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Yi HM, Lowerison MR, Song PF, Zhang W. A Review of Clinical Applications for Super-resolution Ultrasound Localization Microscopy. Curr Med Sci 2022; 42:1-16. [PMID: 35167000 DOI: 10.1007/s11596-021-2459-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Accepted: 03/11/2021] [Indexed: 12/21/2022]
Abstract
Microvascular structure and hemodynamics are important indicators for the diagnosis and assessment of many diseases and pathologies. The structural and functional imaging of tissue microvasculature in vivo is a clinically significant objective for the development of many imaging modalities. Contrast-enhanced ultrasound (CEUS) is a popular clinical tool for characterizing tissue microvasculature, due to the moderate cost, wide accessibility, and absence of ionizing radiation of ultrasound. However, in practice, it remains challenging to demonstrate microvasculature using CEUS, due to the resolution limit of conventional ultrasound imaging. In addition, the quantification of tissue perfusion by CEUS remains hindered by high operator-dependency and poor reproducibility. Inspired by super-resolution optical microscopy, super-resolution ultrasound localization microscopy (ULM) was recently developed. ULM uses the same ultrasound contrast agent (i.e. microbubbles) in CEUS. However, different from CEUS, ULM uses the location of the microbubbles to construct images, instead of using the backscattering intensity of microbubbles. Hence, ULM overcomes the classic compromise between imaging resolution and penetration, allowing for the visualization of capillary-scale microvasculature deep within tissues. To date, many in vivo ULM results have been reported, including both animal (kidney, brain, spinal cord, xenografted tumor, and ear) and human studies (prostate, tibialis anterior muscle, and breast cancer tumors). Furthermore, a variety of useful biomarkers have been derived from using ULM for different preclinical and clinical applications. Due to the high spatial resolution and accurate blood flow speed estimation (approximately 1 mm/s to several cm/s), ULM presents as an enticing alternative to CEUS for characterizing tissue microvasculature in vivo. This review summarizes the principles and present applications of CEUS and ULM, and discusses areas where ULM can potentially provide a better alternative to CEUS in clinical practice and areas where ULM may not be a better alternative. The objective of the study is to provide clinicians with an up-to-date review of ULM technology, and a practical guide for implementing ULM in clinical research and practice.
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Affiliation(s)
- Hui-Ming Yi
- Department of Medical Ultrasound, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China.,Beckman Institute for Advanced Science and Technology, University of Illinois at Urbana-Champaign, Urbana, 61801, USA.,Department of Electrical and Computer Engineering, University of Illinois at Urbana-Champaign, Urbana, 61801, USA
| | - Matthew R Lowerison
- Beckman Institute for Advanced Science and Technology, University of Illinois at Urbana-Champaign, Urbana, 61801, USA.,Department of Electrical and Computer Engineering, University of Illinois at Urbana-Champaign, Urbana, 61801, USA
| | - Peng-Fei Song
- Beckman Institute for Advanced Science and Technology, University of Illinois at Urbana-Champaign, Urbana, 61801, USA.,Department of Electrical and Computer Engineering, University of Illinois at Urbana-Champaign, Urbana, 61801, USA
| | - Wei Zhang
- Department of Medical Ultrasound, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China. .,Beckman Institute for Advanced Science and Technology, University of Illinois at Urbana-Champaign, Urbana, 61801, USA. .,Department of Electrical and Computer Engineering, University of Illinois at Urbana-Champaign, Urbana, 61801, USA.
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2
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Chang NW, Wang HK, Liu CS, Loong CC, Lai YC, Chiou HJ, Chou YH. First-Pass Arrival Interval of Ultrasound Contrast Medium in the Hepatic Artery and Portal Vein as a Marker for Assessment of Liver Transplant Recipients. Transplant Proc 2021; 53:2329-2334. [PMID: 34446308 DOI: 10.1016/j.transproceed.2021.07.050] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Accepted: 07/22/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND This study measures the first-pass arrival times in the hepatic artery and portal vein of the transplanted liver using contrast-enhanced ultrasound (CEUS) and assess its correlation with graft performance in the early posttransplant period. METHODS This study evaluated 35 liver transplant recipients who underwent CEUS examination within 1 month of transplant surgery. CEUS under contrast-specific harmonic imaging mode were recorded for 60 seconds immediately after intravenous administration of microbubble ultrasound contrast medium (Sonazoid, GE Healthcare, Oslo, Norway). The recorded video clips were reviewed by 2 readers to determine the first-pass arrival times in the hepatic artery and portal vein, and the difference between the 2 was defined as the arterial-portal arrival interval (APAI). Laboratory data on the same date of CEUS examination were collected as indicators to correlate with APAI. RESULTS The intra- and inter-rater reliability for APAI measurement were excellent, with intraclass correlation coefficients > .95. The mean APAI was 4.5 ± 1.8 seconds (range, 2.0-10.5 seconds). The APAI was positively correlated with the serum total bilirubin level (r = 0.357, P = .035) and negatively correlated with the platelet count (r = -0.354, P = .037). At the 5 second cutoff point, a total serum bilirubin of >8 mg/dL was reported in 5 of 11 patients (45.4%) with APAI of >5 seconds and in only 3 of 24 patients (12.5%) with APAI of <5 seconds (P < .05). CONCLUSIONS The APAI is a quantitative marker that links the hemodynamics and the clinical status of the liver graft.
