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Celsa C, Veneziano M, Di Giorgio FM, Cannova S, Lombardo A, Errigo E, Landro G, Simone F, Sinagra E, Calvaruso V. Non-Invasive Diagnostic Tests for Portal Hypertension in Patients with HBV- and HCV-Related Cirrhosis: A Comprehensive Review. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:690. [PMID: 38792873 PMCID: PMC11123262 DOI: 10.3390/medicina60050690] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/18/2024] [Revised: 04/10/2024] [Accepted: 04/17/2024] [Indexed: 05/26/2024]
Abstract
Clinically significant portal hypertension (CSPH) in patients with compensated advanced chronic liver disease indicates an increased risk of decompensation and death. While invasive methods like hepatic venous-portal gradient measurement is considered the gold standard, non-invasive tests (NITs) have emerged as valuable tools for diagnosing and monitoring CSPH. This review comprehensively explores non-invasive diagnostic modalities for portal hypertension, focusing on NITs in the setting of hepatitis B and hepatitis C virus-related cirrhosis. Biochemical-based NITs can be represented by single serum biomarkers (e.g., platelet count) or by composite scores that combine different serum biomarkers with each other or with demographic characteristics (e.g., FIB-4). On the other hand, liver stiffness measurement and spleen stiffness measurement can be assessed using a variety of elastography techniques, and they can be used alone, in combination with, or as a second step after biochemical-based NITs. The incorporation of liver and spleen stiffness measurements, alone or combined with platelet count, into established and validated criteria, such as Baveno VI or Baveno VII criteria, provides useful tools for the prediction of CSPH and for ruling out high-risk varices, potentially avoiding invasive tests like upper endoscopy. Moreover, they have also been shown to be able to predict liver-related events (e.g., the occurrence of hepatic decompensation). When transient elastography is not available or not feasible, biochemical-based NITs (e.g., RESIST criteria, that are based on the combination of platelet count and albumin levels) are valid alternatives for predicting high-risk varices both in patients with untreated viral aetiology and after sustained virological response. Ongoing research should explore novel biomarkers and novel elastography techniques, but current evidence supports the utility of routine blood tests, LSM, and SSM as effective surrogates in diagnosing and staging portal hypertension and predicting patient outcomes.
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Affiliation(s)
- Ciro Celsa
- Gastroenterology and Hepatology Unit, Department of Health Promotion, Mother & Child Care, Internal Medicine & Medical Specialties, University of Palermo, 90127 Palermo, Italy; (M.V.); (F.M.D.G.); (S.C.); (A.L.); (E.E.); (G.L.); (F.S.); (V.C.)
- Department of Surgery & Cancer, Imperial College London, Hammersmith Hospital, London W12 0NN, UK
| | - Marzia Veneziano
- Gastroenterology and Hepatology Unit, Department of Health Promotion, Mother & Child Care, Internal Medicine & Medical Specialties, University of Palermo, 90127 Palermo, Italy; (M.V.); (F.M.D.G.); (S.C.); (A.L.); (E.E.); (G.L.); (F.S.); (V.C.)
| | - Francesca Maria Di Giorgio
- Gastroenterology and Hepatology Unit, Department of Health Promotion, Mother & Child Care, Internal Medicine & Medical Specialties, University of Palermo, 90127 Palermo, Italy; (M.V.); (F.M.D.G.); (S.C.); (A.L.); (E.E.); (G.L.); (F.S.); (V.C.)
| | - Simona Cannova
- Gastroenterology and Hepatology Unit, Department of Health Promotion, Mother & Child Care, Internal Medicine & Medical Specialties, University of Palermo, 90127 Palermo, Italy; (M.V.); (F.M.D.G.); (S.C.); (A.L.); (E.E.); (G.L.); (F.S.); (V.C.)
| | - Antonino Lombardo
- Gastroenterology and Hepatology Unit, Department of Health Promotion, Mother & Child Care, Internal Medicine & Medical Specialties, University of Palermo, 90127 Palermo, Italy; (M.V.); (F.M.D.G.); (S.C.); (A.L.); (E.E.); (G.L.); (F.S.); (V.C.)
| | - Emanuele Errigo
- Gastroenterology and Hepatology Unit, Department of Health Promotion, Mother & Child Care, Internal Medicine & Medical Specialties, University of Palermo, 90127 Palermo, Italy; (M.V.); (F.M.D.G.); (S.C.); (A.L.); (E.E.); (G.L.); (F.S.); (V.C.)
| | - Giuseppe Landro
- Gastroenterology and Hepatology Unit, Department of Health Promotion, Mother & Child Care, Internal Medicine & Medical Specialties, University of Palermo, 90127 Palermo, Italy; (M.V.); (F.M.D.G.); (S.C.); (A.L.); (E.E.); (G.L.); (F.S.); (V.C.)
| | - Fabio Simone
- Gastroenterology and Hepatology Unit, Department of Health Promotion, Mother & Child Care, Internal Medicine & Medical Specialties, University of Palermo, 90127 Palermo, Italy; (M.V.); (F.M.D.G.); (S.C.); (A.L.); (E.E.); (G.L.); (F.S.); (V.C.)
| | - Emanuele Sinagra
- Gastroenterology and Endoscopy Unit, Fondazione Istituto G. Giglio, 90015 Cefalù, Italy;
| | - Vincenza Calvaruso
- Gastroenterology and Hepatology Unit, Department of Health Promotion, Mother & Child Care, Internal Medicine & Medical Specialties, University of Palermo, 90127 Palermo, Italy; (M.V.); (F.M.D.G.); (S.C.); (A.L.); (E.E.); (G.L.); (F.S.); (V.C.)
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Chen SH, Lai HC, Su WP, Kao JT, Hsu WF, Wang HW, Chen HY, Peng CY. Liver stiffness and spleen stiffness predict distinct liver-related events after hepatitis C eradication with direct-acting antivirals. J Formos Med Assoc 2024:S0929-6646(24)00142-6. [PMID: 38453531 DOI: 10.1016/j.jfma.2024.02.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Revised: 02/25/2024] [Accepted: 02/28/2024] [Indexed: 03/09/2024] Open
Abstract
BACKGROUND /Purpose: This study aimed to directly compare the utility of liver stiffness (LS) and spleen stiffness (SS) at sustained virologic response (SVR) for predicting hepatocellular carcinoma (HCC) and non-HCC events in patients with chronic hepatitis C (CHC) after direct-acting antiviral therapy. METHODS This retrospective study included 695 CHC patients who achieved SVR and underwent LS and SS measurements. LS and SS were measured using point shear wave elastography and compared head-to-head. RESULTS During a median follow-up of 29.5 months, 49 (7.1%) patients developed liver-related events (LREs), including 28 HCC and 22 non-HCC events after SVR. Multivariable Cox regression analysis revealed that age, albumin level, and LS (≥ versus <1.46 m/s) at SVR (adjusted hazard ratio [aHR]: 5.390; 95% confidence interval [CI]: 2.349-12.364; p < 0.001), but not SS at SVR, significantly predicted the overall risk of post-SVR LREs (n = 49). Furthermore, age and LS (≥ versus <1.46 m/s) at SVR (aHR: 6.759; 95% CI: 2.317-19.723; p < 0.001), but not SS at SVR, independently predicted the risk of post-SVR incident HCC. In contrast, SS (≥ versus <2.87 m/s) at SVR (aHR: 11.212; 95% CI: 1.564-20.132; p = 0.021) and albumin level, but not LS at SVR, significantly predicted the risk of post-SVR non-HCC events. CONCLUSION Post-SVR LS better predicts HCC risk. Post-SVR SS helps predict non-HCC risk after antiviral therapy for CHC. LS and SS at SVR provide complementary prognostic information regarding risks of HCC and non-HCC events in the post-SVR setting. Further validation is warranted in larger cohorts.
