What did we learn from the first 3,459 cases of liver stiffness measurement by transient elastography (FibroScan®)?

PURPOSE

Chronic viral hepatopathies can be evaluated through invasive or noninvasive methods. The aim of this paper was to assess the indications and results of transient elastographic (TE) evaluation of the liver in patients with chronic viral hepatitis and cirrhosis.

MATERIALS AND METHODS

We retrospectively assessed all the liver stiffness measurements (LSM) (FibroScan®) performed over a two-year period (2007 - 2009).

RESULTS

3,459 TE evaluations were made mainly for the assessment of: HCV hepatitis, HBV infection (chronic hepatitis and inactive HBV carriers), biviral hepatitis (B + C or B + D), cirrhosis and in 176 normal subjects (to establish the normal values of LSM). From the 3,459 FS evaluations, we could not obtain valid LSM in 183 cases (5.3 %). 93.9 % of the patients in the failure group were overweight (BMI > 25 kg/m²). In 527 cases (16 %) the SR (success rate = number of valid measurements/total number of measurements) was < 60 %. TE reproducibility was analyzed in 287 cases. The ICCs for the three operators were 0.985, 0.949, and 0.874 respectively, and the overall ICC was 0.982. 596 cases of cirrhosis were evaluated. A cut-off value of 23.3kPa was found to predict the presence of at least grade 2 esophageal varices.

CONCLUSION

LSM by means of TE is a promising noninvasive evaluation method, which can be used in numerous clinical situations, some in which its value is well established (suspicion of LC, predicting significant fibrosis) and some in which its value is less known (HBV chronic hepatitis, inactive HBV carriers or severity of portal hypertension).

Acoustic radiation force impulse elastography as compared to transient elastography and liver biopsy in patients with chronic hepatopathies

PURPOSE

To compare two methods of noninvasive assessment: transient elastography (TE) and acoustic radiation force impulse elastography (ARFI).

PATIENTS AND METHODS

Our study included 114 subjects: 38 healthy volunteers, (considered to have no fibrosis - F 0) and 76 patients with chronic liver disease: 53 who had undergone liver biopsy (LB) (7 with F 1, 24 with F 2, 22 with F 3 Metavir) and 23 previously diagnosed with cirrhosis (F4 Metavir). In each patient we performed a liver stiffness measurement by means of TE and ARFI. ARFI (shear wave velocity quantification) was performed at 3 points: at 0 - 1 cm, at 1 - 2 cm and at 2 - 3 cm under the capsule. For each depth, 5 valid measurements were made, and a median value was calculated, measured in m/sec.

RESULTS

A direct, strong, linear correlation (Spearman rho = 0.848) was found between TE and the stage of fibrosis (p < 0.001). A significant, direct correlation was found between ARFI measurements made 1 - 2 cm and 2 - 3 cm below the liver capsule and the severity of fibrosis (rho = 0.675 and 0.714 respectively). The subcapsularly measured ARFI values showed a poor correlation with fibrosis (rho = 0.469). The best test for predicting significant fibrosis (F ≥ 2) was TE, with the area under receiver-operating characteristic curve (AUROC) 0.908, significantly larger than the AUROCs for ARFI. If only ARFI is considered, measurements made 1 - 2 and 2 - 3 cm below the capsule have the best predictive value, with AUROCs not significantly different from each other (0.767 and 0.731, respectively). For predicting fibrosis (F > 0), TE had the best predictive value: optimized cut-off 5.65 kPa (AUROC -0.898). For ARFI, the cut-offs were: 1.4 m/sec, AUROC -0.747 (1 - 2 cm), and 1.26 m/sec AUROC -0.721 (2 - 3 cm). For predicting cirrhosis (F = 4 Metavir), the optimized cut-offs were: TE -12.9 kPa (AUROC -0.994); ARFI - 1.78 m/sec for measurements made 2 - 3 cm below the capsule, AUROC - 0.951.

CONCLUSION

At present, liver elasticity evaluation by means of ARFI is not superior to TE for the assessment of liver fibrosis. For ARFI, the most reliable results are obtained if measurements are made 1 - 2 and 2 - 3 cm below the liver capsule. ARFI is an accurate test for the diagnosis of cirrhosis.

