–401

    Article  Google Scholar 

  21. Ahn Y, Yoon JS, Lee SS et al (2020) Deep learning algorithm for automated segmentation and volume measurement of the liver and spleen using portal venous phase computed tomography images. Korean J Radiol 21:987–997

    Article  Google Scholar 

  22. Chen L-C ZY, Papandreou G, Schroff F, Adam H (2018) Encoder-decoder with atrous separable convolution for semantic image segmentation. European Conference on Computer Vision (ECCV), Munich

  23. Idezuki Y (1995) General rules for recording endoscopic findings of esophagogastric varices (1991). Japanese Society for Portal Hypertension. World J Surg 19:420–422 discussion 423

    Article  CAS  Google Scholar 

  24. Landis JR, Koch GG (1977) The measurement of observer agreement for categorical data. Biometrics 33:159–174

    Article  CAS  Google Scholar 

  25. Bohning D, Holling H, Patilea V (2011) A limitation of the diagnostic-odds ratio in determining an optimal cut-off value for a continuous diagnostic test. Stat Methods Med Res 20:541–550

    Article  Google Scholar 

  26. Ronot M, Lambert S, Elkrief L et al (2014) Assessment of portal hypertension and high-risk oesophageal varices with liver and spleen three-dimensional multifrequency MR elastography in liver cirrhosis. Eur Radiol 24:1394–1402

    PubMed  Google Scholar 

  27. Shin SU, Lee JM, Yu MH et al (2014) Prediction of esophageal varices in patients with cirrhosis: usefulness of three-dimensional MR elastography with echo-planar imaging technique. Radiology 272:143–153

    Article  Google Scholar 

  28. European Association for the Study of the Liver (2018) EASL clinical practice guidelines for the management of patients with decompensated cirrhosis. J Hepatol 69:406–460

  29. Rockey DC, Caldwell SH, Goodman ZD, Nelson RC, Smith AD, American Association for the Study of Liver Diseases (2009) Liver biopsy. Hepatology 49:1017–1044

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This research was supported by the National Research Foundation of Korea (NRF) grant funded by the Korea government (Grant Number, 2020R1F1A1048826) and the Bio and Medical Technology Development Program of the NRF funded by the Ministry of Science and ICT, and Future Planning (Grant Number, NRF-2016M3A7918706).

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Correspondence to Seung Soo Lee.

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Lee, Cm., Lee, S.S., Choi, WM. et al. An index based on deep learning–measured spleen volume on CT for the assessment of high-risk varix in B-viral compensated cirrhosis. Eur Radiol 31, 3355–3365 (2021).

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