Doppler in hepatic cirrhosis and chronic hepatitis

Case report and literature review: Isolated HCC- recurrence in gallbladder after curative resection

Background

Liver resection (LR) is considered the mainstay treatment for eligible patients with hepatocellular carcinoma (HCC) and provides a 5-year overall survival (OS) of 60%-80%. However, the recurrence rate within five years after LR remains high, ranging from 40% to 70%. Recurrence in gallbladder after liver resection is extremely rare. Here, we present a case of isolated recurrence in gallbladder after curative resection of HCC and review the relevant literature. No similar cases have been reported before.

Case presentation

A 55-year-old male patient was diagnosed with HCC in 2009 and subsequently underwent a right posterior sectionectomy of the liver. In 2015, the patient underwent liver tumor radiofrequency ablation and three transarterial chemoembolization (TACE) procedures in succession for HCC recurrence. In 2019, a gallbladder lesion was detected by computed tomography (CT) without perceivable intrahepatic focus. We performed an en bloc resection of the gallbladder and hepatic segment IVb. The pathological biopsy suggested that the gallbladder tumor was moderately differentiated HCC. The patient survived more than 3 years in good condition, and there were no signs of tumor recurrence.

Conclusions

In patients with isolated gallbladder metastasis, if the lesion can be resected en bloc without remnants, surgery should be the preferred option. Both postoperative molecularly targeted drugs and immunotherapy are expected to improve the long-term prognosis.

Ultrasonography in the diagnosis of complications in patients with portal hypertension

This review focuses on ultrasonography (US) to diagnose patients with complications in portal hypertension. Clinicians first use US to evaluate patients with suspected portal hypertension, because US is quick, simple, and radiation free. US is necessary for grading and performing paracentesis for ascites. Doppler US-based detection of reverse splanchnic vein flow or the presence of a spontaneous portosystemic shunt is highly specific in patients with cirrhosis. Since it is important to estimate spleen size in patients with portal hypertension, spleen size is usually measured by US. Spleen volume can be more accurately measured with 3D-US. Estimation of viable residual splenic volume after partial splenic embolization should be limited to cases with total splenic volume less than 1000 ml. Portal vein thrombosis is often detected during the US examination performed when symptoms first appear or during the follow-up. Two-dimensional transthoracic echocardiography is an excellent noninvasive screening test in patients with pulmonary portal hypertension who can undergo it. By measuring the maximum and minimum diastolic blood flow velocities in the renal arteries using renal color Doppler US, the pulsatility index (PI) and resistive index (RI) can be calculated. The PI and RI in cirrhotic patients were significantly higher than those in healthy subjects and patients with chronic hepatitis, and showed a significant positive correlation with the Child-Pugh Score. In conclusion, US is an essential tool for the diagnosis and treatment of patients with portal hypertension.

Targeting integrin αvβ3 by a rationally designed protein for chronic liver disease treatment

Chronic Liver Diseases (CLD) are characterized by abnormal accumulation of collagen fibrils, neo-angiogenesis, and sinusoidal remodeling. Collagen deposition along with intrahepatic angiogenesis and sinusoidal remodeling alters sinusoid structure resulting in portal hypertension, liver failure, and other complications. Efforts were made to develop treatments for CLDs. However, the success of such treatments is limited and unpredictable. We report a strategy for CLD treatment by induction of integrin αvβ3 mediated cell apoptosis using a rationally designed protein (ProAgio). ProAgio is designed to target integrin αvβ3 at a novel site. Integrin αvβ3 is highly expressed in activated Hepatic Stellate Cells (HSC), angiogenic endothelium, and capillarized Liver Sinusoidal Endothelial Cells (LSEC). ProAgio induces apoptosis of these disease causative cells. Tests with liver fibrosis mouse models demonstrate that ProAgio reverses liver fibrosis and relieves blood flow resistance by depleting activated HSC and capillarized LSEC. Our studies demonstrate an effective approach for CLD treatment.

Preoperative Evaluation and Anesthetic Management of Patients With Liver Cirrhosis Undergoing Cardiac Surgery

Preoperative evaluation and anesthetic management of patients with liver cirrhosis undergoing cardiac surgery remain a clinical challenge because of its high risk for perioperative complications. This narrative review article summarizes the pathophysiology and anesthetic implication of liver cirrhosis on each organ system. It will help physicians to evaluate surgical candidates, to optimize intraoperative management, and to anticipate complications in liver cirrhosis patients undergoing cardiac surgery. Morbidity typically results from bleeding, sepsis, multisystem organ failure, or hepatic insufficiency. These complications occur as a result of the presence of coagulopathy, poor nutritional status, immune dysfunction, cirrhotic cardiomyopathy, and renal and pulmonary dysfunction that occur with liver cirrhosis. Therefore, liver cirrhosis should not be seen as a single disease, but one that manifests with multiorgan dysfunction. Cardiac surgery in patients with liver cirrhosis increases the risk of perioperative complications, and it presents a particular challenge to the anesthesiologist in that nearly every aspect of normally functioning physiology may be jeopardized in a unique way. Accurately classifying the extent of liver disease, preoperative optimization, and surgical risk communication with the patient are crucial. In addition, all teams involved in the surgery should communicate openly and coordinate in order to ensure optimal care. To reduce perioperative complications, consider using off-pump cardiopulmonary bypass techniques and optimal perfusion modalities to mimic current physiologic conditions.

Mortality after Transplantation for Hepatocellular Carcinoma: A Study from the European Liver Transplant Registry

BACKGROUND AND AIMS

Prognosis after liver transplantation differs between hepatocellular carcinoma (HCC) arising in cirrhotic and non-cirrhotic livers and aetiology is poorly understood. The aim was to investigate differences in mortality after liver transplantation between these patients.

METHODS

We included patients from the European Liver Transplant Registry transplanted due to HCC from 1990 to November 2016 and compared cirrhotic and non-cirrhotic patients using propensity score (PS) calibration of Cox regression estimates to adjust for unmeasured confounding.

RESULTS

We included 22,787 patients, of whom 96.5% had cirrhosis. In the unadjusted analysis, non-cirrhotic patients had an increased risk of overall mortality with a hazard ratio (HR) of 1.37 (95% confidence interval [CI] 1.23-1.52). However, the HR approached unity with increasing adjustment and was 1.11 (95% CI 0.99-1.25) when adjusted for unmeasured confounding. Unadjusted, non-cirrhotic patients had an increased risk of HCC-specific mortality (HR 2.62, 95% CI 2.21-3.12). After adjustment for unmeasured confounding, the risk remained significantly increased (HR 1.62, 95% CI 1.31-2.00).