Ultrasound examination of the normal gastrointestinal tract

The sonographic evaluation of the gastrointestinal tract regards experienced sonographers who are able to identify all abdominal and parenchymal structures. Transabdominal ultrasonography allows the evaluation of the entire digestive tract, starting with the oesophagus (especially the oesogastric junction), followed by the examination of the stomach, duodenum and small bowel, and ending with the appendix and colon. In order to be able to find pathological aspects, we should be familiar with the normal ultrasound aspect of different parts of the gastrointestinal tract. By becoming more experienced in abdominal ultrasonography, the visualization of the gastrointestinal tract will become easier.

How useful is contrast enhanced ultrasonography for the characterization of focal liver lesions?

AIM

Focal liver lesions (FLLs) are quite frequently discovered in daily practice at routine ultrasound. The aim of our study is to present a single centre experience concerning the use of contrast enhanced ultrasound (CEUS) in the characterization of FLL and to find when one can avoid using other expensive imaging modalities such as contrast enhanced CT or MRI.

METHOD

We performed a prospective, single centre study during September 2009 - April 2010, and we evaluated 379 FLLs. A CEUS examination was considered conclusive if the FLL had a typical enhancement pattern according to the EFSUMB guidelines.

RESULTS

From the 379 cases with FLL, 198 (52.2%) were patients without known liver disease and 181 (47.8%) with known chronic liver disease (156 had cirrhosis, 25 chronic hepatitis); in 296/379 cases (78.1%) CEUS was conclusive. CEUS allowed the positive diagnosis of benign vs. malignant lesion in 261/294 (88.8%) de novo FLLs (CEUS performed for the first time), while in 33 (11.2%) cases it was inconclusive and could not differentiate between benign or malignant lesions. The CEUS results included 129 (49.4%) benign lesions and 132 (50.6%) malignant.

CONCLUSION

CEUS was conclusive in approximately 80% of the FLLs and the benign or malignant character of a lesion was demonstrated in about 90% of cases. Thus, when faced with an uncharacteristic FLL on standard ultrasound examination, our local strategy is to perform CEUS as a first-line investigation, thus avoiding other expensive examinations.

Liver stiffness measurements in patients with HBV vs HCV chronic hepatitis: a comparative study

AIM

To assess the values of liver stiffness (LS) in patients with hepatitis B virus (HBV) chronic hepatitis and to compare them with those in patients with hepatitis C virus (HCV) chronic hepatitis.

METHODS

The study included 140 patients with HBV chronic hepatitis, and 317 patients with HCV chronic hepatitis, in which LS was measured (FibroScan®-Echosens®) and liver biopsy was performed in the same session (assessed according to the Metavir score).

RESULTS

According to the Metavir score of the 140 HBV patients: one had F0, 32 had F1, 67 had F2, 33 had F3 and 7 had F4. Of the 317 HCV patients: 5 had F0, 34 had F1, 146 had F2, 93 had F3 and 39 had F4. For the same severity of fibrosis, the mean values of LS in HBV patients were similar to those in HCV patients: F1, 6.5 ± 1.9 kPa vs 5.8 ± 2.1 kPa (P = 0.0889); F2, 7.1 ± 2 kPa vs 6.9 ± 2.5 kPa (P = 0.3369); F3, 9.1 ± 3.6 kPa vs 9.9 ± 5 kPa (P = 0.7038); F4, 19.8 ± 8.6 kPa vs 17.3 ± 6.1 kPa (P = 0.6574). A significant direct correlation between LS measurements and fibrosis was found in HCV patients (Spearman's r = 0.578, P < 0.0001), as well as in HBV patients (r = 0.408, P < 0.0001). The correlation was more significant in HCV than in HBV patients (Fisher's Z-test, Z = 2.210, P = 0.0271).

CONCLUSION

In our group, the mean values of LS in patients with chronic B hepatitis were similar to those in patients with chronic HCV hepatitis, for the same stage of fibrosis. Also, LS was correlated with the severity of fibrosis both in HBV and HCV chronic hepatitis patients.

Outcome of antiviral treatment in patients with chronic genotype 1 HCV hepatitis. A retrospective study in 507 patients

BACKGROUND AND AIM

The current standard of care in chronic HCV genotype 1 hepatitis is the combination of pegylated interferon (PegIFN) with ribavirin for 48 weeks. The aim of our paper was to verify if there are significant differences regarding the sustained virologic response (SVR) in patients treated with PegIFN alfa-2a vs. those treated PegIFN alpha-2b, both in combination with ribavirin.