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Affiliation(s)
- Sheng-Hung Chen
- School of Medicine, China Medical University, Taichung, Taiwan; Center for Digestive Medicine, Department of Internal Medicine, China Medical University Hospital, Taichung, Taiwan
| | - Hsueh-Chou Lai
- Center for Digestive Medicine, Department of Internal Medicine, China Medical University Hospital, Taichung, Taiwan; School of Chinese Medicine, China Medical University, Taichung, Taiwan
| | - Wen-Pang Su
- Center for Digestive Medicine, Department of Internal Medicine, China Medical University Hospital, Taichung, Taiwan
| | - Jung-Ta Kao
- School of Medicine, China Medical University, Taichung, Taiwan; Center for Digestive Medicine, Department of Internal Medicine, China Medical University Hospital, Taichung, Taiwan
| | - Wei-Fan Hsu
- Center for Digestive Medicine, Department of Internal Medicine, China Medical University Hospital, Taichung, Taiwan; School of Chinese Medicine, China Medical University, Taichung, Taiwan
| | - Hung-Wei Wang
- School of Medicine, China Medical University, Taichung, Taiwan; Center for Digestive Medicine, Department of Internal Medicine, China Medical University Hospital, Taichung, Taiwan
| | - Hung-Yao Chen
- School of Medicine, China Medical University, Taichung, Taiwan; Center for Digestive Medicine, Department of Internal Medicine, China Medical University Hospital, Taichung, Taiwan
| | - Cheng-Yuan Peng
- School of Medicine, China Medical University, Taichung, Taiwan; Center for Digestive Medicine, Department of Internal Medicine, China Medical University Hospital, Taichung, Taiwan.
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Kotani K, Kawada N. Recent Advances in the Pathogenesis and Clinical Evaluation of Portal Hypertension in Chronic Liver Disease. Gut Liver 2024; 18:27-39. [PMID: 37842727 PMCID: PMC10791512 DOI: 10.5009/gnl230072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 06/16/2023] [Accepted: 06/25/2023] [Indexed: 10/17/2023] Open
Abstract
In chronic liver disease, hepatic stellate cell activation and degeneration of liver sinusoidal endothelial cells lead to structural changes, which are secondary to fibrosis and the presence of regenerative nodules in the sinusoids, and to functional changes, which are related to vasoconstriction. The combination of such changes increases intrahepatic vascular resistance and causes portal hypertension. The subsequent increase in splanchnic and systemic hyperdynamic circulation further increases the portal blood flow, thereby exacerbating portal hypertension. In clinical practice, the hepatic venous pressure gradient is the gold-standard measure of portal hypertension; a value of ≥10 mm Hg is defined as clinically significant portal hypertension, which is severe and is associated with the risk of liver-related events. Hepatic venous pressure gradient measurement is somewhat invasive, so evidence on the utility of risk stratification by elastography and serum biomarkers is needed. The various stages of cirrhosis are associated with different outcomes. In viral hepatitis-related cirrhosis, viral suppression or elimination by nucleos(t)ide analog or direct-acting antivirals results in recompensation of liver function and portal pressure. However, careful follow-up should be continued, because some cases have residual clinically significant portal hypertension even after achieving sustained virologic response. In this study, we reviewed the current and future prospects for portal hypertension.
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Affiliation(s)
- Kohei Kotani
- Department of Hepatology, Graduate School of Medicine, Osaka Metropolitan University, Osaka, Japan
| | - Norifumi Kawada
- Department of Hepatology, Graduate School of Medicine, Osaka Metropolitan University, Osaka, Japan
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Fraquelli M, Fichera A. Ultrasound-based elastography combined with Baveno VI criteria: A new era begins in the prediction of high-risk varices in cirrhotic patients. Dig Liver Dis 2023; 55:1060-1061. [PMID: 37164893 DOI: 10.1016/j.dld.2023.04.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Revised: 04/25/2023] [Accepted: 04/28/2023] [Indexed: 05/12/2023]
Affiliation(s)
- Mirella Fraquelli
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via F. Sforza 35, Milan 20122, Italy.
| | - Anna Fichera
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via F. Sforza 35, Milan 20122, Italy
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Fraquelli M, Vranić L, Nadarevic T, Štimac D, Manzotti C, Fichera A, Casazza G, Colli A. Liver and spleen stiffness for the diagnosis of oesophageal varices in adults with chronic liver disease. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2023; 2023:CD015547. [PMCID: PMC9890918 DOI: 10.1002/14651858.cd015547] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
This is a protocol for a Cochrane Review (diagnostic). The objectives are as follows: To assess the diagnostic accuracy of liver stiffness and spleen stiffness, separately or in combination, as measured by vibration‐controlled transient elastography (VCTE) in detection of any oesophageal varices in adults with chronic liver disease. We will regard a combination of tests as positive when at least one is positive. To compare the diagnostic accuracy of individual tests (liver stiffness and spleen stiffness measured by VCTE) directly and versus the combination of both tests (considering positive when at least one is positive) in detecting any oesophageal varices. To assess the diagnostic accuracy of liver stiffness and spleen stiffness, separately or in combination, as measured by other elastography techniques (2D‐shear wave elastography (2D‐SWE), point shear wave elastography (pSWE), magnetic resonance elastography (MRE)) in detection of any oesophageal varices in adults with chronic liver disease. We will regard a combination of tests as positive when at least one is positive. To compare the diagnostic accuracy of liver stiffness and spleen stiffness measured by VCTE with other techniques (pSWE, 2D‐SWE, MRE) in detection of any oesophageal varices in adults with chronic liver disease.
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Affiliation(s)
| | - Mirella Fraquelli
- Gastroenterology and Endoscopy UnitFondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, MilanoMilanItaly
| | - Luka Vranić
- Department of GastroenterologyClinical Hospital Centre RijekaRijekaCroatia
| | - Tin Nadarevic
- Department of RadiologyClinical Hospital Centre RijekaRijekaCroatia
| | - Davor Štimac
- Department of GastroenterologyClinical Hospital Centre RijekaRijekaCroatia
| | - Cristina Manzotti
- Department of Pathophysiology and TransplantationUniversità degli Studi di MilanoMilanItaly
| | - Anna Fichera
- UOC di Gastroenterologia ed EpatologiaPoliclinico Paolo GiacconePalermoItaly
| | - Giovanni Casazza
- Department of Clinical Sciences and Community Health – Laboratory of Medical Statistics, Biometry and Epidemiology "G.A. Maccacaro"Università degli Studi di MilanoMilanItaly
| | - Agostino Colli
- Department of Transfusion Medicine and HaematologyFondazione IRCCS Ca' Granda Ospedale Maggiore PoliclinicoMilanItaly
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Spleen and Liver Stiffness Evaluation by ARFI Imaging: A Reliable Tool for a Short-Term Monitoring of Portal Hypertension? Int J Hepatol 2022; 2022:7384144. [PMID: 36117519 PMCID: PMC9481411 DOI: 10.1155/2022/7384144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Accepted: 08/16/2022] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Assessment of hepatic venous pressure gradient (HVPG) is the most reliable, though invasive method for evaluation of portal hypertension. Non-invasive, elastography-based techniques are well established in diagnosis, but not in monitoring of portal hypertension. The aim of our prospective study was to determine the value of acoustic radiation force impulse (ARFI) elastography technique of the liver and spleen in diagnosis and monitoring of portal hypertension. METHODS We prospectively assessed portal hypertension by HVPG and corresponding elastography of the liver and spleen in 31 patients with liver cirrhosis and an indication for primary prophylaxis by non-cardio selective beta-blockers. Investigations were performed at baseline and a follow-up visit after 6-8 weeks. To address the known large variability of values for spleen elastography, well-defined corresponding areas in the spleen were used for baseline and follow-up elastography. Sensitivity, specificity, and AUC-ROC values for both spleen and liver elastography monitoring of portal hypertension were calculated. RESULTS Liver but not spleen elastography significantly correlated with HVPG results and was suitable for initial evaluation of portal hypertension. However, changes in HVPG results did not show any correlation with alterations of ARFI values from baseline to follow-up visits both for liver and spleen elastography. Spleen stiffness results were not homogeneous across the whole organ differing significantly between the upper, hilar, and bottom placed investigation areas. CONCLUSIONS In this prospective study ARFI-based assessment of liver elastography showed itself suitable for initial assessment but not for monitoring of portal hypertension. Spleen elastography was not appropriate for both, evaluation and monitoring of portal hypertension. A possible explanation for this new data that are in some contrast to previously published results is the degree of portal hypertension in our study, a comparatively short follow-up period, and well-defined investigation areas for spleen elastography in repetitive ARFI investigations. This trial is registered with NCT03315767.