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Affiliation(s)
- Nai-Wen Chang
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Hsin-Kai Wang
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan; School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.
| | - Chin-Su Liu
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan; Division of Transplantation Surgery, Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan; Division of Pediatric Surgery, Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Che-Chuan Loong
- Division of Transplantation Surgery, Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Yi-Chen Lai
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan; School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Hong-Jen Chiou
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan; School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Yi-Hong Chou
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan; School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan; Department of Medical Imaging and Radiological Technology, Yuanpei University of Medical Technology, Hsinchu, Taiwan; Department of Radiology, Yee Zen General Hospital, Taoyuan, Taiwan
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Lupsor-Platon M, Serban T, Silion AI, Tirpe GR, Tirpe A, Florea M. Performance of Ultrasound Techniques and the Potential of Artificial Intelligence in the Evaluation of Hepatocellular Carcinoma and Non-Alcoholic Fatty Liver Disease. Cancers (Basel) 2021; 13:790. [PMID: 33672827 PMCID: PMC7918928 DOI: 10.3390/cancers13040790] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2020] [Revised: 12/14/2020] [Accepted: 02/09/2021] [Indexed: 12/12/2022] Open
Abstract
Global statistics show an increasing percentage of patients that develop non-alcoholic fatty liver disease (NAFLD) and NAFLD-related hepatocellular carcinoma (HCC), even in the absence of cirrhosis. In the present review, we analyzed the diagnostic performance of ultrasonography (US) in the non-invasive evaluation of NAFLD and NAFLD-related HCC, as well as possibilities of optimizing US diagnosis with the help of artificial intelligence (AI) assistance. To date, US is the first-line examination recommended in the screening of patients with clinical suspicion of NAFLD, as it is readily available and leads to a better disease-specific surveillance. However, the conventional US presents limitations that significantly hamper its applicability in quantifying NAFLD and accurately characterizing a given focal liver lesion (FLL). Ultrasound contrast agents (UCAs) are an essential add-on to the conventional B-mode US and to the Doppler US that further empower this method, allowing the evaluation of the enhancement properties and the vascular architecture of FLLs, in comparison to the background parenchyma. The current paper also explores the new universe of AI and the various implications of deep learning algorithms in the evaluation of NAFLD and NAFLD-related HCC through US methods, concluding that it could potentially be a game changer for patient care.
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Affiliation(s)
- Monica Lupsor-Platon
- Medical Imaging Department, Regional Institute of Gastroenterology and Hepatology, Iuliu Hatieganu University of Medicine and Pharmacy, 400162 Cluj-Napoca, Romania
| | - Teodora Serban
- Medical Imaging Department, Iuliu Hatieganu University of Medicine and Pharmacy, 400162 Cluj-Napoca, Romania; (T.S.); (A.I.S.)
| | - Alexandra Iulia Silion
- Medical Imaging Department, Iuliu Hatieganu University of Medicine and Pharmacy, 400162 Cluj-Napoca, Romania; (T.S.); (A.I.S.)
| | - George Razvan Tirpe
- County Emergency Hospital Cluj-Napoca, 3-5 Clinicilor Street, 400000 Cluj-Napoca, Romania;
| | - Alexandru Tirpe
- Research Center for Functional Genomics, Biomedicine and Translational Medicine, Iuliu Hatieganu University of Medicine and Pharmacy, 23 Marinescu Street, 400337 Cluj-Napoca, Romania;
| | - Mira Florea
- Community Medicine Department, Iuliu Hatieganu University of Medicine and Pharmacy, 400001 Cluj-Napoca, Romania;
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4
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Basavarajappa L, Baek J, Reddy S, Song J, Tai H, Rijal G, Parker KJ, Hoyt K. Multiparametric ultrasound imaging for the assessment of normal versus steatotic livers. Sci Rep 2021; 11:2655. [PMID: 33514796 PMCID: PMC7846566 DOI: 10.1038/s41598-021-82153-z] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Accepted: 01/15/2021] [Indexed: 12/13/2022] Open
Abstract
Liver disease is increasing in prevalence across the globe. We present here a multiparametric ultrasound (mpUS) imaging approach for assessing nonalcoholic fatty liver disease (NALFD). This study was performed using rats (N = 21) that were fed either a control or methionine and choline deficient (MCD) diet. A mpUS imaging approach that includes H-scan ultrasound (US), shear wave elastography, and contrast-enhanced US measurements were then performed at 0 (baseline), 2, and 6 weeks. Thereafter, animals were euthanized and livers excised for histological processing. A support vector machine (SVM) was used to find a decision plane that classifies normal and fatty liver conditions. In vivo mpUS results from control and MCD diet fed animals reveal that all mpUS measures were different at week 6 (P < 0.05). Principal component analysis (PCA) showed that the H-scan US data contributed the highest percentage to the classification among the mpUS measurements. The SVM resulted in 100% accuracy for classification of normal and high fat livers and 92% accuracy for classification of normal, low fat, and high fat livers. Histology findings found considerable steatosis in the MCD diet fed animals. This study suggests that mpUS examinations have the potential to provide a comprehensive estimation of the main components of early stage NAFLD.