METHOD

We performed a retrospective study on 507 patients with chronic viral C hepatitis treated with PegIFN alpha-2a 180 microg/kg/week or PegIFN alpha-2b 1.5 microg/kg/week plus ribavirin in the recommended doses according to weight, following the current treatment guidelines. We evaluated the SVR defined as PCR RNA-HCV undetectable 24 weeks after the end of treatment.

RESULTS

There were no differences regarding the baseline characteristics among the subgroups of patients treated with PegIFN alpha-2a or PegIFN alpha-2b concerning the pretreatment viral load (p=0.2445), the severity of fibrosis (p=0.2403), the mean age of the patients (p=0.9597) and the women/men ratio (p=0.2087). The SVR rates in patients treated with PegIFN alpha-2a were similar to those in patients treated with PegIFN alpha-2b: 208/338 (61.5%) vs. 94/169 (55.6%) (p=0.2129).

CONCLUSION

Sustained virologic response rates were similar in HCV genotype 1 patients treated with PegIFN alpha-2a and with Peg-IFN alpha-2b.

Colonoscopy and sedation in Romania: early experience using a balanced propofol regimen

The aim of this study was to evaluate if the sedation during colonoscopy is correctly performed in our patients, especially because it is usually performed by residents in anesthesiology.

METHODS

we retrospectively evaluated sedation in all the colonoscopies performed in our Endoscopy Department in 2007, by analyzing the sedation scheme that was used.

RESULTS

974 colonoscopies were evaluated. The following sedation schemes were used in the majority of cases: midazolam+propofol+fentanyl-507 patients (52.1%) and diazepam+propofol+fentanyl-258 patients (26.5%). Propofol (in combination with one or more other agents) was used for sedation in 96.9% of cases. The mean doses of drugs were: propofol 125.2+/-67.7 mg, midazolam 2.29+/-0.84 mg (or diazepam 3.4+/-1.4 mg) and fentanyl 59+/-10 microg. The following complications were observed during sedation for colonoscopy: 6 patients (0.6%) developed hypoxemia, which was managed successfully with supplemental oxygen administration or flumazenil injection; 1 patient (0.1%) suffered a cardiac arrest that was successfully managed. There were no deaths or other complications.

CONCLUSIONS

Propofol, combined with an opioid and a benzodiazepine, was used in approximately 97% of cases. The rate of significant oxygen desaturation was low (0.6%). No fatal complications occurred. The mean doses of propofol used were higher than those from published data, while the doses of midazolam and fentanyl were similar.

Acoustic Radiation Force Impulse (ARFI)--a new modality for the evaluation of liver fibrosis

AIM

to assess the accuracy of transient elastography (TE) and Acoustic Radiation Force Impulse (ARFI) for liver fibrosis assessment, as compared to percutaneous liver biopsy (LB) in patients with chronic hepatitis.

PATIENTS AND METHODS

Our study included 71 patients (P) (54 with HCV and 17 with HBV chronic hepatitis) in which we compared TE and ARFI to the LB (evaluated according to the Metavir scoring system).

RESULTS

On LB, from the 71P, 6P (8.4%) had F1, 25P (35.2%) had F2, 24P (33.8%) had F3 and 16P (22.5%) had F4. A direct, strong, linear correlation (Spearman r=0.707) was found between TE measurements and fibrosis (p<0.0001) and a weaker one, between ARFI and fibrosis (rho=0.469; p<0.0001). TE measurements were also correlated with ARFI measurements r=0.532, p<0.0001. By comparing the AUROC curves, TE and ARFI had similar predictive values for the presence of significant fibrosis (F greater or equal to 2 Metavir): AUROC ARFI=0.649, AUROC TE=0.731 (p=0.476); and cirrhosis (F=4 Metavir): AUROC ARFI=0.868, AUROC TE= 0.936 (p=0.294)

CONCLUSION

LS measurements assessed by means of TE correlate better than those assessed by means of ARFI to the histological fibrosis in patients with HBV and HCV chronic hepatitis. Both methods have excellent predictive values for the presence of cirrhosis.

Current situation of colonoscopy in Romania--3 years of colonoscopy performance

The aim of this paper is to evaluate the situation of colonoscopy in Romania in 2007, as compared to a study we performed in 2004.