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Vranić L, Nadarevic T, Štimac D, Fraquelli M, Manzotti C, Casazza G, Colli A. Liver and spleen stiffness as assessed by vibration controlled transient elastography for diagnosing clinically significant portal hypertension in comparison with other elastography-based techniques in adults with chronic liver disease. Hippokratia 2022. [DOI: 10.1002/14651858.cd015415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Luka Vranić
- Department of Gastroenterology; Clinical Hospital Centre Rijeka; Rijeka Croatia
| | - Tin Nadarevic
- Department of Radiology; Clinical Hospital Centre Rijeka; Rijeka Croatia
| | - Davor Štimac
- Department of Gastroenterology; Clinical Hospital Centre Rijeka; Rijeka Croatia
| | - Mirella Fraquelli
- Gastroenterology and Endoscopy Unit; Fondazione IRCCS Ca´ Granda - Ospedale Maggiore Policlinico, Milano; Milan Italy
| | - Cristina Manzotti
- Department of Pathophysiology and Transplantation; Università degli Studi di Milano; Milan Italy
| | - Giovanni Casazza
- Department of Clinical Sciences and Community Health - Laboratory of Medical Statistics, Biometry and Epidemiology "G.A. Maccacaro"; Università degli Studi di Milano; Milan Italy
| | - Agostino Colli
- Department of Transfusion Medicine and Haematology; Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico; Milan Italy
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Hai Y, Chong W, Eisenbrey JR, Forsberg F. Network Meta-Analysis: Noninvasive Imaging Modalities for Identifying Clinically Significant Portal Hypertension. Dig Dis Sci 2022; 67:3313-3326. [PMID: 34275089 PMCID: PMC8761784 DOI: 10.1007/s10620-021-07168-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Accepted: 07/07/2021] [Indexed: 12/16/2022]
Abstract
BACKGROUND Although measurement of the hepatic venous pressure gradient (HVPG) is the current reference standard for obtaining portal venous pressures, several noninvasive imaging-based modalities have been proposed as alternatives. AIMS We performed a systematic review and meta-analysis to compare the diagnostic accuracy of noninvasive imaging approaches for identifying clinically significant portal hypertension (CSPH). METHODS Two independent reviewers conducted a literature search of PubMed, SCOPUS, and the Cochrane Library from inception until January 5, 2021. The following imaging modalities were compared to HVPG: computed tomography (CT), magnetic resonance imaging (MRI), magnetic resonance elastography, ultrasound, transient elastography (TE), shear wave elastography (SWE), acoustic radiation force impulse (ARFI) imaging, contrast-enhanced ultrasound (CEUS), and subharmonic-aided pressure estimation (SHAPE). Sensitivity, specificity, diagnostic odds ratio (DOR), and area under the curve (AUC) for summary receiver operating characteristic were calculated using both frequentist random effects and Bayesian network meta-analytic approaches. RESULTS We analyzed 45 studies of 5678 patients. A broad overlapping confidence interval (CI) of DOR was observed among different imaging modalities: ARFI (30.5; 95% CI 12.7-73.3), CEUS and SHAPE (21.1; 95% CI 6.4-69.8), TE of liver stiffness (21.1; 95% CI 13.3-33.5), CT and MRI (13.7; 95% CI 7.40-25.4), SWE of liver stiffness (10.5; 95% CI 5.2-21.1), and ultrasound (9.5; 95% CI 4.9-18.4). The AUC of all imaging methods exceeded 0.8, indicating very good performance. At a cutoff of 80% specificity, TE, CEUS, and SHAPE exceeded 80% sensitivity. CONCLUSION Overall, noninvasive imaging modalities perform well for identifying CSPH. Clinicians should consider these noninvasive and cost-efficient tests when diagnosing CSPH.
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Affiliation(s)
- Yang Hai
- Department of Radiology, Thomas Jefferson University, 132 South 10th Street, Suite 763 H, Main Building, Philadelphia, PA, 19107, USA
| | - Weelic Chong
- Department of Radiology, Thomas Jefferson University, 132 South 10th Street, Suite 763 H, Main Building, Philadelphia, PA, 19107, USA
| | - John R Eisenbrey
- Department of Radiology, Thomas Jefferson University, 132 South 10th Street, Suite 763 H, Main Building, Philadelphia, PA, 19107, USA
| | - Flemming Forsberg
- Department of Radiology, Thomas Jefferson University, 132 South 10th Street, Suite 763 H, Main Building, Philadelphia, PA, 19107, USA.
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Seo KI, Hwang H, Yun BC, Moon HH, Choi YI, Shin DH, Yoon M. A prospective study of the correlation between hepatic fibrosis and noninvasively measured fibrosis markers including serum M2BPGi and acoustic radiation force impulse elastography. KOSIN MEDICAL JOURNAL 2022. [DOI: 10.7180/kmj.22.110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Background: Mac-2 binding protein glycosylation isomer (M2BPGi) was introduced as a noninvasively measurable serologic marker for liver fibrosis. Acoustic radiation force impulse imaging (ARFI) elastography is another noninvasive method of measuring hepatic fibrosis. There are limited data about the correlations between histologic fibrosis grade and noninvasively measured markers, including M2BPGi and ARFI.Methods: This prospective study was conducted among patients admitted consecutively for liver resection, cholecystectomy, or liver biopsy. ARFI elastography, serum M2BPGi levels, and the AST to Platelet Ratio Index (APRI) score were evaluated before histologic evaluation. Histologic interpretation was performed by a single pathologist using the METAVIR scoring system.Results: In patients with high METAVIR scores, M2BPGi levels and ARFI values showed statistically significant differences between patients with fibrosis and those without fibrosis. In 41 patients with hepatocellular carcinoma, as METAVIR scores increased, M2BPGi levels also tended to increase (p=0.161). ARFI values changed significantly as METAVIR scores increased (p=0.039). In 33 patients without hepatocellular carcinoma, as METAVIR scores increased, M2BPGi levels significantly increased (p=0.040). ARFI values also changed significantly as METAVIR scores increased (p=0.033). M2BPGi levels were significantly correlated with ARFI values (r=0.604, p<0.001), and APRI values (r=0.704, p<0.001), respectively. Conclusions: Serum M2BPGi levels increased with liver fibrosis severity and could be a good marker for diagnosing advanced hepatic fibrosis regardless of the cause of liver disease.