CONCLUSIONS

Using PS calibration, we showed that HCC in non-cirrhotic liver has similar overall mortality, but higher HCC-specific mortality. This may be a result of a more aggressive cancer form in the non-cirrhotic liver as higher mortality could not be explained by tumour characteristics or other prognostic variables.

Clinical characteristics of patients with liver cirrhosis and spontaneous portosystemic shunts detected by ultrasound in a tertiary care and transplantation centre

OBJECTIVES

The clinical relevance of spontaneous portosystemic shunts detected by ultrasound is insufficiently investigated. The aim of this retrospective study was to assess the frequency and clinical relevance of spontaneous portosystemic shunts in patients with liver cirrhosis.

METHODS

We evaluated portosystemic shunts, liver cirrhosis and spleen size by ultrasound in 982 patients with liver cirrhosis and correlated these with laboratory results, clinical data and the incidence of clinical endpoint deaths, liver transplantation and the development of HCC during the follow-up period (mean 1.26 ± 1.53 years [range 0-7.2 years]).

RESULTS

Portosystemic shunts were detected in 34% of the patients. These patients had a higher rate of alcohol-related cirrhosis (37% vs. 30%, p = .003), a higher MELD score (p < .001) and Child-Pugh grade (p < .001), as well as more frequent hepatic encephalopathy (p < .001) and oesophageal varices (p < .003). The most frequent portosystemic shunt in this cohort was an umbilical vein shunt (69%) followed by splenorenal (16%), mesenteric (7%) and combined/other shunts (8%). Patients with umbilical vein shunts had a higher rate of alcohol-related cirrhosis (p = .041) and suffered more frequently from Child B/C stages (p = .03), hepatorenal syndrome (p = .03), massive ascites (p = .001) and spontaneous bacterial peritonitis (p = .011).

CONCLUSIONS

Patients with portosystemic shunts that are detected by ultrasound should be monitored carefully as these patients are associated with advanced liver disease and multiple clinical risk factors.

Diagnostic Value of Hepatic Vein Ultrasound in Early Detection of Liver Cirrhosis

Background

Cirrhosis is a common disease that destroys liver cells, and it has various etiologies. The early diagnosis of cirrhosis can be effective in improving prognosis. Considering the availability and affordability of ultrasound devices throughout the world, in this study we evaluated the diagnostic value of hepatic vein ultrasound examination in the early detection of liver cirrhosis.

Materials and Methods

In this study, 45 patients referred to the radiology department of Ghaem Hospital for liver biopsy were evaluated for changes in the hepatic veins under ultrasound with a transducer of 5-7MHz. One piece of the hepatic vein was selected for ultrasound, and the wall of hepatic veins was examined for straightness and uniformity of echogenicity. Subsequently, patients underwent biopsy by ultrasound guide. Of all the study subjects, eight patients presented mild chronic hepatitis without fibrosis, four patients were diagnosed with fatty liver, and 33 patients had severe cirrhosis or chronic hepatitis with fibrosis.

Results

Our results showed that hepatitis patients with or without fibrosis had irregular and wavy hepatic vein wall (impairment in straightness) with non-uniform echo (impairment in uniformity of echogenicity). While patients without hepatitis and cirrhosis, but diagnosed with fatty liver, had a smooth and regular hepatic vein wall with a uniform echo.

Conclusion

The present study showed that hepatic vein examination in terms of echogenicity and straightness could be used to diagnose hepatitis, its severity as well as its course towards fibrosis and cirrhosis.

Graft Regeneration and Functional Recovery in Patients with Early Allograft Dysfunction After Living-Donor Liver Transplantation

Background

Successful graft regeneration is important in living-donor liver transplantation (LDLT) because partial liver grafts are used. Early allograft dysfunction (EAD) is an intermediate outcome that affects the long-term postoperative course in liver transplantation. The aim of the present study was to investigate liver graft regeneration under EAD development in LDLT.

Material/Methods

The data of 226 patients who underwent LDLT from September 2010 to July 2014 were retrospectively analyzed. The patients were classified into 2 groups: one with and one without EAD. Graft regeneration, functional recovery, and long-term patient survival were compared between the 2 groups.

Results

The grafts grew more vigorously in the EAD group than in the non-EAD group, as evidenced by the larger absolute (ALV) and relative liver volumes (RLV) of the former on postoperative days (POD) 7 and 21. The median (interquartile range) RLVs of the non-EAD group versus the EAD group were as follows: 55.2 (47.9–65.8) vs. 53.7 (46.6–64.5)% preoperatively, p>0.05; 76.1 (66.9–85.7) vs. 86.7 (73.9–96.8)% on POD 7, p<0.01; 79.6 (69.3–91.2) vs. 93.7 (79.6–101.6)%, p<0.01 on POD 21. In the early postoperative period, hepatic function, measured as total bilirubin and international normalized ratio, was higher in the EAD group; however, after EAD development, graft function recovered in these patients. In the follow-up period, overall patient survival was comparable between the 2 groups.

Conclusions

The liver grafts of EAD patients steadily regenerated, such that the development of EAD did not affect long-term patient survival after LDLT.

Doppler assessment of children with liver cirrhosis and portal hypertension in comparison with a healthy control group: An analytical cross-sectional study

Background:

Doppler ultrasonography (Doppler US) plays an important role in evaluating patients with liver cirrhosis. This study aims to investigate the hemodynamic alterations of hepatic artery and portal vein among children with liver cirrhosis and portal hypertension (esophageal varices).

Materials and Methods:

We conducted an analytical cross-sectional study in Imam Hossein Children's Hospital, Isfahan, Iran, in 2016. A number of 33 cirrhotic children with or without esophageal varices were selected through convenience sampling method to be compared with 19 healthy children as controls using color and spectral Doppler US.

Results:

Portal vein mean velocities were 15.03 ± 7.3 cm/s in cirrhotics, 16.47 ± 6.4 cm/s in controls (P = 0.51), 11.6 ± 4.7 cm/s in patients with varices, and 17.9 ± 7.3 cm/s in patients without varices (P = 0.015). Mean diameters of caudate lobe, portal vein, and splenic vein, as well as the mean values of liver and spleen span, were significantly higher in cirrhotic children. The frequency of flow reversal (hepatofugal flow) was not detected significantly different in cirrhotics. Peak systolic velocity, end diastolic velocity, pulsatility index, and resistive index for hepatic artery as well as liver vascular index were not significantly different in cirrhotics in comparison with controls.

