Portal hypertension in children can result from a wide range of liver diseases, both cirrhotic and non-cirrhotic. Non-invasive diagnosis of esophageal varices, a potentially life-threatening complication, is of utmost importance in these patients.

To assess the agreement between spleen stiffness by bidimensional shear wave elastography (2D SWE) and endoscopic findings (presence and grading of esophageal varices) in pediatric patients with portal hypertension.

Single-center retrospective observational study between February 2021 and August 2024. Data from pediatric patients (< 18 years old) who underwent esophagogastroduodenoscopy within a month of a grayscale ultrasound including spleen elastography were collected. Patients were divided into three groups: varices-free, low-risk varices, and high-risk varices (enlarged tortuous varices with red color sign, or large size varices). The area under the receiver operating characteristic curve (AUROC), positive predictive value (PPV), and negative predictive value (NPV) were estimated.

We included 163 patients (86 males, 77 females; median age: 9 years (interquartile range (IQR) 6–13 years)). The sample included 80 varices-free (49%), 38 low-risk varices (23%), and 45 high-risk varices (28%) cases. The median spleen elastography was 20 kPa (2.58 m/s), 34 kPa (3.36 m/s), and 40 kPa (3.65 m/s) in the varices-free, low-risk, and high-risk varices groups, respectively. When a cut-off value of 28.5 kPa (3.08 m/s) was used to detect varices of any grade, the sensitivity was 93% (95% confidence interval: 85–97), the specificity was 94% (86–98), PPV 94% (86–98), and NPV 93% (85–97). An AUROC of 0.93 (0.90–0.98) was obtained. When comparing the high versus low-risk varices groups, using a cut-off point of 35.35 kPa (3.43 m/s), we obtained an AUROC of 0.66, with a sensitivity of 71%, specificity of 61%, PPV 68%, and NPV of 64%.

Spleen stiffness by bidimensional shear wave elastography showed excellent diagnostic performance for detecting esophageal varices in children with portal hypertension and a moderate performance for distinguishing patients with low-risk varices from those with high-risk varices.