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Llop E, Perelló C, Fontanilla T, de la Revilla J, Conde MH, López M, Minaya J, Ferre C, Abad J, Carrillo CF, Martínez JL, Puga NF, Trapero M, Hajra IE, Santos E, Calleja JL. Spleen Transient Elastography and Damping Index Identify a Subgroup of Patients Without an Acute or Chronic Response to Beta-Blockers. Front Med (Lausanne) 2022; 9:900073. [PMID: 35814751 PMCID: PMC9258685 DOI: 10.3389/fmed.2022.900073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2022] [Accepted: 05/30/2022] [Indexed: 11/18/2022] Open
Abstract
Background and Aims Monitoring of acute or chronic response to beta-blockers in patients with liver cirrhosis is based on the measurement of the HVPG. Our aim was to evaluate the response to beta-blockers with non-invasive techniques. Patients and Methods This is a prospective observational study. Consecutive patients with an indication of primary or secondary prophylaxis of variceal bleeding who did not meet exclusion criteria were included. Acute response and chronic response were evaluated. Baseline and after acute and chronic response hepatosplenic measurements of TE and ARFI were obtained. Contrast-enhanced Doppler ultrasound was performed before and after acute and chronic responses. Results From June 2015 to May 2018, 55 patients (14 with exclusion criteria) were included. We analyzed 41 patients, mean age 57 (SD: 8), 82.9% men, alcohol 43.9%, children A/B/C 78%/17.1%/4.9%, and 87.8% on primary prophylaxis. In all, the acute response was performed and was positive in 68.3% (CI 95: 55–85%). The chronic response was performed in 30 (73.2%) and was positive in 36.7% (CI 95: 18–55%). Basal measurements significantly related to acute response were spleen TE [responders 58.4 (SD: 23.0) KPa vs. non-responders 75 (SD: 0) KPa; p = 0.02] and damping index [non-responders 0.96 (0.8) vs. responders 0.44 (0.4), p = 0.01], and with chronic response, the spleen TE [responders 58.1 (SD: 21.4) KPa vs. non-responders 73.2 (SD: 5.5) KPa; p = 0.02], and damping index [non-chronic responders 0.8 (0.7) vs. chronic responders 0.4 (0.4), p = 0.04]. A spleen TE ≥ 74 KPa had a high sensitivity of 100% and specificity of 60% and a high NPV100% for predicting poor acute response to beta-blockers. The damping index > 0.6 showed moderate sensitivity of 67% and specificity of 69% with a high NPV of 82% for predicting poor acute response to beta-blockers. The combination of both measurements for predicting poor acute response to beta-blockers had an AUC of 0.8 (CI 95: 0.5–0.9). A spleen TE ≥ 74 KPa had a high sensitivity of 87% and specificity of 71% with a high NPV of 71% for predicting poor chronic response to beta-blockers. A damping index > 0.6 had moderate sensitivity of 60%, specificity of 82%, and NPV of 56% for predicting poor chronic response to beta-blockers. The combination of both measurements for predicting poor chronic response to beta-blockers had an AUC of 0.8 (CI 95: 0.7–0.9). Conclusion Spleen TE and damping index can identify a subgroup of patients with poor acute or chronic response to beta-blockers.
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Affiliation(s)
- Elba Llop
- Department of Gastroenterology and Hepatology, Hospital Universitario Puerta de Hierro Majadahonda, Madrid, Spain
- Instituto de Investigación Sanitaria Puerta Hierro-Segovia Arana (IDIPHISA), Madrid, Spain
- CIBERHD, Madrid, Spain
| | - Christie Perelló
- Department of Gastroenterology and Hepatology, Hospital Universitario Puerta de Hierro Majadahonda, Madrid, Spain
- Instituto de Investigación Sanitaria Puerta Hierro-Segovia Arana (IDIPHISA), Madrid, Spain
- CIBERHD, Madrid, Spain
| | - Teresa Fontanilla
- Instituto de Investigación Sanitaria Puerta Hierro-Segovia Arana (IDIPHISA), Madrid, Spain
- Department of Radiology, Hospital Universitario Puerta de Hierro Majadahonda, Madrid, Spain
| | - Juan de la Revilla
- Department of Gastroenterology and Hepatology, Hospital Universitario Puerta de Hierro Majadahonda, Madrid, Spain
| | - Marta Hernández Conde
- Department of Gastroenterology and Hepatology, Hospital Universitario Puerta de Hierro Majadahonda, Madrid, Spain
- Instituto de Investigación Sanitaria Puerta Hierro-Segovia Arana (IDIPHISA), Madrid, Spain
- CIBERHD, Madrid, Spain
| | - Marta López
- Department of Gastroenterology and Hepatology, Hospital Universitario Puerta de Hierro Majadahonda, Madrid, Spain
- Instituto de Investigación Sanitaria Puerta Hierro-Segovia Arana (IDIPHISA), Madrid, Spain
- CIBERHD, Madrid, Spain
| | - Javier Minaya
- Instituto de Investigación Sanitaria Puerta Hierro-Segovia Arana (IDIPHISA), Madrid, Spain
- Department of Radiology, Hospital Universitario Puerta de Hierro Majadahonda, Madrid, Spain
| | - Carlos Ferre
- Department of Gastroenterology and Hepatology, Hospital Universitario Puerta de Hierro Majadahonda, Madrid, Spain
- Instituto de Investigación Sanitaria Puerta Hierro-Segovia Arana (IDIPHISA), Madrid, Spain
- CIBERHD, Madrid, Spain
| | - Javier Abad
- Department of Gastroenterology and Hepatology, Hospital Universitario Puerta de Hierro Majadahonda, Madrid, Spain
- Instituto de Investigación Sanitaria Puerta Hierro-Segovia Arana (IDIPHISA), Madrid, Spain
- CIBERHD, Madrid, Spain
| | - Carlos Fernández Carrillo
- Department of Gastroenterology and Hepatology, Hospital Universitario Puerta de Hierro Majadahonda, Madrid, Spain
- Instituto de Investigación Sanitaria Puerta Hierro-Segovia Arana (IDIPHISA), Madrid, Spain
- CIBERHD, Madrid, Spain
| | - José Luís Martínez
- Department of Gastroenterology and Hepatology, Hospital Universitario Puerta de Hierro Majadahonda, Madrid, Spain
- Instituto de Investigación Sanitaria Puerta Hierro-Segovia Arana (IDIPHISA), Madrid, Spain
- CIBERHD, Madrid, Spain
| | - Natalia Fernández Puga
- Department of Gastroenterology and Hepatology, Hospital Universitario Puerta de Hierro Majadahonda, Madrid, Spain
- Instituto de Investigación Sanitaria Puerta Hierro-Segovia Arana (IDIPHISA), Madrid, Spain
- CIBERHD, Madrid, Spain
| | - María Trapero
- Department of Gastroenterology and Hepatology, Hospital Universitario Puerta de Hierro Majadahonda, Madrid, Spain
- Instituto de Investigación Sanitaria Puerta Hierro-Segovia Arana (IDIPHISA), Madrid, Spain
- CIBERHD, Madrid, Spain
| | - Ismael El Hajra
- Department of Gastroenterology and Hepatology, Hospital Universitario Puerta de Hierro Majadahonda, Madrid, Spain
| | - Elena Santos
- Department of Gastroenterology and Hepatology, Hospital Universitario Puerta de Hierro Majadahonda, Madrid, Spain
| | - José Luis Calleja
- Department of Gastroenterology and Hepatology, Hospital Universitario Puerta de Hierro Majadahonda, Madrid, Spain
- Instituto de Investigación Sanitaria Puerta Hierro-Segovia Arana (IDIPHISA), Madrid, Spain
- CIBERHD, Madrid, Spain
- *Correspondence: José Luis Calleja,
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11
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Reiberger T. The Value of Liver and Spleen Stiffness for Evaluation of Portal Hypertension in Compensated Cirrhosis. Hepatol Commun 2022; 6:950-964. [PMID: 34904404 PMCID: PMC9035575 DOI: 10.1002/hep4.1855] [Citation(s) in RCA: 49] [Impact Index Per Article: 24.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2021] [Revised: 09/23/2021] [Accepted: 10/17/2021] [Indexed: 12/11/2022] Open
Abstract
Patients with compensated advanced chronic liver disease who develop clinically significant portal hypertension (CSPH) are at high risk for hepatic decompensation and mortality if left untreated. Liver biopsy and hepatic venous pressure gradient (HVPG) measurements are the current gold standard procedures for determining fibrosis severity and diagnosing CSPH, respectively; however, both are invasive, limiting their use in clinical practice and larger trials of novel agents. As such, there is an unmet clinical need for reliable, validated, noninvasive measures to detect CSPH and to further assess portal hypertension (PH) severity. Alterations in the biomechanical properties of the liver or spleen in patients with cirrhosis can be quantified by tissue elastography, which examines the elastic behavior of tissue after a force has been applied. A variety of methods are available, including magnetic resonance elastography, shear-wave elastography, and the most thoroughly investigated measure, vibration-controlled transient elastography. Liver stiffness (LS) and spleen stiffness (SS) measurements offer valuable alternatives to detect and monitor CSPH. Both LS and SS correlate well with HVPG, with thresholds of LS >20-25 kPa and SS >40-45 kPa indicating a high likelihood of CSPH. Because SS is a direct and dynamic surrogate of portal pressure, it has the potential to monitor PH severity and assess PH improvement as a surrogate marker for clinical outcomes. Importantly, SS seems to be superior to LS for monitoring treatment response in clinical trials focusing on reducing PH.