Conclusion:

Alterations in Doppler parameters of portal vein including diameter and velocity may be the helpful indicators of liver cirrhosis and esophageal varices in children, respectively. Parameters of hepatic artery may not differentiate children with liver cirrhosis.

Genetic Polymorphisms of Fas/FasL Promoter Associated with Hepatitis C cirrhosis and HCC

Aim:

The present study was performed to determine any associations of genetic polymorphisms of Fas/FasL promoter regions, at Fas670 and Fas1377 and FasL844, with hepatitis C cirrhosis and HCC, with a focus on severity of disease.

Methods:

Totals of 120 patients with cirrhosis and 101 with hepatocellular carcinoma (HCC) were enrolled. All had chronic HCV infection as indicated by positive anti-HCV antibodies and positive HCV RNA on real time PCR. One hundred healthy control subjects were also included in the study. Patients were subjected to full clinical, radiological and histopathological examinations. In addition to routine laboratory tests for liver function tests, Fas670 and Fas1377 and FasL844 genetic polymorphisms of Fas/FasL promoter regions were assessed by RFLP-PCR (restriction fragment length polymorphism with polymerase chain reaction).

Results:

Significant higher levels of the AG genotype in Fas670 and Fas1773 were observed in patients with cirrhosis and HCC (P=0.0001) as compared to control subjects. In addition, the CC genotype in FASL844 was also more common in patients (P=0.01). Furtehrmore, there was a significant association of substitution of A by G alleles in Fas670 and Fas1773 with advanced BCA staging (P=0.02, P=0.0001 respectively) and larger tumor size >5cm (P=0.01, P=0.0001 respectively) and in Fas670 with advanced pathological grading (P=0.0001). Moreover the CC genotype of FASL844 was significantly linked with advanced BCA, large tumor size >5cm and advanced pathological grading (P=0.0001).

Conclusion:

The findings of the present study highlight associations of genetic polymorphisms of promoter regions in Fas and Fas L with cirrhosis and HCC associated with chronic HCV. Support was also obtained for the conclusion that single nucleotide polymorphisms of the Fas/ FasL system impact on clinical and histopathological grading of HCCs. Further large scale studies are recommended for confirmation.

胃肾及脾肾分流道对胃底曲张静脉内镜治疗的影响

肝硬化可以导致门静脉高压, 并通过形成侧支循环和自发性分流来降低门静脉压力, 其中以食管、胃静脉曲张及胃肾、脾肾分流最多见. 因为随机对照研究的缺乏, 规范化治疗胃底静脉曲张破裂出血的临床方案仍未能统一, 现最有效且常用的方法是内镜下组织胶黏合剂注射, 但对于合并自发性分流者可导致异位栓塞等严重并发症; 自发性分流道的存在也影响着胃底曲张静脉治疗方案的选择. 本文就近年来对自发性分流道的研究及其对胃底曲张静脉内镜治疗方案的选择及疗效作一简要综述.

Pulsed-wave Doppler ultrasonographic evaluation of hepatic vein in dogs with tricuspid regurgitation

This study was performed to identify the relationships between hepatic vein (HV) measurements, including flow velocity and waveform, using pulsed-wave (PW) Doppler ultrasonography, and the severity of tricuspid regurgitation (TR) in dogs. The study included 22 dogs with TR and 7 healthy dogs. The TR group was subdivided into 3 groups according to TR jet profile obtained by echocardiography. The hepatic venous waveform was obtained and classified into 3 types. A variety of HV measurements, including the maximal velocities of the atrial systolic, systolic (S), end ventricular systolic, and diastolic (D) waves and the ratio of the S- and D- wave velocities (S/D ratio), were acquired. TR severity was significantly correlated with the S- (r = −0.380, p = 0.042) and D- (r = 0.468, p = 0.011) wave velocities and the S/D ratio (r = −0.747, p < 0.001). Receiver operating characteristic curve analysis revealed the highest sensitivity and specificity for the S/D ratio (89% and 75%, respectively) at a threshold of 0.97 with excellent accuracy (AUC = 0.911, p < 0.001). In conclusion, PW Doppler ultrasonography of the HV can be used to identify the presence of significant TR and to classify TR severity in dogs.

Tricky Findings in Liver Transplant Imaging: A Review of Pitfalls With Solutions

Orthotopic liver transplantation is the preferred treatment for end-stage liver disease. Imaging plays an important role in the follow-up of transplant recipients by identifying a variety of complications. Posttransplant liver imaging can be challenging with altered vascular and nonvascular postoperative findings closely mimicking pathologies. A thorough knowledge of these common imaging findings in a posttransplant liver is essential for the radiologist to avoid erroneous diagnoses and unnecessary workup. We focus on such imaging findings and provide tips to avoid misinterpretation.

Doppler Ultrasound in Liver Cirrhosis: Correlation of Hepatic Artery and Portal Vein Measurements With Model for End-Stage Liver Disease Score

OBJECTIVES

To determine whether hepatic arterial and portal venous Doppler ultrasound measurements of the liver in cirrhotic patients correlate with patients' Model for End-Stage Liver Disease (MELD) scores, splenomegaly, or ascites.

MATERIALS AND METHODS

Sonographic images and reports were reviewed of 264 patients with hepatic cirrhosis who underwent abdominal ultrasound with Doppler in this internal review board-approved retrospective study. MELD scores were recorded at the time of ultrasound. On gray-scale ultrasound, spleen length was measured and the presence of ascites was noted. Hepatic arterial velocity (HAv) with angle correction, hepatic arterial resistive index, and portal vein velocity with angle correction were measured on Doppler ultrasound. Correlation of hepatic arterial and portal venous Doppler values with MELD score, presence of splenomegaly, and presence of ascites was tested using linear or binary logistic regression analysis. Diagnostic performance of Doppler parameters for high-risk MELD was assessed.

RESULTS

The HAv statistically significantly correlated with the MELD score (P = .0001), spleen size (P =.027), and presence of ascites (P =.0001), whereas the hepatic arterial resistive index and portal vein velocity did not correlate with these factors. For MELD scores greater than 19, an HAv greater than 120 cm/s showed accuracy, sensitivity, specificity, positive predictive value, and negative predictive value of 74, 42, 90, 67, and 76%, respectively. With an HAv greater than 160 cm/s, the odds ratio for MELD scores greater than 19 was 42.1.

CONCLUSIONS

We found a statistically significant correlation with elevated HAv and increasing MELD scores, splenomegaly, and presence of ascites in patients with cirrhotic liver disease; this may be a useful imaging biomarker in the evaluation of patients with cirrhosis.