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Affiliation(s)
- Lokesh Basavarajappa
- Department of Bioengineering, University of Texas at Dallas, BSB 13.929, 800 W Campbell Rd, Richardson, TX, 75080, USA
| | - Jihye Baek
- Department of Electrical and Computer Engineering, University of Rochester, Rochester, NY, USA
| | - Shreya Reddy
- Department of Bioengineering, University of Texas at Dallas, BSB 13.929, 800 W Campbell Rd, Richardson, TX, 75080, USA
| | - Jane Song
- Department of Bioengineering, University of Texas at Dallas, BSB 13.929, 800 W Campbell Rd, Richardson, TX, 75080, USA
| | - Haowei Tai
- Department of Electrical and Computer Engineering, University of Texas at Dallas, Richardson, TX, USA
| | - Girdhari Rijal
- Department of Medical Laboratory Sciences, Tarleton State University, Forth Worth, TX, USA
| | - Kevin J Parker
- Department of Electrical and Computer Engineering, University of Rochester, Rochester, NY, USA
| | - Kenneth Hoyt
- Department of Bioengineering, University of Texas at Dallas, BSB 13.929, 800 W Campbell Rd, Richardson, TX, 75080, USA. .,Department of Radiology, University of Texas Southwestern Medical Center, Dallas, TX, USA.
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Maruyama H, Kato N. Advances in ultrasound diagnosis in chronic liver diseases. Clin Mol Hepatol 2019; 25:160-167. [PMID: 30773001 PMCID: PMC6589854 DOI: 10.3350/cmh.2018.1013] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Accepted: 12/25/2018] [Indexed: 02/07/2023] Open
Abstract
Chronic liver disease is a major disorder worldwide. A better understanding of anatomy, blood flow, and pathophysiology may be a key issue for their proper management. Ultrasound (US) is a simple and non-invasive diagnostic tool in the abdominal field. Doppler mode offers real-time hemodynamic evaluation, and the contrast-enhanced US is one of the most frequently used modalities for the detailed assessment. Further development in digital technology enables threedimensional (3D) visualization of target images with high resolution. This article reviews the wide ranges of application in the abdominal US and describes the recent progress in the diagnosis of chronic liver diseases.
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Affiliation(s)
- Hitoshi Maruyama
- Department of Gastroenterology, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Naoya Kato
- Department of Gastroenterology, Chiba University Graduate School of Medicine, Chiba, Japan
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Xuan J, Chen Y, Zhu L, Guo Y, Deng L, Zheng Y, Wang Z, Wang Z, Ao M. Ultrasound molecular imaging with cRGD-PLGA-PFOB nanoparticles for liver fibrosis staging in a rat model. Oncotarget 2017; 8:108676-108691. [PMID: 29312560 PMCID: PMC5752473 DOI: 10.18632/oncotarget.21358] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2017] [Accepted: 08/28/2017] [Indexed: 12/15/2022] Open
Abstract
Hepatic fibrosis is the only chronic liver disease process that can be reversed. Developing non-invasive and effective methods to quantitatively assess the degree of liver fibrosis is of great clinical significance and remains a major challenge. The key factors in hepatic fibrosis pathogenesis are the activation and proliferation of hepatic stellate cells that subsequently express integrin αvβ3. An ultrasound (US) agent combined with a targeting peptide may be used for the early and non-invasive diagnosis of hepatic fibrosis. Herein, we report the synthesis of core-shell nanoparticles (NPs) successfully engineered by conjugation with cyclic arginine-glycine-aspartic acid (cRGD) octapeptide, allowing hepatic integrin αvβ3 targeting for liver fibrosis staging. This system consists of a perfluorooctyl bromide (PFOB) liquid in the core that is stabilized with a Poly (lactic-co-glycolic acid) (PLGA) polymer shell and modified with a cRGD. These core-shell NPs (cRGD-PLGA-PFOB NPs) exhibited useful US molecular imaging features including high imaging contrast among liver fibrotic stages and the adjacent tissues. Our results indicate that the cRGD-PLGA-PFOB NPs have significant potential to distinguish different liver fibrotic stages and could be used in clinical applications.
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Affiliation(s)
- Jiqing Xuan
- Department of Ultrasound, The Second Affiliated Hospital of Chongqing Medical University & Chongqing Key Laboratory of Ultrasound Molecular Imaging, Chongqing 400010, China.,Department of Ultrasound, The Affiliated Hospital of Southwest Medical University, Luzhou, 646000, China
| | - Yuli Chen
- Department of Ultrasound, The Second Affiliated Hospital of Chongqing Medical University & Chongqing Key Laboratory of Ultrasound Molecular Imaging, Chongqing 400010, China
| | - Leilei Zhu
- Department of Ultrasound, The Second Affiliated Hospital of Chongqing Medical University & Chongqing Key Laboratory of Ultrasound Molecular Imaging, Chongqing 400010, China
| | - Yuan Guo
- Department of Ultrasound, The Second Affiliated Hospital of Chongqing Medical University & Chongqing Key Laboratory of Ultrasound Molecular Imaging, Chongqing 400010, China
| | - Liming Deng
- Department of Ultrasound, The Second Affiliated Hospital of Chongqing Medical University & Chongqing Key Laboratory of Ultrasound Molecular Imaging, Chongqing 400010, China
