The role of four-dimensional flow MRI as an adjunct to endoscopy for predicting variceal bleeding in patients with cirrhosis

Non-invasive approach other than conventional endoscopy could be effectively used for screening and monitoring esophageal variceal bleeding (EVB). To retrospectively investigate the role of four-dimensional (4D) flow magnetic resonance imaging (MRI) as an add-on tool to endoscopy for predicting EVB in cirrhotic patients with esophageal varices (EVs). A cohort of 109 cirrhotic patients with EVs was divided into four groups: A = negative red color [RC] sign, no EVB, n = 60; B = negative RC sign, EVB, n = 13; C = positive RC sign, no EVB, n = 10; and D = positive RC sign, EVB, n = 26. All patients underwent laboratory assessments and 4D flow MRI using a 3-T scanner to analyze hemodynamic parameters within the main portal vein (PV), splenic vein, and superior mesenteric vein. Comparative analysis of 4D flow parameters among the groups was performed using the Mann-Whitney U-test, and diagnostic accuracy was assessed through the area under the receiver operator characteristic curve (AUC). In the main PV, all 4D flow parameters were significantly lower in patients with a positive RC sign compared to those with a negative RC sign (P < 0.05). Patients with EVB had lower parameters than those without EVB (P < 0.05). The AUC values predicting actual variceal bleeding was 0.762 for endoscopy alone and 0.770-0.787 for 4D flow MRI. Integrating the endoscopic classification with the 4D flow MRI significantly improved the AUC value to 0.871 (P < 0.05). Four-dimensional flow MRI may be useful as an add-on tool to endoscopy for predicting actual bleeding in cirrhotic patients with EVs.