Duplex Doppler Ultrasound of the Hepatic Artery: A Window to Diagnosis of Diffuse Liver Pathology

The use of Doppler sonography for evaluation of the liver is well established, and evaluation of the portal and hepatic veins in native livers, as well as the hepatic artery in transplant livers, is a standard part of the examination. Less well known, however, is that assessment hepatic of artery blood flow velocities and waveforms can permit inferences to be made about liver and system pathophysiology even in native livers. This review will illustrate that hepatic parenchymal abnormalities, as well as primary vascular abnormalities both upstream and downstream of the proper hepatic artery, can be inferred from careful interrogation of its Doppler signature during routine abdominal sonography.

Capsule Endoscopy for Portal Hypertensive Enteropathy

Portal hypertensive enteropathy (PHE) is a mucosal abnormality of the small bowel that is observed in patients with portal hypertension (PH) and can lead to gastrointestinal bleeding and anemia. The pathogenesis is still not completely understood. The introduction of new endoscopic methods, including capsule endoscopy (CE) or balloon-assisted enteroscopy, has increased the detection of these abnormalities. CE can also serve as a road map for deciding subsequent interventions and evaluating the treatment effect. The prevalence of PHE is reportedly 40-70% in patients with PH. Endoscopic findings can be roughly divided into vascular and nonvascular lesions such as inflammatory-like lesions. Traditionally, PHE-associated factors include large esophageal varices, portal hypertensive gastropathy or colopathy, Child-Turcotte-Pugh class B or C, a history of variceal treatment, and acute gastrointestinal bleeding. More recently, on using scoring systems, a high computed tomography or transient elastography score was reportedly PHE-related factors. However, the prevalence of PHE and its related associated factors remain controversial. The management of PHE has not yet been standardized. It should be individualized according to each patient's situation, the availability of therapy, and each institutional expertise.

Low Serum Hepatitis B Surface Antigen Level Predicts Compensated Cirrhosis Caused by Chronic Hepatitis B in HBeAg Positive Patients in East China

BACKGROUNDS

Serum hepatitis B surface antigen (HBsAg) levels are associated with fibrosis in patients with chronic hepatitis B (CHB) infection.

OBJECTIVES

The aim of our study was to evaluate serum HBsAg level as a biomarker for compensated cirrhosis in hepatitis B e antigen (HBeAg) positive CHB patients.

PATIENTS AND METHODS

Two-hundred and one HBeAg-positive Chinese CHB patients with or without cirrhosis were enrolled in this retrospective study. Cirrhosis was diagnosed based on liver biopsy. Furthermore, patients with decompensated cirrhosis were excluded. A statistical analysis was performed regarding the association between serum HBsAg level and compensated cirrhosis.

RESULTS

Patients with compensated cirrhosis had a significantly lower mean serum HBsAg level compared to those without cirrhosis (3.27 Log10 IU/mL VS 4.17 Log10 IU/mL, P < 0.001). Furthermore, examining the correlation with compensated cirrhosis revealed that lower level of serum HBsAg was a significant factor in multivariate analysis. The area under the receiver operating characteristics curve of serum HBsAg was 0.856 for compensated cirrhosis. A positive predictive value of 66.2% and negative predictive value of 90.7% were obtained with a cut-off value of < 3.60 Log10 IU/mL (4000 IU/mL) of serum HBsAg. Moreover, the rate of compensated cirrhosis increased to 75.0% after combining with APRI > 2.

CONCLUSIONS

In HBeAg positive CHB patients, low serum HBsAg level is a useful predictor of compensated cirrhosis.

Portal hypertensive gastropathy in cirrhotics without varices: a case-control study

OBJECTIVE

Information is lacking on portal hypertensive gastropathy (PHG) in cirrhotics without varices; our aim it is to evaluate whether clinical and sonographic parameters are associated with PHG and may provide information suitable for the management of these patients.

PATIENTS AND METHODS

After endoscopic selection of 145 cirrhotics without varices, 75 with PHG and 70 without PHG, clinical and sonographic characteristics were assessed.

RESULTS

Forty portosystemic shunts were present in 27 patients. The mean Child-Pugh score was 6.3±1.4 and 5.6±0.5 in patients with severe and mild PHG, respectively (P=0.004). The mean portal vein diameter was 10.4±1.7 and 11.6±2.0 mm in cirrhotics without and with PHG, respectively (P=0.0002).

CONCLUSION

A link between the presence of PHG and a more advanced phase of cirrhosis was found. Duplex Doppler sonography was confirmed to be a valuable diagnostic method in monitoring cirrhosis. Management of these patients cannot be performed on the basis of a single diagnostic method, and a multimodal diagnostic approach is required.

Major predictors of portal hypertensive enteropathy in patients with liver cirrhosis

BACKGROUND AND AIM

Portal hypertensive enteropathy (PHE) is acknowledged as a source of bleeding, and predicting its presence has become more important. We assessed PHE using capsule endoscopy (CE) and investigated factors that may predict its presence, including portosystemic shunts (PSs).

METHODS

We analyzed data from 134 consecutive patients with liver cirrhosis, from February 2009 to September 2013. All patients had undergone dynamic computed tomography and esophagogastroduodenoscopy before CE examination. The frequencies and types of PHE lesions, and the relationships between the presence of PHE and patients' clinical characteristics were evaluated. The distribution of the lesions was also determined.

RESULTS

PHE was found in 91 (68%), erythema in 70 (52%), erosions in 25 (19%), angioectasia in 24 (18%), villous edema in 18 (13%), and varices in 10 (7%) patients. Most lesions were located in the jejunum. The clinical characteristics associated with the presence of PHE were a Child-Pugh grade of B or C (P = 0.0058), and the presence of PSs (P < 0.0001), ascites (P = 0.0017), portal thrombosis (P = 0.016), esophageal varices (P = 0.0017), and portal hypertensive gastropathy (P = 0.0029). The presence of PSs was an independent predictor of PHE (odds ratio [OR]: 3.15; 95% confidence interval [CI]: 1.27-7.95). Among the shunt types, left gastric vein (OR: 5.31; 95% CI: 1.97-17.0) and splenorenal shunts (OR: 4.26; 95% CI: 1.29-19.4) were independent predictors of PHE.

CONCLUSION

PSs, especially left gastric vein and splenorenal shunts, appear to reliably predict the presence of PHE.