| | - Yuanyi Zheng
- Department of Ultrasound, The Second Affiliated Hospital of Chongqing Medical University & Chongqing Key Laboratory of Ultrasound Molecular Imaging, Chongqing 400010, China.,Institute of Ultrasound in Medicine, Shanghai Jiaotong University Affiliated Shanghai Sixth People's Hospital, Shanghai 200233, China
| | - Zhaoxia Wang
- Department of Ultrasound, The Children's Hospital of Chongqing Medical University, Chongqing 400010, China
| | - Zhigang Wang
- Department of Ultrasound, The Second Affiliated Hospital of Chongqing Medical University & Chongqing Key Laboratory of Ultrasound Molecular Imaging, Chongqing 400010, China
| | - Meng Ao
- Department of Ultrasound, The Second Affiliated Hospital of Chongqing Medical University & Chongqing Key Laboratory of Ultrasound Molecular Imaging, Chongqing 400010, China
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7
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Kim G, Shim KY, Baik SK. Diagnostic Accuracy of Hepatic Vein Arrival Time Performed with Contrast-Enhanced Ultrasonography for Cirrhosis: A Systematic Review and Meta-Analysis. Gut Liver 2017; 11:93-101. [PMID: 27538445 PMCID: PMC5221866 DOI: 10.5009/gnl16031] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2016] [Revised: 03/07/2016] [Accepted: 03/14/2016] [Indexed: 12/15/2022] Open
Abstract
Background/Aims We identified reports in the literature regarding the diagnostic accuracy of hepatic vein arrival time (HVAT) measured by contrast-enhanced ultrasonography (CEUS) to assess hepatic fibrosis in cirrhosis. Methods The Ovid MEDLINE, Embase, and Cochrane databases were searched for all studies published up to 23 July 2015 that evaluated liver status using CEUS and liver biopsy (LB). The QUADAS-II (quality assessment of diagnostic accuracy studies-II) was applied to assess the internal validity of the diagnostic studies. Selected studies were subjected to a meta-analysis with MetaDisc 1.4 and RevMan 5.3. Results A total of 12 studies including 844 patients with chronic liver disease met our inclusion criteria. The overall summary sensitivity, specificity, positive likelihood ratio, and negative likelihood ratio of the HVAT measured by CEUS for the detection of cirrhosis compared to LB were 0.83 (95% confidence interval [CI], 0.77 to 0.89), 0.75 (95% CI, 0.69 to 0.79), 3.45 (95% CI, 1.60 to 7.43), and 0.28 (95% CI, 0.10 to 0.74), respectively. The summary diagnostic odds ratio (random effects model) was 15.23 (95% CI, 3.07 to 75.47), the summary receiver operator characteristics area under the curve was 0.74 (standard error [SE]=0.14), and the index Q was 0.69 (SE=0.11). Conclusions Based on a systematic review, the measurement of HVAT by CEUS exhibited an increased accuracy and correlation for the detection of cirrhosis.
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Affiliation(s)
- Gaeun Kim
- Department of Nursing, Keimyung University College of Nursing, Daegu, Korea
| | - Kwang Yong Shim
- Department of Internal Medicine, Wonju Severance Christian Hospital, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Soon Koo Baik
- Department of Internal Medicine, Wonju Severance Christian Hospital, Yonsei University Wonju College of Medicine, Wonju, Korea
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Horowitz JM, Venkatesh SK, Ehman RL, Jhaveri K, Kamath P, Ohliger MA, Samir AE, Silva AC, Taouli B, Torbenson MS, Wells ML, Yeh B, Miller FH. Evaluation of hepatic fibrosis: a review from the society of abdominal radiology disease focus panel. Abdom Radiol (NY) 2017. [PMID: 28624924 DOI: 10.1007/s00261-017-1211-7] [Citation(s) in RCA: 97] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Hepatic fibrosis is potentially reversible; however early diagnosis is necessary for treatment in order to halt progression to cirrhosis and development of complications including portal hypertension and hepatocellular carcinoma. Morphologic signs of cirrhosis on ultrasound (US), computed tomography (CT), and magnetic resonance imaging (MRI) alone are unreliable and are seen with more advanced disease. Newer imaging techniques to diagnose liver fibrosis are reliable and accurate, and include magnetic resonance elastography and US elastography (one-dimensional transient elastography and point shear wave elastography or acoustic radiation force impulse imaging). Research is ongoing with multiple other techniques for the noninvasive diagnosis of hepatic fibrosis, including MRI with diffusion-weighted imaging, hepatobiliary contrast enhancement, and perfusion; CT using perfusion, fractional extracellular space techniques, and dual-energy, contrast-enhanced US, texture analysis in multiple modalities, quantitative mapping, and direct molecular imaging probes. Efforts to advance the noninvasive imaging assessment of hepatic fibrosis will facilitate earlier diagnosis and improve patient monitoring with the goal of preventing the progression to cirrhosis and its complications.
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Affiliation(s)
- Jeanne M Horowitz
- Department of Radiology, Feinberg School of Medicine, Northwestern University, 676 St. Clair St, Suite 800, Chicago, IL, 60611, USA.