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Affiliation(s)
- Thomas Reiberger
- Division of Gastroenterology and HepatologyDepartment of Internal Medicine IIIMedical University of ViennaViennaAustria.,Vienna Hepatic Hemodynamic LaboratoryDivision of Gastroenterology and HepatologyDepartment of Internal Medicine IIIMedical University of ViennaViennaAustria.,Christian-Doppler Laboratory for Portal Hypertension and Liver FibrosisMedical University of ViennaViennaAustria
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12
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Chen Y, Li J, Zhou Q, Lyu G, Li S. Detection of liver and spleen stiffness in rats with portal hypertension by two-dimensional shear wave elastography. BMC Med Imaging 2022; 22:68. [PMID: 35418033 PMCID: PMC9006581 DOI: 10.1186/s12880-022-00786-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Accepted: 03/28/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The measurement of liver stiffness (LS) and spleen stiffness (SS) based on ultrasound elastography can be used for non-invasive assessment of portal hypertension (PH). However, there are few studies on the corresponding mechanism of increased spleen stiffness. Our aim was to use two-dimensional shear wave elastrography (2D-SWE) to evaluate the relationship between LS and SS and the severity of PH in rats. And explore the mechanism of the increase of LS and SS in PH. METHODS Sixty male Sprague-Dawley rats were randomly divided into portal hypertension (PH group, n = 45) and normal control (NC group, n = 15). At 12 weeks, LS and SS was detected by 2D-SWE in vivo. Related hemodynamic parameters and portal vein pressure (PVP) was measured. Spleen and liver 2D-SWE detection was performed again after sacrifice. Pathological changes were observed. RESULTS The SS and LS were increased in PH group (P < 0.05). The SS decreased after sacrifice, and what's more the magnitude of SS decline significantly higher in PH group than in NC group (P < 0.05). The correlation between SS and PVP is stronger than LS (r = 0.624, P < 0.001). SS has positive correlation with indexes of hyperdynamic circulation, but LS was weakly. The correlation between SS and the pathological grade (r = 0.633, P < 0.001) was lower than that in LS (r = 0.905, P < 0.001). Multiple linear regression analysis revealed that SS, portal vein inner diameter (PVD) and splenic vein blood flow velocity (SVV) were significantly associated with PH. CONCLUSIONS Spleen and liver measurement by 2D-SWE may be helpful in evaluating PVP. The correlation between SS and PVP is stronger than LS in rats measured by 2D-SWE. Hemodynamic circulation are important in the elevation of SS with portal hypertension. Pathological changes also have a degree of influence, but have more significance for the elevation of LS. SS may be a more effective noninvasive predictor of PH than LS.
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Affiliation(s)
- YongJian Chen
- Department of Ultrasound, The Second Affiliated Hospital of Fujian Medical University, No. 34 North Zhongshan Road, Licheng District, , Quanzhou, 362000, Fujian, China
| | - JingYun Li
- Maternal and Child Health Service Application Technology Collaborative Innovation Center, Quanzhou Medical College, Quanzhou, Fujian, China
| | - Qin Zhou
- Department of Ultrasound, The Second Affiliated Hospital of Fujian Medical University, No. 34 North Zhongshan Road, Licheng District, , Quanzhou, 362000, Fujian, China
| | - GuoRong Lyu
- Department of Ultrasound, The Second Affiliated Hospital of Fujian Medical University, No. 34 North Zhongshan Road, Licheng District, , Quanzhou, 362000, Fujian, China. .,Maternal and Child Health Service Application Technology Collaborative Innovation Center, Quanzhou Medical College, Quanzhou, Fujian, China.
| | - ShiLin Li
- Department of Ultrasound, The Second Affiliated Hospital of Fujian Medical University, No. 34 North Zhongshan Road, Licheng District, , Quanzhou, 362000, Fujian, China
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13
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Aitharaju V, De Silvestri A, Barr RG. Assessment of chronic liver disease by multiparametric ultrasound: results from a private practice outpatient facility. Abdom Radiol (NY) 2021; 46:5152-5161. [PMID: 34304291 DOI: 10.1007/s00261-021-03225-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Revised: 07/18/2021] [Accepted: 07/19/2021] [Indexed: 12/17/2022]
Abstract
PURPOSE To assess chronic liver disease (CLD) using multiparametric US in a private practice setting in a cohort of patients with increased skin-to-liver distance. METHODS 110 consecutive patients with increased skin-to-liver distance scheduled for US assessment of CLD were reviewed for study completion time, liver stiffness values (LS), attenuation imaging, and shear wave dispersion slope. The ROI was placed 2 cm below the liver capsule. The study included patients with NAFLD/NASH (68), hepatitis C (30), prior Fontan surgery (1), elevated liver function tests (5), alcohol abuse (3), hepatitis B (2), and primary biliary cirrhosis (1). IQR/M values were obtained. Comparison of less experienced sonographers (LES) and more experienced sonographers (MES) were evaluated through Student's t test for independent data. Pearson coefficient r of correlation among quantitative variables was calculated. RESULTS The mean time to perform the exam was 129.7 ± 62.1 s. There was a statistically significant difference between LES and MES. The mean IQR/M for LS was 12.3 ± 5.5% m/s. Overall, in a cohort of difficult patients, 4.5% of LS values were not reliable. Fat quantification using attenuation imaging had a mean value of 0.60 ± 0.15 dB/cm/MHz (range 0.35-0.98 cm/dB/MHz) with an IQR/M of 14.7 ± 9.2%. Less reliable measurements of steatosis were obtained in 4.5% of patients. The mean shear wave dispersion slope was 12.74 ± 4.05 (m/s)/kHz (range 7.7-27.5 (m/s)/kHz) with an IQR/M of 38.7 ± 20.2% (range 3-131%). 20.9% of patients had values suggestive of compensated advanced chronic liver disease (cACLD). CONCLUSION Multiparametric US can provide assessment of CLD in less than 3 min in most patients and identify patients at risk for cACLD.