Spleen stiffness and splenoportal venous flow: assessment before and after transjugular intrahepatic portosystemic shunt placement

OBJECTIVES

To prospectively assess changes in spleen stiffness and splenoportal venous flow before and after transjugular intrahepatic portosystemic shunt (TIPS) placement.

METHODS

We prospectively evaluated spleen stiffness measured by the mean shear wave velocity with acoustic radiation force impulse imaging and the splenoportal venous velocity with color Doppler sonography in 12 patients (mean age ± SD, 42.6 ± 11.0 years; range, 29-65 years) who underwent TIPS placement for portal hypertension and gastroesophageal bleeding. The mean shear wave velocity and angle-corrected splenoportal venous velocity at the main portal and splenic veins were measured 1 day before and 3 to 9 days after TIPS placement (mean interval, 6.0 ± 1.95 days; range, 4-10 days) and were compared with portal vein pressure measured during the procedure.

RESULTS

There was a significant difference in portal vein pressure before and after TIPS (25.34 ± 6.21 versus 15.66 ± 6.07 mm Hg; P = .0005). After TIPS, the mean shear wave velocity decreased significantly in all 12 cases (3.50 ± 0.46 versus 3.15 ± 0.39 m/s before and after TIPS; P = .00015). The flow velocity at the main portal vein increased significantly after TIPS (22.21 ± 4.13 versus 47.25 ± 12.37 cm/s; P = .0000051). The splenic vein velocity and spleen index measured 25.57 ± 6.98 cm/s and 55.99 ± 21.27 cm(2), respectively, before TIPS and 35.72 ± 11.10 cm/s and 50.11 ± 21.12 cm(2) after TIPS (P = .0004 and .003).

CONCLUSIONS

A significant decrease in the mean shear wave velocity and increase in the splenoportal venous velocity occurred with reduced portal vein pressure after TIPS placement. Hence, both parameters can be used as noninvasive quantitative markers for monitoring TIPS function after placement.

Variation in hepatic segmental volume distribution according to different causes of liver cirrhosis: CT volumetric evaluation

OBJECTIVE

To investigate if there is difference in hepatic segmental volume distribution according to causes of liver cirrhosis (LC) using computed tomography volumetric analysis.

METHODS

On computed tomographic scans, hepatic segmental volumes were measured in 90 patients with LC of 4 different causes (alcohol, hepatitis B virus (HBV), hepatitis C virus (HCV), and cryptogenic cirrhosis). The volumetric indices were compared.

RESULTS

The volume proportion of the lateral segment in the liver in patients with HBV was significantly higher than in the patients with HCV (P = 0.038). Hepatic volume distribution in alcoholic LC showed differences: larger caudate lobe volume than HBV- and HCV-induced LC (P = 0.029 and P = 0.031), larger right lobe volume (P = 0.043) and smaller proportion of the lateral segment in the liver (P = 0.003) than in HBV-induced LC.

CONCLUSIONS

Computed tomography volumetric analysis showed differences in hepatic segmental volume distribution in cirrhotic patients according to causes of LC.

Assessment of portal venous index as a non-invasive method for diagnosing liver fibrosis in patients with chronic hepatitis C

CONTEXT: Hepatitis C is an important cause of chronic liver disease worldwide. The grading of hepatic fibrosis in chronic hepatitis C is important for better clinical management. However, until now, liver biopsy is the only test accepted for this purpose, despite their contraindications and complications. New methods for non-invasive assessment of hepatic fibrosis are under investigation. One proposal is the Doppler ultrasound, as a non-invasive, widely available and inexpensive. OBJECTIVE: To compare Doppler parameters of portal vein in patients with chronic hepatitis C with a healthy control group and to correlate these parameters with fibrosis degree obtained by liver biopsy. METHODS: Fifty patients with chronic hepatitis C submitted to liver biopsy and 44 healthy controls had Doppler of the portal vein performed, with the calculation of the portal venous index. We conducted a comparison between the averages of the two groups of portal venous index. For the correlation between portal venous index and fibrosis was employed the Spearman test. RESULTS: There was a difference between the average portal venous index between controls (0.33 ± 0.07) and patients (0.23 ± 0.09) with P<0.001. No difference was observed between the portal venous index in patients with chronic hepatitis C who have significant fibrosis or not. The correlation between the portal venous index and fibrosis degree was reverse and moderate (r =-0.448 P<0.001). The area under the ROC curve was 78.4% (95% CI: 68.8% to 88%). The cutoff for the portal venous index was 0.28 with sensitivity of 73.5% and specificity of 71.1%. CONCLUSION: The portal venous index was useful in distinguishing healthy patients from patients with CHC. However, there was no significant difference in the quantification of degree of fibrosis.

Doppler US of the liver made simple

Doppler ultrasonography (US) is usually the first-line modality for evaluating flow in native liver vessels and transjugular intrahepatic portosystemic shunts (TIPS). Waveforms, which represent flow in each of the major vessels and in TIPS, have been well described. The appearance of these waveforms should be recognized, and the mechanisms behind their generation should be understood by those interpreting these examinations. Understanding how waveforms are formed--that is, their mechanisms for generation--is predicated on knowing basic vascular Doppler concepts and established nomenclature. This article is a review of these basic concepts and nomenclature as applied to the interpretation of liver Doppler US waveforms.

What are the implications of the spontaneous spleno-renal shunts in liver cirrhosis?

Background

Although significant advances are expected to be made in the assessment of the portal hypertension-related complications, the prognostic role of spleno-renal shunts has not been fully explored so far. Clarifying this aspect could help tackle the life-treating events occurring in patients suffering from liver cirrhosis. The aim of the study was to analyze the relationships between the spleno-renal shunts presence at doppler ultrasound and the liver cirrhosis complications.

Methods

Design: eighty one patients out of 129 formed the study population (35 females). Chronic liver damage in these patients was caused by HCV (66), HBV (2), alcohol abuse (2) or unknown etiology, likely non-alcoholic steatohepatitis (11). Setting: two Liver Units of university/primary hospitals in Southern Italy. Main outcome measures: grading of esofageal varices; detection of ascites: assessment of hepatic encephalopathy; evaluation of liver cirrhosis severity; tracking hepatocellular carcinoma; doppler features of spleno-renal shunts and splenic flow velocity; spleen longitudinal diameter at sonography.