| | - Sudhakar K Venkatesh
- Department of Radiology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Richard L Ehman
- Department of Radiology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Kartik Jhaveri
- Division of Abdominal Imaging, Joint Department of Medical Imaging, University Health Network, Mt. Sinai Hospital & Women's College Hospital, University of Toronto, 610 University Ave, Toronto, ON, M5G 2M9, Canada
| | - Patrick Kamath
- Division of Gastroenterology and Hepatology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Michael A Ohliger
- Department of Radiology and Biomedical Imaging, UCSF School of Medicine, Zuckerberg San Francisco General Hospital, 1001 Potrero Ave, San Francisco, CA, 94110, USA
| | - Anthony E Samir
- Department of Radiology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA
| | - Alvin C Silva
- Department of Radiology, Mayo Clinic in Arizona, 13400 E. Shea Blvd., Scottsdale, AZ, 85259, USA
| | - Bachir Taouli
- Department of Radiology and Translational and Molecular Imaging Institute, Icahn School of Medicine at Mount Sinai, 1470 Madison Ave, Box 1234, New York, NY, 10029, USA
| | - Michael S Torbenson
- Department of Laboratory Medicine and Pathology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Michael L Wells
- Department of Radiology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Benjamin Yeh
- Department of Radiology and Biomedical Imaging, UCSF School of Medicine, Zuckerberg San Francisco General Hospital, 1001 Potrero Ave, San Francisco, CA, 94110, USA
| | - Frank H Miller
- Department of Radiology, Feinberg School of Medicine, Northwestern University, 676 St. Clair St, Suite 800, Chicago, IL, 60611, USA
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9
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Li J, Feng JC, Peng XY, Wu XW, Du TT, Wang JJ, Tian SX, Lu GL. Usefulness of Contrast-Enhanced Ultrasonography for Predicting Esophageal Varices in Patients with Hepatitis B Virus (HBV)-Related Cirrhosis. Med Sci Monit 2017; 23:2241-2249. [PMID: 28496092 PMCID: PMC5437916 DOI: 10.12659/msm.904227] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Background The aim of this study was to investigate the usefulness of contrast-enhanced ultrasonography (CEUS) in predicting of esophageal varices (EV) and assessing high-risk EV in patients with hepatitis B virus (HBV)-related cirrhosis. Material/Methods Patients with HBV-related cirrhosis who had undergone endoscopy were prospectively recruited. Hepatic dynamic CEUS was performed. Regions of interest (ROI) were drawn on the hepatic artery, hepatic vein, portal vein, and liver parenchyma to measure the corresponding features, such as arrival times. Spearman’s correlation analysis was used to determine the relations between several dynamic CEUS features and the degree of EV. Receiver operating characteristics (ROC) curves were constructed to investigate the diagnostic performance of CEUS in assessing the presence of EV and high-risk EV. Results Fifty-eight patients (44 men; mean age 51.3 years) were included in this study. Of these, 18 (31.0%), 12 (20.7%), 11 (19.0%), and 17 (29.3%) of patients had grade 0, 1, 2, and 3 EV, respectively. Grade 2 and grade 3 EV were considered high-risk EV. Among the CEUS features, the area under the ROC curves of intrahepatic transit time (HV–HA, i.e., the difference between hepatic vein arrival time and hepatic artery arrival time) both for assessment of the presence of EV and high-risk EV (0.883 and 0.915, respectively) were larger than the other indices. HV–HA was negatively correlated with the grade of EV. An HV–HA of under 8.2 s indicated the presence of EV and under 7 s indicated high-risk EV. Conclusions Dynamic CEUS imaging is useful in assessing the presence of EV and high-risk EV in patients with HBV-related cirrhosis.
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Affiliation(s)
- Jun Li
- Department of Ultrasound, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China (mainland).,Department of Ultrasound, The First Affiliated Hospital, Shihezi University School of Medicine, Shihezi, Xinjiang, China (mainland)
| | - Jin-Chun Feng
- Department of Hepatobiliary Surgery, The First Affiliated Hospital, Shihezi University School of Medicine, Shihezi, Xinjiang, China (mainland)
| | - Xin-Yu Peng
- Department of Hepatobiliary Surgery, The First Affiliated Hospital, Shihezi University School of Medicine, Shihezi, Xinjiang, China (mainland)
| | - Xiang-Wei Wu
- Department of Hepatobiliary Surgery, The First Affiliated Hospital, Shihezi University School of Medicine, Shihezi, Xinjiang, China (mainland)
| | - Ting-Ting Du
- Department of Ultrasound, The First Affiliated Hospital, Shihezi University School of Medicine, Shihezi, Xinjiang, China (mainland)
| | - Jia-Jia Wang
- Department of Ultrasound, The First Affiliated Hospital, Shihezi University School of Medicine, Shihezi, Xinjiang, China (mainland)
| | - Shu-Xin Tian
- Department of Gastroenterology-Hepatology, The First Affiliated Hospital, Shihezi University School of Medicine, Shihezi, Xinjiang, China (mainland)
| | - Gui-Lin Lu
- Department of Ultrasound, The First Affiliated Hospital, Shihezi University School of Medicine, Shihezi, Xinjiang, China (mainland)
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10
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Lizaola B, Bonder A, Tapper EB, Afdhal N. Role of Noninvasive Fibrosis Methods in Management of Chronic Hepatitis B Virus. ACTA ACUST UNITED AC 2016. [DOI: 10.1007/s11901-016-0311-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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11
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Yuan Y. Imaging methods for evaluation of liver fibrosis. Shijie Huaren Xiaohua Zazhi 2016; 24:1532-1538. [DOI: 10.11569/wcjd.v24.i10.1532] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Liver fibrosis is a development stage of various chronic liver diseases. Since liver fibrosis is still a reversible process, the development of irreversible cirrhosis can be delayed or prevented if the patient is early diagnosed and receives timely and effective treatment. Therefore, how to accurately, effectively and easily evaluate the severity of liver fibrosis remains a clinical problem to be solved. Ultrasound, CT and MRI are common examinations for hepatic lesions. Imaging examinations can non-invasively and accurately evaluate the degree of liver fibrosis. With the development and application of new imaging technologies, flexible technology has been widely applied in the assessment of liver fibrosis. This article reviews the application of various imaging modalities, especially elastic technology, for assessment of hepatic fibrosis.