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Affiliation(s)
- Varun Aitharaju
- Department of Radiology, Northeastern Ohio Medical University, Rootstown, OH, USA
| | - Annalisa De Silvestri
- Clinical Epidemiology and Biometeric Unit, -, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Richard G Barr
- Department of Radiology, Northeastern Ohio Medical University, Rootstown, OH, USA.
- Southwoods Imaging, 7623 Market Street, Youngstown, OH, 44512, USA.
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14
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Lesmana CRA, Paramitha MS, Hasan I, Sulaiman AS, Gani RA. Portal Hypertension in Non-alcoholic Fatty Liver Disease in the Era of Non-invasive Assessment. EUROPEAN MEDICAL JOURNAL 2021. [DOI: 10.33590/emj/21-00039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Non-alcoholic fatty liver disease (NAFLD) is one of the emerging global health problems due to an increase of burden worldwide. It has been known that NAFLD is strongly associated with metabolic syndrome. The progression of NAFLD is a complex and multifactorial mechanism. Portal hypertension is still the main key in liver disease progression management. In NAFLD, portal hypertension might occur in the non-cirrhotic condition. Hepatic vein pressure gradient measurement has been considered as the gold standard for portal pressure assessment; however, due to its invasiveness and the need for a high-expertise centre, it is considered a non-practical measurement tool in clinical practice. Many other non-invasive parameters have been developed to replace the invasive measurement; however, there are still some limitations with regard to the technical issue, patient’s condition, and its accuracy in the different stages of the disease. Therefore, the authors review portal hypertension related to the clinical course of NAFLD, and the development of portal pressure evaluation in patients with NAFLD.
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Affiliation(s)
- Cosmas Rinaldi Adithya Lesmana
- Department of Internal Medicine, Hepatobiliary Division, Dr. Cipto Mangunkusumo National General Hospital, Universitas Indonesia, Jakarta, Indonesia; Digestive Disease & GI Oncology Center, Medistra Hospital, Jakarta, Indonesia
| | - Maria Satya Paramitha
- Department of Internal Medicine, Hepatobiliary Division, Dr. Cipto Mangunkusumo National General Hospital, Universitas Indonesia, Jakarta, Indonesia
| | - Irsan Hasan
- Department of Internal Medicine, Hepatobiliary Division, Dr. Cipto Mangunkusumo National General Hospital, Universitas Indonesia, Jakarta, Indonesia
| | - Andri Sanityoso Sulaiman
- Department of Internal Medicine, Hepatobiliary Division, Dr. Cipto Mangunkusumo National General Hospital, Universitas Indonesia, Jakarta, Indonesia
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15
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Matsui T, Nagai H, Watanabe G, Yoshimine N, Amanuma M, Kobayashi K, Ogino Y, Mukozu T, Matsukiyo Y, Daido Y, Wakui N, Nakano S, Shinohara M, Momiyama K, Kudo T, Maruyama K, Igarashi Y. Usefulness of virtual touch tissue quantification for predicting the presence of esophageal varices in patients with liver cirrhosis. JGH Open 2021; 5:695-704. [PMID: 34124388 PMCID: PMC8171162 DOI: 10.1002/jgh3.12558] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Revised: 04/20/2021] [Accepted: 04/29/2021] [Indexed: 12/20/2022]
Abstract
BACKGROUND AND AIM Measuring the hepatic venous pressure gradient (HVPG) is an established technique to detect increased portal pressure and predict the presence of esophageal varices (EVs); however, the risk of the test is greater than the information it provides. This study aimed to clarify the usefulness of virtual touch tissue quantification (VTQ), which assesses liver stiffness, in predicting the presence of EVs in patients with liver cirrhosis by comparing it with HVPG. METHODS Two hundred seventeen patients with liver cirrhosis underwent VTQ, HVPG measurement, and upper endoscopy. Patients were divided into three groups: group V, hepatitis C virus liver cirrhosis (n = 40); group A, alcoholic liver cirrhosis (n = 116); and group N, other liver cirrhosis (n = 61). In each group, we performed linear regression analysis of VTQ and HVPG data. The accuracy of VTQ and HVPG measurement in predicting the presence of EVs and high-risk EVs (EV category F2 and F3) was assessed by area under the receiver operating characteristic curve (AUROC). RESULTS VTQ was significantly correlated with the HVPG in the whole patients and in each group, and both VTQ and HVPG values were significantly higher in patients with EVs and high-risk EVs than in those without. The AUROC for the presence of EVs for VTQ was 0.76 in the whole sample, 0.76 in group V, 0.79 in group A, and 0.67 in group N; and for HVPG, 0.92, 0.94, 0.93, and 0.88, respectively. For VTQ, the AUROC for the presence of high-risk EVs was 0.78 in the whole sample, 0.78 in group V, 0.73 in group A, and 0.73 in group N; and for HVPG, it was 0.85, 0.82, 0.85, and 0.82, respectively. CONCLUSION VTQ was reliable at predicting the presence of EVs and high-risk EVs. Therefore, we propose that VTQ is a useful, noninvasive tool for predicting the presence of EVs in daily medical care.