Results

The prevalence of spleno-renal shunts was 18.5%, without no difference concerning the etiology (HCV versus non-HCV, p = 0.870); the prevalence of hepatocellular carcinoma in patients with spleno-renal shunts was superior to that of patients without them (Pearson Chi-square, p = 0.006, power of sample size 74%), also after adjustment for liver decompensation (p = 0.024). The median score of hepatic encephalopathy in patients with and without spleno-renal shunts was similar, i.e., 0 (range, 0-2) versus 0 (0 - 3), p = 0.67. The median splenic vein flow velocity in patients with spleno-renal shunts was significantly inferior to that of patients without them, i.e., 13 cm/sec (95% confidence intervals, 6-18) versus 21 cm/sec (17-24), p < 0.0001. By far the largest percentage of large esophageal varices was in patients without spleno-renal shunts (p = 0.005). In contrast, the frequency of ascites and hepatic encephalopathy severity was overlapping in the two groups. BMI values but not Child-Pugh's classification predicted spleno-renal shunts (Ors = 1.84, 95% confidence intervals = 1.28-2.64, p = 0.001 and 1.145, 95% confidence intervals = 0.77-1.51, p = 0.66).

Conclusion

Taking into consideration the relatively small sample size, patients with spleno-renal shunts are burdened by an increased incidence of hepatocellular carcinoma. BMI predicted the spleno-renal shunts presence.

Changes in hepatic venous morphology with cirrhosis on MRI

PURPOSE

To identify changes in vascular morphology on magnetic resonance imaging (MRI) in patients with cirrhosis and to compare these findings to liver donors.

MATERIALS AND METHODS

Patients undergoing liver transplantation with biopsy-proven cirrhosis (n = 74) and liver donor candidates (n = 85) underwent dynamic gadolinium-enhanced 3D MR at 1.5T. Vessel diameters were measured independently by three radiologists and features of cirrhosis were identified and correlated with cirrhosis.

RESULTS

Hepatic veins were smaller in patients with cirrhosis (4.9, 4.5, and 5.0 mm for right, middle, and left vs. 9.9, 7.6, and 8.9 mm in donors, P << 0.001) and were negatively correlated with cirrhosis (P < 0.001). Right hepatic vein (RHV) <5 mm diagnosed cirrhosis with 59% sensitivity and 99% specificity; the sensitivity and specificity were 88% and 85% for RHV <7 mm. Main portal vein was minimally larger in cirrhosis, 14 versus 12 mm (P < 0.001) in donors. Right portal veins were smaller in cirrhotic patients, 6.5 and 6.2 mm compared to 8.4 and 7.6 mm (P << 0.001), respectively, in donors.

CONCLUSION

Vascular features of cirrhosis include small hepatic veins, minimally enlarged main portal vein, and small intrahepatic portal veins; these features may facilitate identification of cirrhosis.

Portosystemic shunts in a large cohort of patients with liver cirrhosis: detection rate and clinical relevance

BACKGROUND

This study aimed to determine the detection rate and clinical relevance of portosystemic collaterals.

METHODS

We studied 326 cirrhotics. Portosystemic collaterals, portal vein diameter, and splenic area were evaluated by color Doppler sonography; esophageal varices were detected by endoscopy.

RESULTS

Of the cirrhotics, 130 had portosystemic collaterals (39.9% total, left gastric vein 11%, paraumbilical vein 7.4%, splenorenal shunts 13.8%, and combined shunts 7.7%). Cirrhotics without portosystemic collaterals or with a paraumbilical vein had a significantly narrower portal vein diameter than cirrhotics with a left gastric vein (P < 0.001). Cirrhotics with a paraumbilical vein had a significantly smaller splenic area than cirrhotics with a left gastric vein (P < 0.001), splenorenal shunts (P < 0.001), combined shunts (P < 0.001), or without portosystemic collaterals (P < 0.05). A significant association between portosystemic collaterals and Child's classes or presence and type of esophageal varices was found (P < 0.0001 and P = 0.0004, respectively). The highest prevalence of Child's class C and large (F-3) esophageal varices was found in cirrhotics with a left gastric vein (41.7% and 36.1%, respectively), whereas esophageal varices were absent in 47.4% of cirrhotics without portosystemic collaterals and in 58.3% of cirrhotics with a paraumbilical vein.

CONCLUSIONS

The left gastric vein is associated with some sonographic and clinical markers of disease severity, whereas the absence of portosystemic collaterals or the presence of paraumbilical veins seems to identify cirrhotics with markers predictive of a more favorable clinical course.

Normal Doppler spectral waveforms of major pediatric vessels: specific patterns

Every major vessel in the human body has a characteristic flow pattern that is visible in spectral waveforms obtained in that vessel with Doppler ultrasonography (US). Spectral waveforms reflect the physiologic status of the organ supplied by the vessel, as well as the anatomic location of the vessel in relation to the heart. In addition, the waveforms may be affected by age- and development-related hemodynamic differences. For example, adults tend to have higher flow velocities, whereas neonates, particularly those born prematurely, have higher resistance to flow, especially in the cerebral and renal vascular beds. As Doppler US is performed with increasing frequency for vascular evaluation in children, the recognition of normal flow patterns has become imperative. Familiarity with the waveforms characteristic of specific veins and arteries in children is important. In addition, an understanding of the hemodynamic factors involved provides a useful basis for interpreting waveform abnormalities.

Statistical relevance of ultrasonographic criteria in the assessment of diffuse liver disease in dogs and cats

OBJECTIVE

To determine whether objectively applied ultrasonographic interpretive criteria are statistically useful in differentiating among 7 defined categories of diffuse liver disease in dogs and cats.

SAMPLE POPULATION

Ultrasonographic images of 229 dogs and 104 cats.

PROCEDURES

Liver parenchymal or related sonographic criteria established by the authors were retrospectively and independently applied by 3 radiologists who were not aware of patient status or patient laboratory data. Seven histologic or cytologic categories of diffuse (infiltrative but not nodular) liver diseases were jointly established by the authors and included normal liver; inflammation; round-cell neoplasia; non-round-cell infiltrative, prenodular (early) metastatic neoplasia; lipidosis; vacuolar hepatopathy; and other. Liver parenchymal sonographic criteria included parenchymal sound attenuation with increasing depth, comparative organ echogenicity (liver, spleen, and kidneys), diffuse or patchy hyperechoic or hypoechoic echotexture, uniform or coarse echotexture, portal venous clarity, and liver lobe geometry. Related extrahepatic criteria included gallbladder wall thickness, bile duct diameter, amount and character of gallbladder precipitate, nondependent shadowing in the gallbladder, hepatic vein diameter versus caudal vena cava diameter, peritoneal fluid, spleen echotexture (normal vs abnormal [characterized]), and kidney echotexture. Ultrasonographic criteria were statistically compared to the 7 categories of diffuse liver disease in search of clinically exploitable relationships.