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12
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Maruyama H, Shiha G, Yokosuka O, Kumar A, Sharma BC, Ibrahim A, Saraswat V, Lesmana CRA, Omata M. Non-invasive assessment of portal hypertension and liver fibrosis using contrast-enhanced ultrasonography. Hepatol Int 2015; 10:267-76. [PMID: 26696585 DOI: 10.1007/s12072-015-9670-9] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2015] [Accepted: 09/10/2015] [Indexed: 12/11/2022]
Abstract
Portal hypertension and hepatic fibrosis are key pathophysiologies with major manifestations in cirrhosis. Although the degree of portal pressure and hepatic fibrosis are pivotal parameters, both are determined using invasive procedures. Ultrasound (US) is a simple and non-invasive technique that is available for use worldwide in the abdominal field. Because of its safety and easy of use, contrast-enhanced US is one of the most frequently used tools in the management of liver tumors for the detection and characterization of lesions, assessment of malignancy grade, and evaluation of therapeutic effects. This wide range of applications drives the practical use of contrast-enhanced US for evaluation of the severity of portal hypertension and hepatic fibrosis. The present article reviews the recent progress in contrast-enhanced US for the assessment of portal hypertension and hepatic fibrosis.
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Affiliation(s)
- Hitoshi Maruyama
- Department of Gastroenterology and Nephrology, Chiba University Graduate School of Medicine, 1-8-1, Inohana, Chuou-ku, Chiba, 260-8670, Japan.
| | - Gamal Shiha
- Egyptian Liver Research Institute and Hospital (ELRIAH), Mansoura, Egypt
| | - Osamu Yokosuka
- Department of Gastroenterology and Nephrology, Chiba University Graduate School of Medicine, 1-8-1, Inohana, Chuou-ku, Chiba, 260-8670, Japan
| | - Ashish Kumar
- Department of Gastroenterology & Hepatology, Ganga Ram Institute for Postgraduate Medical Education & Research (GRIPMER), Sir Ganga Ram Hospital, Rajinder Nagar, New Delhi, 110 060, India
| | | | - Alaa Ibrahim
- GI/Liver division, GIT Endoscopy Unit, University of Benha, Banha, Egypt
| | - Vivek Saraswat
- Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, UP, 226014, India
| | - Cosmas Rinaldi A Lesmana
- Department of Internal Medicine, Hepatobiliary Division, Cipto Mangunkusumo Hospital, University of Indonesia, Jawa Barat, Indonesia
| | - Masao Omata
- Yamanashi Hospitals (Central and Kita) Organization, 1-1-1 Fujimi, Kofu-shi, Yamanashi, 400-8506, Japan
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Lurie Y, Webb M, Cytter-Kuint R, Shteingart S, Lederkremer GZ. Non-invasive diagnosis of liver fibrosis and cirrhosis. World J Gastroenterol 2015; 21:11567-11583. [PMID: 26556987 PMCID: PMC4631961 DOI: 10.3748/wjg.v21.i41.11567] [Citation(s) in RCA: 227] [Impact Index Per Article: 25.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2015] [Revised: 07/23/2015] [Accepted: 09/15/2015] [Indexed: 02/07/2023] Open
Abstract
The evaluation and follow up of liver fibrosis and cirrhosis have been traditionally performed by liver biopsy. However, during the last 20 years, it has become evident that this “gold-standard” is imperfect; even according to its proponents, it is only “the best” among available methods. Attempts at uncovering non-invasive diagnostic tools have yielded multiple scores, formulae, and imaging modalities. All are better tolerated, safer, more acceptable to the patient, and can be repeated essentially as often as required. Most are much less expensive than liver biopsy. Consequently, their use is growing, and in some countries the number of biopsies performed, at least for routine evaluation of hepatitis B and C, has declined sharply. However, the accuracy and diagnostic value of most, if not all, of these methods remains controversial. In this review for the practicing physician, we analyze established and novel biomarkers and physical techniques. We may be witnessing in recent years the beginning of the end of the first phase for the development of non-invasive markers. Early evidence suggests that they might be at least as good as liver biopsy. Novel experimental markers and imaging techniques could produce a dramatic change in diagnosis in the near future.
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Zhai L, Qiu LY, Zu Y, Yan Y, Ren XZ, Zhao JF, Liu YJ, Liu JB, Qian LX. Contrast-enhanced ultrasound for quantitative assessment of portal pressure in canine liver fibrosis. World J Gastroenterol 2015; 21:4509-4516. [PMID: 25914459 PMCID: PMC4402297 DOI: 10.3748/wjg.v21.i15.4509] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2014] [Revised: 12/31/2014] [Accepted: 02/12/2015] [Indexed: 02/06/2023] Open
Abstract
AIM: To explore the feasibility of non-invasive quantitative estimation of portal venous pressure by contrast-enhanced ultrasound (CEUS) in a canine model.
METHODS: Liver fibrosis was established in adult canines (Beagles; n = 14) by subcutaneous injection of carbon tetrachloride (CCl4). CEUS parameters, including the area under the time-intensity curve and intensity at portal/arterial phases (Qp/Qa and Ip/Ia, respectively), were used to quantitatively assess the blood flow ratio of the portal vein/hepatic artery at multiple time points. The free portal venous pressures (FPP) were measured by a multi-channel baroreceptor using a percutaneous approach at baseline and 8, 16, and 24 wk after CCl4 injections in each canine. Liver biopsies were obtained at the end of 8, 16, and 24 wk from each animal, and the stage of the fibrosis was assessed according to the Metavir scoring system. A Pearson correlation test was performed to compare the FPP with Qp/Qa and Ip/Ia.