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Affiliation(s)
- Teppei Matsui
- Division of Gastroenterology and HepatologyToho University Omori Medical CenterTokyoJapan
| | - Hidenari Nagai
- Division of Gastroenterology and HepatologyToho University Omori Medical CenterTokyoJapan
| | - Gou Watanabe
- Division of Gastroenterology and HepatologyToho University Omori Medical CenterTokyoJapan
| | - Naoyuki Yoshimine
- Division of Gastroenterology and HepatologyToho University Omori Medical CenterTokyoJapan
| | - Makoto Amanuma
- Division of Gastroenterology and HepatologyToho University Omori Medical CenterTokyoJapan
| | - Kojiro Kobayashi
- Division of Gastroenterology and HepatologyToho University Omori Medical CenterTokyoJapan
| | - Yuu Ogino
- Division of Gastroenterology and HepatologyToho University Omori Medical CenterTokyoJapan
| | - Takanori Mukozu
- Division of Gastroenterology and HepatologyToho University Omori Medical CenterTokyoJapan
| | - Yasushi Matsukiyo
- Division of Gastroenterology and HepatologyToho University Omori Medical CenterTokyoJapan
| | - Yasuko Daido
- Division of Gastroenterology and HepatologyToho University Omori Medical CenterTokyoJapan
| | - Noritaka Wakui
- Division of Gastroenterology and HepatologyToho University Omori Medical CenterTokyoJapan
| | - Shigeru Nakano
- Division of GastroenterologySaiseikai Yokohamashi Tobu HospitalYokohamaJapan
| | - Mie Shinohara
- Division of Gastroenterology and HepatologyToho University Omori Medical CenterTokyoJapan
| | - Koichi Momiyama
- Division of Gastroenterology and HepatologyToho University Omori Medical CenterTokyoJapan
| | - Takehide Kudo
- Division of Biomedical LaboratoryToho University Omori Medical CenterTokyoJapan
| | - Kenichi Maruyama
- Division of Biomedical LaboratoryToho University Omori Medical CenterTokyoJapan
| | - Yoshinori Igarashi
- Division of Gastroenterology and HepatologyToho University Omori Medical CenterTokyoJapan
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16
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Non-invasive laboratory, imaging and elastography markers in predicting varices with high risk of bleeding in cirrhotic patients. ROMANIAN JOURNAL OF INTERNAL MEDICINE = REVUE ROUMAINE DE MÉDECINE INTERNE 2021; 59:194-200. [PMID: 33544557 DOI: 10.2478/rjim-2021-0001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Indexed: 11/21/2022]
Abstract
Introduction. Upper digestive tract endoscopy remains the gold-standard for detecting esophageal or gastric varices and assessment of bleeding risk, but this method is invasive. The aim of the study was to identify non-invasive factors that could be incorporated into an algorithm for estimating the risk of variceal bleeding.Methods. A prospective study was performed on 130 cirrhotic patients. Tests were performed on all patients which included liver enzymes, complete blood count and coagulation parameters, abdominal ultrasound, elastography of both the liver and the spleen. Upper gastrointestinal endoscopy was performed in all patients included in the study and the results were classified, in accordance with Baveno VI into 2 outcome groups: Group 1 - patients with low bleeding risk and Group 2 - patients with varices needing treatment.Results. The study lot (130 patients) was divided into: Group I (low bleeding risk - 102 patients), and Group II (high bleeding risk - 28 patients). Parameters found to have significant differences in univariate analysis were transaminases, platelet count, spleen size, INR, portal vein diameter and both liver and spleen elastography. Calculating AUROC for each parameter identifies spleen elastography as having the best result, followed by INR, AST and platelet count. Liver elastography had the worst AUROC. Independent variables identified by logistic regression included spleen elastography, INR, platelet count, spleen diameter, ALT, age, and gender.Conclusions. Spleen stiffness is the best single parameter predicting the presence of high-risk esophageal varices.
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17
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Vuille-Lessard É, Rodrigues SG, Berzigotti A. Noninvasive Detection of Clinically Significant Portal Hypertension in Compensated Advanced Chronic Liver Disease. Clin Liver Dis 2021; 25:253-289. [PMID: 33838850 DOI: 10.1016/j.cld.2021.01.005] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Patients with compensated advanced chronic liver disease have different prognoses depending on the presence of portal hypertension. Current non-invasive diagnostic methods allow identification of clinically significant portal hypertension. Portosystemic collaterals on imaging or liver stiffness of more than 20 to 25 kPa by using transient elastography identifies patients with clinically significant portal hypertension. Patients with liver stiffness of less than 20 kPa and platelet count of greater than 150 g/L can avoid endoscopy. This rule could be expanded using spleen stiffness. Methods to risk stratify for portal hypertension in compensated advanced chronic liver disease and successfully treated chronic hepatitis C and B are subject of research.
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Affiliation(s)
- Élise Vuille-Lessard
- Hepatology, University Clinic for Visceral Surgery and Medicine (UVCM), Inselspital, University Hospital of Bern, Freiburgstrasse, 3010 Bern, Switzerland; Department of Biomedical Research, University of Bern, Switzerland
| | - Susana G Rodrigues
- Hepatology, University Clinic for Visceral Surgery and Medicine (UVCM), Inselspital, University Hospital of Bern, Freiburgstrasse, 3010 Bern, Switzerland; Department of Biomedical Research, University of Bern, Switzerland
| | - Annalisa Berzigotti
- Hepatology, University Clinic for Visceral Surgery and Medicine (UVCM), Inselspital, University Hospital of Bern, Freiburgstrasse, 3010 Bern, Switzerland; Department of Biomedical Research, University of Bern, Switzerland.
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18
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Dajti E, Marasco G, Ravaioli F, Alemanni LV, Rossini B, Colecchia L, Vestito A, Festi D, Colecchia A. The role of liver and spleen elastography in advanced chronic liver disease. Minerva Gastroenterol (Torino) 2021; 67:151-163. [PMID: 34027932 DOI: 10.23736/s2724-5985.20.02793-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
Portal hypertension is the main driver of complications in patients with advanced chronic liver disease (ACLD). In the last decade, many non-invasive tests, such us liver and spleen elastography, have been proposed and validated for the identification of patients with clinically significant portal hypertension (CSPH) and its complications, mainly hepatic decompensation and liver-related morbidity and mortality. Moreover, elastography accurately stratifies for the risk of HCC development, HCC recurrence and decompensation after liver surgery. Recent studies suggest a role of SSM in monitoring response to treatments and interventions in ACLD, such as viral eradication, non-selective beta-blockers and transjugular intrahepatic portosystemic shunt placement. However, one of the most indications to perform elastography in ACLD still remains the screening for esophageal varices. In fact, according to the Baveno VI consensus, liver stiffness measurement (LSM) <20 kPa and platelet count >150,000/mm3 can safely identify patients at low risk of varices requiring treatment (VNT) and could therefore avoid invasive upper invasive endoscopy; LSM>20-25 kPa can accurately rule-in CSPH in patients with viral etiology. Spleen stiffness measurement (SSM) is a direct surrogate of portal hypertension and has been demonstrated more accurate in predicting portal hypertension severity and VNT. A combined model including Baveno VI Criteria and SSM (≤46 kPa) can significantly increase the number of spared endoscopies (>40-50%), maintaining a low (<5%) of missed VNT.
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Affiliation(s)
- Elton Dajti
- Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy
| | - Giovanni Marasco
- Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy
| | - Federico Ravaioli
- Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy
| | - Luigina V Alemanni
- Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy
| | - Benedetta Rossini
- Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy
| | - Luigi Colecchia
- Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy
| | - Amanda Vestito
- Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy
| | - Davide Festi
- Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy
| | - Antonio Colecchia
- Unit of Gastroenterology, Borgo Trento University Hospital of Verona, Verona, Italy -
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19
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Dajti E, Alemanni LV, Marasco G, Montagnani M, Azzaroli F. Approaches to the Diagnosis of Portal Hypertension: Non-Invasive or Invasive Tests? Hepat Med 2021; 13:25-36. [PMID: 33776492 PMCID: PMC7987277 DOI: 10.2147/hmer.s278077] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2020] [Accepted: 02/19/2021] [Indexed: 12/15/2022] Open
Abstract
Portal hypertension is the main driver of complications in patients with advanced chronic liver disease (ACLD) and is defined by values of hepatic venous pressure gradient measurement (HVPG) >5 mmHg. Values of HVPG ≥10 mmHg determine the presence of clinically significant portal hypertension (CSPH), the main predictor of the risk of variceal bleeding, hepatic decompensation, and mortality. However, its measurement is invasive and requires high expertise, so its routine use outside third level centers or clinical trials is limited. In the last decades, several non-invasive tests (NITs) have been developed and validated for the diagnosis of portal hypertension. Among these, liver (LSM) and spleen stiffness measurement (SSM) are the most promising tools available, as they have been proven accurate to predict CSPH, high-risk esophageal varices, decompensation, and mortality in patients with ACLD. In the last Baveno VI Consensus proceedings, LSM evaluation was recommended for the first time for diagnosis of CSPH (LSM >20-25 kPa) and the screening of patients with a low probability of having high-risk varices (LSM <20 kPa and platelet count >150.000/mm3). In this review, we aimed to summarize the growing evidence supporting the use of non-invasive tests for the evaluation of portal hypertension in patients with chronic liver disease.