RESULTS

Statistical evaluation of the applied ultrasonographic criteria did not yield clinically acceptable accuracy for discrimination among the 7 categories of diffuse liver diseases (including normal liver) in either species.

CONCLUSIONS AND CLINICAL RELEVANCE

Criterion-based ultrasonographic appearance was insufficient to discriminate among canine and feline diffuse infiltrative liver diseases.

Liver cirrhosis

Cirrhosis is defined as the histological development of regenerative nodules surrounded by fibrous bands in response to chronic liver injury, which leads to portal hypertension and end-stage liver disease. Recent advances in the understanding of the natural history and pathophysiology of cirrhosis, and in treatment of its complications, have resulted in improved management, quality of life, and life expectancy of patients. Liver transplantation remains the only curative option for a selected group of patients, but pharmacological treatments that can halt progression to decompensated cirrhosis or even reverse cirrhosis are currently being developed. This Seminar focuses on the diagnosis, complications, and management of cirrhosis, and new clinical and scientific developments.

Liver cirrhosis

Cirrhosis is defined as the histological development of regenerative nodules surrounded by fibrous bands in response to chronic liver injury, which leads to portal hypertension and end-stage liver disease. Recent advances in the understanding of the natural history and pathophysiology of cirrhosis, and in treatment of its complications, have resulted in improved management, quality of life, and life expectancy of patients. Liver transplantation remains the only curative option for a selected group of patients, but pharmacological treatments that can halt progression to decompensated cirrhosis or even reverse cirrhosis are currently being developed. This Seminar focuses on the diagnosis, complications, and management of cirrhosis, and new clinical and scientific developments.

Portalsystemic hemodynamic changes in chronic severe hepatitis B: An ultrasonographic study

AIM: To evaluate portalsystemic hemodynamic changes in chronic severe hepatitis B.

METHODS: Hemodynamic parameters included portal vein diameter (PVD), portal vein peak velocity (PVPV), portal vein volume (PVV), spleen length (SPL), spleen vein diameter (SPVD), spleen vein volume (SPVV) and umbilical vein recanalization. They were measured by Color Doppler ultrasonography in 36 patients with chronic severe hepatitis B, compared with 51 normal controls, 61 patients with chronic hepatitis B, 46 patients with compensable cirrhosis, and 36 patients with decompensable cirrhosis.

RESULTS: In the group of chronic severe hepatitis B, PVD (12.38 ± 1.23 mm) was significantly different from the normal control, compensable cirrhosis and decompensable cirrhosis groups (P = 0.000-0.026), but not significantly different from the chronic hepatitis group. PVPV (16.15 ± 3.82 cm/s) dropped more significantly in the chronic severe hepatitis B group than the normal control, chronic hepatitis B and compensable cirrhosis groups (P = 0.000-0.011). PVV (667.53 ± 192.83 mL/min) dropped significantly as compared with the four comparison groups (P = 0.000-0.004). SPL (120.42 ± 18.36 mm) and SPVD (7.52 ± 1.52 mm) were longer in the normal control and chronic hepatitis B groups (P = 0.000-0.009), yet they were significantly shorter than those in the decompensable cirrhosis group (P = 0.000). SPVV (242.51 ± 137.70 mL/min) was also lower than the decompensable cirrhosis group (P = 0.000). The umbilical vein recanalization rate (75%) was higher than the chronic hepatitis B and compensable cirrhosis groups. In the course of progression from chronic hepatitis to decompensable cirrhosis, PVD, SPL and SPVD gradually increased and showed significant differences between every two groups (P = 0.000-0.002).

CONCLUSION: Patients with chronic severe hepatitis B have a tendency to develop acute portal hypertension, resulting in significantly reduced portal vein perfusion. Observation of the portalsystemic hemodynamic changes may be contributed to the disease progression of chronic liver disease.

Correlation between ultrasonographic and pathologic diagnosis of liver fibrosis due to chronic virus hepatitis

AIM: To evaluate the validity of ultrasonographic and pathologic diagnosis of liver fibrosis in patients with chronic viral hepatitis.

METHODS: The liver fibrosis status in 324 patients was evaluated by both needle biopsy and ultrasonography. Liver fibrosis was divided into S0 -S4 stages. S4 stage was designated as definite cirrhosis. The ultrasonographic examination included qualitative variables, description of liver surface and parenchyma, and quantitative parameters, such as diameter of vessels, blood flow velocity and spleen size.

RESULTS: Ultrasonographic qualitative description of liver surface and parenchyma was related with the severity of fibrosis. Among the quantitative ultrasonographic parameters, cut-off value of spleen length (12.1 cm) had a sensitivity of 0.600 and a specificity of 0.753 for diagnosis of liver cirrhosis. The diameters of spleen (8 mm) and portal vein (12 mm) had a diagnostic sensitivity of 0.600 and 0.767, and a diagnostic specificity of 0.781 and 0.446, respectively. The diagnostic accuracy for liver cirrhosis was moderately satisfactory, and the negative predictive values of these parameters reached near 0.95.

CONCLUSION: Ultrasonography can predict the degree of liver fibrosis or cirrhosis. A single ultrasonographic parameter is limited in sensitivity and specificity for the diagnosis of early cirrhosis. The presence or absence of liver cirrhosis in patients with chronic virus hepatitis can be detected using 2 or 3 quantitative and qualitative parameters, especially the length of spleen, the diameter of spleen vein and echo pattern of liver surface.

Diagnosis of liver cirrhosis: a comparison of modified ultrasound and laparoscopy in 100 consecutive patients

BACKGROUND/GOALS

Liver cirrhosis, the final stage of chronic liver disease, is characterized by an unfavorable prognosis and an increased risk of hepatocellular carcinoma and also requires an appropriate management. Laparoscopy, the gold standard in the diagnosis of cirrhosis, is hampered by its invasiveness. Therefore, a noninvasive method for diagnosing liver cirrhosis would be of great benefit.

STUDY

A consecutive series of 100 patients, sent to our gastroenterological unit for diagnostic laparoscopy, underwent a standardized ultrasonographic examination prior to laparoscopy.

RESULTS

Conventional ultrasonographic examination revealed a sensitivity of 55% and a specificity of 86% in the diagnosis of cirrhosis. Considering the assessment of the transmission of heart pulsation on the liver surface, the corresponding values improved by increasing to 85% and 93%.

CONCLUSION

Evaluating the transmission of heart pulsation on the liver surface improves the ability of ultrasound to diagnose liver cirrhosis; therefore, it should be an integral part of routine sonographic examination of the liver.