MATERIAL AND METHOD

We performed a multicentric prospective study, by means of a questionnaire distributed to 36 centers of endoscopy from Romania, requesting the total number of colonoscopies performed in March 2007, the number of complete and incomplete colonoscopies, the number of colonoscopies performed with or without sedation. A number of 28 centers responded to our questionnaire, 15 university and 13 non-university departments.

RESULTS

According to the responses we received, 2,684 colonoscopies were performed in March 2007, with a mean number of 96 colonoscopies/month/center, 76.9% of them total. In the university departments 1,776 colonoscopies were performed, 78.9% total, while in the non university departments 908 colonoscopies were performed, 73.1% total (p=0.0021). 46.7% of the colonoscopies were performed without sedation, 53.2% with sedation and 0.1% under general anesthesia (intra surgery colonoscopy). In conclusion, this multicentric prospective study has shown a slight increase in the number of colonoscopies as compared to 2004 (though insignificant), but with an improvement in quality (total colonoscopies 76.9%-2007 vs. 70.5%-2004, p<0.001). There still exists a difference regarding the performance in university vs. non university departments, and the percentage of cases in which sedation was used during colonoscopy is approximately the same (46.7%), still very small.

Diabetes mellitus and chronic HCV infection

The aim of our paper was to assess the prevalence of anti HCV antibodies among diabetics from Romania.

MATERIAL AND METHOD

We performed two studies: a prospective randomized one, on 559 diabetics from Timişoara, and a second, retrospective-descriptive one, on 625 diabetics from Petroşani, who were tested for anti HCV antibodies.

RESULTS

I. In Timişoara, 559 diabetics were prospectively evaluated, 4.5% (25p.) were anti HCV positive. There were no statistically significant differences between the proportions of type I DM in the anti HCV positive group (4%-1p.) as compared to the entire group (12%-67p.) (p=0.3429), nor in the F: M ratio, 1.3:1 vs. 1.5:1 (p=0.838). II. In Petroşani, 625 diabetics were retrospectively evaluated, 7.7% (48p.) were anti HCV positive. There were no significant differences between the proportions of type I DM in the anti HCV positive group (6%-3p.) vs. the entire group (8%-53p.) (p=0.788), nor in the F: M ratio, 1.7:1 vs. 1.7:1 (p=1).

CONCLUSION

The prevalence of anti HCV antibodies among diabetics from Romania is rather high (4.5% in a randomized prospective trial and 7.7% in a retrospective descriptive trial) so that this special population (especially type II DM) should be screened for HCV infection, even if the aminotransferases are normal.

Comparison of the liver stiffness measurement by transient elastography with the liver biopsy

AIM: To compare the liver stiffness (LS) measurement by transient elastography (TE) to the liver biopsy (LB)-considered the “gold standard” in the evaluation of patients with chronic hepatitis C.

METHODS: During a period of 12 mo, we evaluated 199 consecutive patients with chronic hepatitis due to hepatitis C virus (HCV), in which LB and LS assessments (by means of TE) were performed during the same session.

RESULTS: Out of 199 patients, a valid measurement of the LS could not be obtained in 8. The mean value of LS in the cohort of 191 valid measurements was 8.45 ± 4.96 kPa, ranging from 2.3 to 38 kPa.The mean value of LS in patients with significant fibrosis at biopsy (161 patients with F ≥ 2 according to Metavir) was 9.02 ± 5.15 kPa, significantly higher than in patients with no or mild fibrosis (30 patients with F < 2 Metavir): 5.39 ± 1.81 kPa (P < 0.0001). For a cut-off value of 6.8 kPa, the LS had a PPV of 98%, a NPV of 30.1%, a sensitivity of 59.6% and a specificity of 93.3% for the presence of significant fibrosis (at least F2 Metavir), with a diagnostic performance of 77.3% (AUROC 0.773). Using this cut-off value, we reached the best discrimination between absence of fibrosis/mild fibrosis (F < 2 Metavir) and the presence of moderate to severe fibrosis (F ≥ 2 Metavir).

CONCLUSION: In patients with chronic hepatitis due to HCV, a cut-off value of 6.8 kPa measured by TE can differentiate between significant fibrosis and absent or mild fibrosis, with a PPV of 98%, a NPV of 30.1%, a sensitivity of 59.6%, a specificity of 93.3%, and a diagnostic performance of 77.3%.