RESULTS: Pathologic examination of 42 biopsies from the 14 canines at weeks 8, 16, and 24 revealed that liver fibrosis was induced by CCl4 and represented various stages of liver fibrosis, including F0 (n = 3), F1 (n = 12), F2 (n = 14), F3 (n = 11), and F4 (n = 2). There were significant differences in the measurements of Qp/Qa (19.85 ± 3.30 vs 10.43 ± 1.21, 9.63 ± 1.03, and 8.77 ± 0.96) and Ip/Ia (1.77 ± 0.37 vs 1.03 ± 0.12, 0.83 ± 0.10, and 0.69 ± 0.13) between control and canine fibrosis at 8, 16, and 24 wk, respectively (all P < 0.001). There were statistically significant negative correlations between FPP and Qp/Qa (r = -0.707, P < 0.001), and between FPP and Ip/Ia (r = -0.759, P < 0.001) in the canine fibrosis model. Prediction of elevated FPP based on Qp/Qa and Ip/Ia was highly sensitive, as assessed by the area under the receiver operating curve (0.866 and 0.895, respectively).
CONCLUSION: CEUS is a potential method to accurately, but non-invasively, estimate portal venous pressure through measurement of Qp/Qa and Ip/Ia parameters.
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Jeong WK, Kim TY, Sohn JH, Kim Y, Kim J. Severe portal hypertension in cirrhosis: evaluation of perfusion parameters with contrast-enhanced ultrasonography. PLoS One 2015; 10:e0121601. [PMID: 25798930 PMCID: PMC4370392 DOI: 10.1371/journal.pone.0121601] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2014] [Accepted: 02/13/2015] [Indexed: 12/20/2022] Open
Abstract
OBJECTIVE To investigate the role of contrast-enhanced ultrasonography (CEUS) and Doppler ultrasonography (DUS) in the diagnosis of severe portal hypertension (PH) in patients with liver cirrhosis (LC). METHODS Patients with PH scheduled to receive hepatic venous pressure gradient (HVPG) measurement were recruited for this study. Hepatic DUS and CEUS were performed successively. Several Doppler and CEUS parameters were explored for correlation with HVPG values and their association with severe PH (≥ 12 mmHg of HVPG). Comparison of the parameters between the severe and non-severe PH groups and their correlation with HVPG values was evaluated. A receiver operating characteristic (ROC) curve analysis was also performed to investigate the performance in order to diagnose severe PH. RESULTS Fifty-three consecutive patients were enrolled in this study. Among them, 43 patients did not have significant ascites. Compared with the non-severe PH group, portal venous velocity and intrahepatic transit time (ITT) were significantly reduced in the severe PH group (all p<0.05). Difference between inspiratory and expiratory hepatic venous damping indices (ΔHVDI), hepatic venous arrival time (HVAT) and ITT moderately correlated with HVPG (r = -0.358, -0.338, and -0.613, respectively). Areas under the curves for severe PH were 0.94 of ITT and 0.72 of HVAT, respectively (all p<0.05). ITT under 6 seconds indicated severe PH with a sensitivity of 92% and a specificity of 89%. CONCLUSIONS Hepatic CEUS may be more useful in estimating the HVPG value and determining the presence of severe PH compared to DUS, and ITT was the most accurate parameter to diagnose severe PH.
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Affiliation(s)
- Woo Kyoung Jeong
- Department of Radiology and Center for Imaging Science, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Tae Yeob Kim
- Department of Internal Medicine, Hanyang University Guri Hospital, Hanyang University College of Medicine, Guri-si, Gyeonggi-do, Korea
| | - Joo Hyun Sohn
- Department of Internal Medicine, Hanyang University Guri Hospital, Hanyang University College of Medicine, Guri-si, Gyeonggi-do, Korea
- * E-mail:
| | - Yongsoo Kim
- Department of Radiology, Hanyang University Guri Hospital, Hanyang University College of Medicine, Guri-si, Gyeonggi-do, Korea
| | - Jinoo Kim
- Department of Radiology, Ajou University Hospital, Ajou University College of Medicine, Suwon-si, Gyeonggi-do, Korea
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Soresi M, Giannitrapani L, Cervello M, Licata A, Montalto G. Non invasive tools for the diagnosis of liver cirrhosis. World J Gastroenterol 2014; 20:18131-18150. [PMID: 25561782 PMCID: PMC4277952 DOI: 10.3748/wjg.v20.i48.18131] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2014] [Revised: 09/22/2014] [Accepted: 11/11/2014] [Indexed: 02/06/2023] Open
Abstract
Liver cirrhosis (LC), the end stage of many forms of chronic hepatitis of different etiologies is a diffuse process characterized by fibrosis and the conversion of normal liver architecture into structurally abnormal nodules surrounded by annular fibrosis. This chronic progressive clinical condition, leads to liver cell failure and portal hypertension, which can favour the onset of hepatocellular carcinoma. Defining the phase of the natural history is crucial for therapeutic choice and prognosis. Liver biopsy is currently considered the best available standard of reference but it has some limits, so alternative tools have been developed to substitute liver biopsy when assessing liver fibrosis. Serum markers offer a cost-effective alternative to liver biopsy being less invasive and theoretically without complications. They can be classified into direct and indirect markers which may be used alone or in combination to produce composite scores. Diagnostic imaging includes a number of instruments and techniques to estimate liver fibrosis and cirrhosis like ultrasound (US), US Doppler, contrast enhanced US and Elastography. US could be used for the diagnosis of advanced LC while is not able to evaluate progression of fibrosis, in this case Elastography is more reliable. This review aims to revise the most recent data from the literature about non invasive methods useful in defining liver fibrosis.