Value of portal hemodynamics and hypersplenism in cirrhosis staging

AIM: To determine the correlation between portal hemodynamics and spleen function among different grades of cirrhosis and verify its significance in cirrhosis staging.

METHODS: The portal and splenic vein hemodynamics and spleen size were investigated by ultrasonography in consecutive 38 cirrhotic patients with cirrhosis (Child’s grades A to C) and 20 normal controls. The differences were compared in portal vein diameter and flow velocity between patients with and without ascites and between patients with mild and severe esophageal varices. The correlation between peripheral blood cell counts and Child’s grades was also determined.

RESULTS: The portal flow velocity and volume were significantly lower in patients with Child’s C (12.25±1.67 cm/s vs 788.59±234 mm/min, respectively) cirrhosis compared to controls (19.55±3.28 cm/s vs 1254.03±410 mm/min, respectively) and those with Child’s A (18.5±3.02 cm/s vs 1358.48±384 mm/min, respectively) and Child’s B (16.0±3.89 cm/s vs 1142.23±390 mm/min, respectively) cirrhosis. Patients with ascites had much lower portal flow velocity and volume (13.0±1.72 cm/s vs 1078±533 mm/min) than those without ascites (18.6±2.60 cm/s vs 1394±354 mm/min). There was no statistical difference between patients with mild and severe esophageal varices. The portal vein diameter was not significantly different among the above groups. There were significant differences in splenic vein diameter, flow velocity and white blood cell count, but not in spleen size, red blood cell and platelet counts among the various grades of cirrhosis. The spleen size was negatively correlated with red blood cell and platelet counts (r = -0.620 and r = -0.8.34, respectively).

CONCLUSION: An optimal system that includes parameters representing the portal hemodynamics and spleen function should be proposed for cirrhosis staging.

Emergency Doppler evaluation of the liver and kidneys

Doppler ultrasound is useful in the emergent evaluation of the liver and kidney transplant patient. Arterial stenosis, pseudoaneurysm, and venous thrombosis are treatable causes of allograft failure that can be detected easily with color and spectral Doppler. Doppler has a limited but important role in the emergent evaluation of the native liver and kidneys, usually involving prior biopsy or instrumentation.

Grading and staging of hepatic fibrosis, and its relationship with noninvasive diagnostic parameters

AIM: To explore the grade and stage of pathology and the relationship between grading and staging of hepatic fibrosis and noninvasive diagnostic parameters.

METHODS: Inflammatory activity and fibrosis of consecutive liver biopsies from 200 patients with chronic liver disease were determined according to the Diagnostic Criteria of Chronic Hepatitis in China, 1995. A comparative analysis was made in these patients comparing serum markers, Doppler ultrasonography, CT and/or MR imaging with the findings of liver biopsy.

RESULTS: With increase of inflammatory activity, the degree of fibrosis also rose. There was a close correlation between liver fibrosis and inflammatory activity. AST, GGT, albumin, albumin/globulin, ALP, AFP, hyaluronic acid, N-terminal procollagen III (P III NP), collagen type IV (Col IV), tissue inhibitors of metalloproteinases-1 (TIMP-1), alpha-2-macroglobulin, natural killer cells (NK), some parameters of Doppler ultrasonography, CT and/or MR imaging were all related to the degree of inflammatory activity. GGT, albumin, albumin/globulin, ALP, AFP, hyaluronic acid, Col IV, TIMP-1, alpha-2- macroglobulin, transforming growth factor-beta 1 (TGFβ1), NK, some parameters of Doppler ultrasonography, CT and/or MR imaging were all related to the staging of fibrosis. By regression analysis, the parameters used in combination to differentiate the presence or absence of fibrosis were age, GGT, the parameter of blood flow of portal vein per minute, the maximum oblique diameter of right liver by B ultrasound, the wavy hepatic surface contour by CT and/or MR. The sensitivity, specificity and accuracy of the above parameters were 80.36%, 86.67%, and 81.10%, respectively.

CONCLUSION: There is close correlation between liver fibrosis and inflammatory activity. The grading and staging of liver fibrosis are related to serum markers, Doppler ultrasonography, CT and/or MR imaging. The combination of the above mentioned noninvasive parameters are quite sensitive and specific in the diagnosis of hepatic fibrosis.

Liver fibrosis in chronic viral hepatitis: An ultrasonographic study

AIM: To select valuable ultrasonographic predictors for the evaluation of hepatic inflammation and fibrosis degree in chronic hepatitis, and to study the value of ultrasonography in the evaluation of liver fibrosis and compensated liver cirrhosis in comparison with serology and histology.

METHODS: Forty-four ultrasonographic variables were analyzed and screened using color Doppler ultrasound system in 225 patients with chronic viral hepatitis and compensated liver cirrhosis. The valuable ultrasonographic predictors were selected on the basis of a comparison with histopathological findings. The value of ultrasonography and serology in the evaluation of liver fibrosis degree and the diagnosis of compensated liver cirrhosis was also studied and compared. Meanwhile, the influencing factors on ultrasonographic diagnosis of compensated liver cirrhosis were also analyzed.

RESULTS: By statistical analysis, the maximum velocity of portal vein and the degree of gall-bladder wall smoothness were selected as the valuable predictors for the inflammation grade (G), while liver surface, hepatic parenchymal echo pattern, and the wall thickness of gall-bladder were selected as the valuable predictors for the fibrosis stage (S). Three S-related independent ultrasonographyic predictors and three routine serum fibrosis markers (HA, HPCIII and CIV) were used to discriminate variables for the comparison of ultrasonography with serology. The diagnostic accuracy of ultrasonography in moderate fibrosis was higher than that of serology (P < 0.01), while there were no significant differences in the general diagnostic accuracy of fibrosis as well as between mild and severe fibrosis (P < 0.05). There were no significant differences between ultrasonography and serology in the diagnosis of compensated liver cirrhosis. However, the diagnostic accuracy of ultrasonography was higher in inactive liver cirrhosis and lower in active cirrhosis than that of serology (both P < 0.05). False positive and false negative results where found when the diagnosis of compensated liver cirrhosis was made by ultrasonography.

CONCLUSION: There are different ultrasonographic predictors for the evaluation of hepatic inflammation grade and fibrosis stage of chronic hepatitis. Both ultrasonography and serology have their own advantages and disadvantages in the evaluation of liver fibrosis and compensated liver cirrhosis. Combined application of the two methods is hopeful to improve the diagnostic accuracy.