Non-Invasive Radiological Predictors Of Portal Hypertension And Variceal Bleeding In Chronic Liver Disease Patients: A Prospective Cohort Study At Hayatabad Medical Complex, Peshawar

Background:Portal hypertension and variceal bleeding are leading causes of morbidity and mortality in chronic liver disease (CLD). Invasive tools remain the gold standard for risk assessment, but resource and patient constraints demand validated, non-invasive alternatives, especially in low- and middle-income settings. To determine the diagnostic and prognostic accuracy of non-invasive radiological predictors for portal hypertension and first variceal bleeding in patients with CLD at Hayatabad Medical Complex, Peshawar. Methods:A prospective cohort of 371 adults with cirrhosis was followed for 12 months (May 2024–May 2025). All patients underwent standardized assessment with transient elastography (FibroScan®), contrast-enhanced ultrasound, and MRI. Baseline liver stiffness measurement (LSM), spleen stiffness measurement (SSM), splenic size, portal vein diameter, and platelet count-to-spleen diameter ratio (PSR) were evaluated. Multivariable Cox regression and AUROC analyses identified predictors of portal hypertension and first variceal bleed. Results:Portal hypertension was present in 222/371 (59.8%) at baseline. Over 12 months, 54 patients (14.6%) developed a first variceal bleed. LSM >20 kPa (HR 3.31, 95% CI 2.01–5.44), SSM >46 kPa (HR 2.89, 95% CI 1.67–4.99), portal vein diameter >13 mm (HR 2.61, 95% CI 1.51–4.51), splenomegaly (HR 2.45, 95% CI 1.19–4.97), and PSR <909 (HR 2.38, 95% CI 1.32–4.28) independently predicted variceal bleeding. The combined non-invasive model achieved an AUROC of 0.88 (95% CI 0.83–0.92). Subgroup and sensitivity analyses confirmed robustness across etiology, sex, and Child-Pugh class. Conclusions:A combination of liver and spleen stiffness and simple ultrasound indices offers high diagnostic and prognostic accuracy for portal hypertension and variceal bleeding in CLD. Adoption of these non-invasive tools could significantly improve risk stratification and reduce the need for routine endoscopy, particularly in resource-limited settings.