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Wang Y, Wu Z, Ju Y, Cao L, Shi L, Tong F, Jiang X, Zhu C. Tissue Doppler imaging and tissue strain imaging for the evaluation of hepatic fibrosis in patients with chronic hepatitis B. ULTRASOUND IN MEDICINE & BIOLOGY 2013; 39:1527-1535. [PMID: 23791352 DOI: 10.1016/j.ultrasmedbio.2013.02.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/18/2012] [Revised: 02/16/2013] [Accepted: 02/20/2013] [Indexed: 06/02/2023]
Abstract
We studied the feasibility of evaluating the stages of liver fibrosis with tissue Doppler imaging (TDI) and tissue strain imaging (TSI) for patients with chronic hepatitis B virus infection. One hundred ten patients were divided into two groups: normal adult group (n = 38) and chronic liver disease group (n = 72, patients infected with HBVs). The chronic liver disease group was divided into three subgroups on the basis of the Scheuer scoring system and clinical evidence: mild fibrosis (S0 and S1, n = 11), moderate fibrosis (S2 and S3, n = 27) and cirrhosis (S4 and clinically typical cirrhosis, n = 34) groups. TDI was performed for a chosen oblique section. Four regions of interest (ROIs), A-D, were chosen in the hepatic parenchyma based on the direction of propagation from the heart to the liver. Strain rate curves were obtained on the basis of TDI and TSI findings. Strain peak rates (SPRs) of all ROIs and the differences in times to SPRs for the four ROIs (TA-B, TB-C and TC-D) in the hepatic parenchyma were measured with TDI and TSI. Strain rate curves were analyzed for each ROI. The strain rate curves for the normal adult group were synchronous, whereas those for the chronic liver disease group were asynchronous. SPRs of the ROIs gradually decreased with the progression of liver fibrosis. The SPRs of ROI B significantly correlated with chronic liver disease severity (r = 0.991, p < 0.05). Areas under the curve (AUCs) of the ROI A and ROI B SPRs at the moderate fibrosis and cirrhosis stages were 0.86 ± 0.06, 0.81 ± 0.56 and 0.90 ± 0.65, 0.92 ± 0.04, respectively. The AUC of the SPRs of ROIs A and B correlated better than the platelet/age/phosphatase/α-fetoprotein/aspartate aminotransferase (PAPAS) index for advanced fibrosis. The differences in time to SPRs among the peaks of the four ROIs (TA-B, TB-C and TC-D) gradually increased with the progression of liver fibrosis. TDI and TSI with quantitative measurements using tissue Doppler analysis software (TDIQ, GE Medical Systems, Horten, Norway) provided reliable information for evaluating non-invasive liver fibrosis in patients with chronic hepatitis B.
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Affiliation(s)
- Ying Wang
- Department of Ultrasonography, Clinical Medical College of Yangzhou University, Jiangsu, China
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Claudon M, Dietrich CF, Choi BI, Cosgrove DO, Kudo M, Nolsøe CP, Piscaglia F, Wilson SR, Barr RG, Chammas MC, Chaubal NG, Chen MH, Clevert DA, Correas JM, Ding H, Forsberg F, Fowlkes JB, Gibson RN, Goldberg BB, Lassau N, Leen ELS, Mattrey RF, Moriyasu F, Solbiati L, Weskott HP, Xu HX. Guidelines and good clinical practice recommendations for Contrast Enhanced Ultrasound (CEUS) in the liver - update 2012: A WFUMB-EFSUMB initiative in cooperation with representatives of AFSUMB, AIUM, ASUM, FLAUS and ICUS. ULTRASOUND IN MEDICINE & BIOLOGY 2013; 39:187-210. [PMID: 23137926 DOI: 10.1016/j.ultrasmedbio.2012.09.002] [Citation(s) in RCA: 483] [Impact Index Per Article: 43.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/12/2023]
Abstract
Initially, a set of guidelines for the use of ultrasound contrast agents was published in 2004 dealing only with liver applications. A second edition of the guidelines in 2008 reflected changes in the available contrast agents and updated the guidelines for the liver, as well as implementing some non-liver applications. Time has moved on, and the need for international guidelines on the use of CEUS in the liver has become apparent. The present document describes the third iteration of recommendations for the hepatic use of contrast enhanced ultrasound (CEUS) using contrast specific imaging techniques. This joint WFUMB-EFSUMB initiative has implicated experts from major leading ultrasound societies worldwide. These liver CEUS guidelines are simultaneously published in the official journals of both organizing federations (i.e., Ultrasound in Medicine and Biology for WFUMB and Ultraschall in der Medizin/European Journal of Ultrasound for EFSUMB). These guidelines and recommendations provide general advice on the use of all currently clinically available ultrasound contrast agents (UCA). They are intended to create standard protocols for the use and administration of UCA in liver applications on an international basis and improve the management of patients worldwide.
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Affiliation(s)
- Michel Claudon
- Department of Pediatric Radiology, INSERM U947, Centre Hospitalier Universitaire de Nancy and Université de Lorraine, Vandoeuvre, France
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Jung E, Wiggermann P, Stroszczynski C, Reiser M, Clevert DA. Sonographische Diagnostik diffuser Lebererkrankungen. Radiologe 2012; 52:706-16. [DOI: 10.1007/s00117-012-2307-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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Abstract
The administration of a contrast agent is considered an essential tool to evaluate abdominal diseases using Ultrasound. The most targeted organ is the liver, especially to characterize focal liver lesions and to assess the response to percutaneous treatment. However, the expanding abdominal indications of contrast-enhanced ultrasound make this technique an important tool in the assessment of organ perfusion including the evaluation of ischemic, traumatic, and inflammatory diseases.
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Affiliation(s)
- Carlos Nicolau
- Radiology Department, Hospital Clínic, University of Barcelona, Spain.
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