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Affiliation(s)
- Elton Dajti
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy.,Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy
| | - Luigina Vanessa Alemanni
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy.,Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy
| | - Giovanni Marasco
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy.,Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy
| | - Marco Montagnani
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy.,Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy
| | - Francesco Azzaroli
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy.,Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy
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20
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Yalçın K, Demir BÇ. Spleen stiffness measurement by shear wave elastography using acoustic radiation force impulse in predicting the etiology of splenomegaly. Abdom Radiol (NY) 2021; 46:609-615. [PMID: 32770399 DOI: 10.1007/s00261-020-02649-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Revised: 07/01/2020] [Accepted: 07/09/2020] [Indexed: 12/28/2022]
Abstract
PURPOSE To measure spleen stiffness by shear wave elastography (SWE) using acoustic radiation force impulse (ARFI) in patients with splenomegaly and to evaluate utility of elastography technique in identifying etiology of splenomegaly. METHODS Sixty-one treatment-naïve patients with splenomegaly were enrolled. The control group consisted of 20 healthy subjects without history of any disease including diabetes and hypertension, alcohol consumption, or biochemical or ultrasonographic findings indicating hepatic and renal diseases. B-mode ultrasonography and elastographic examinations were performed by a radiologist blinded to the participants. Spleen stiffness was measured by SWE using ARFI. Shear wave velocity (SWV) values were given in m/s. RESULTS Splenomegaly patients were assigned into three groups according to their etiologies as hepatoportal (n = 21), myeloproliferative (n = 23), and infectious (n = 17). Splenomegaly groups and control group were comparable regarding age and sex. Spleen size was higher in the splenomegaly groups than in the controls. Median SWV was significantly higher in the hepatoportal (3.85 m/s) and myeloproliferative (3.42 m/s) groups than in the infectious (2.66 m/s) and control (2.22 m/s) groups. The correlation between SWV and spleen size was not significant in any of the groups. The cut-off value was 3.42 (sensitivity 80.9%, specificity 56.5%) in distinguishing hepatoportal from myeloproliferative etiology; 3.02 (sensitivity 100%, specificity 100%) in distinguishing hepatoportal from infectious etiology; and 2.84 (sensitivity 91.3%, specificity 88.2%) in distinguishing myeloproliferative from infectious etiology. CONCLUSION Spleen stiffness measured by elastographic techniques in splenomegaly patients was higher than that in healthy subjects. SWV appeared to be beneficial in predicting the etiology of splenomegaly.
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Affiliation(s)
- Kadihan Yalçın
- Radiology Department, Başkent University İstanbul Altunizade Training and Research Hospital, Başkent Üniversitesi, Altunizade, Üsküdar, Istanbul, Turkey.
| | - Bilge Çakar Demir
- Radiology Department, Başkent University İstanbul Altunizade Training and Research Hospital, Başkent Üniversitesi, Altunizade, Üsküdar, Istanbul, Turkey
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Frankova S, Lunova M, Gottfriedova H, Senkerikova R, Neroldova M, Kovac J, Kieslichova E, Lanska V, Urbanek P, Spicak J, Jirsa M, Sperl J. Liver stiffness measured by two-dimensional shear-wave elastography predicts hepatic vein pressure gradient at high values in liver transplant candidates with advanced liver cirrhosis. PLoS One 2021; 16:e0244934. [PMID: 33411729 PMCID: PMC7790429 DOI: 10.1371/journal.pone.0244934] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Accepted: 12/20/2020] [Indexed: 12/15/2022] Open
Abstract
Liver stiffness is a reliable non-invasive predictor of Hepatic Venous Pressure Gradient (HVPG) above 10 mm Hg. However, it failed to predict higher thresholds of HVPG. Our aim was to investigate whether liver stiffness and selected previously published non-invasive blood biomarkers could predict higher HVPG thresholds in liver transplant candidates without ongoing alcohol use. One hundred and nine liver transplant candidates with liver cirrhosis of various aetiologies underwent direct HVPG measurement, liver stiffness measurement by 2D shear-wave elastography (Aixplorer Multiwave, Supersonic Imagine, France) and assessment of blood HVPG biomarkers (osteopontin, VCAM-1, IL-6, TNF-α, IL-1ra/IL-1F3 and ELF score). The correlation between liver stiffness and HVPG was linear up to 30 mm Hg of HVPG (r = 0.765, p < 0.0001). The regression lines had similar slopes for HVPG values below and above 16 mm Hg (p > 0.05) and the correlation in patients with HVPG <16 mm Hg (r = 0.456, p = 0.01) was similar to patients with HVPG ≥ 16 mm Hg (r = 0.499, p < 0.0001). The correlation was similar in the subgroup patients with alcoholic (r = 0.718, p < 0.0001), NASH (r = 0.740, p = 0.008), cryptogenic (r = 0.648, p = 0,0377), cholestatic and autoimmune (r = 0.706, p < 0.0001) and viral cirrhosis (r = 0.756, p < 0.0001). Liver stiffness distinguished patients with HVPG above 16, and 20 mm Hg with AUROCs 0.90243, and 0.86824, sensitivity 0.7656, and 0.7027, and specificity 0.9333, and 0.8750. All studied blood biomarkers correlated better with liver stiffness than with HVPG and their AUROCs did not exceed 0.8 at both HVPG thresholds. Therefore, a composite predictor superior to liver stiffness could not be established. We conclude that liver stiffness is a clinically reliable predictor of higher HVPG thresholds in non-drinking subjects with advanced liver cirrhosis.
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Affiliation(s)
- Sona Frankova
- Department of Hepatogastroenterology, Transplant Centre, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Mariia Lunova
- Laboratory of Experimental Hepatology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Halima Gottfriedova
- Department of Hepatogastroenterology, Transplant Centre, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Renata Senkerikova
- Department of Hepatogastroenterology, Transplant Centre, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
- Charles University, First Faculty of Medicine, Prague, Czech Republic
| | - Magdalena Neroldova
- Laboratory of Experimental Hepatology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Jozef Kovac
- Department of Diagnostic and Interventional Radiology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Eva Kieslichova
- Anaesthesiology, Resuscitation and Intensive Care Department, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Vera Lanska
- Department of Biostatistics, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Petr Urbanek
- Charles University, First Faculty of Medicine, Prague, Czech Republic
- Department of Internal Medicine, Central Military Hospital, Prague, Czech Republic
| | - Julius Spicak
- Department of Hepatogastroenterology, Transplant Centre, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Milan Jirsa
- Laboratory of Experimental Hepatology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
- Charles University, First Faculty of Medicine, Prague, Czech Republic
| | - Jan Sperl
- Department of Hepatogastroenterology, Transplant Centre, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
- Charles University, First Faculty of Medicine, Prague, Czech Republic
- * E-mail:
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22
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Bangaru S, Benhammou JN, Tabibian JH. Noninvasive scores for the prediction of esophageal varices and risk stratification in patients with cirrhosis. World J Hepatol 2020; 12:908-918. [PMID: 33312418 PMCID: PMC7701959 DOI: 10.4254/wjh.v12.i11.908] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Revised: 08/13/2020] [Accepted: 09/10/2020] [Indexed: 02/06/2023] Open
Abstract
The primary purpose of variceal screening in patients with cirrhosis is to detect gastroesophageal varices at high risk of hemorrhage and implement preventative intervention(s). It was previously recommended that all patients with cirrhosis undergo initial and periodic longitudinal variceal screening via upper endoscopy. However, there has been growing interest and methods to identify patients with cirrhosis who may not have clinically significant portal hypertension and therefore be unlikely to have varices requiring intervention or benefit from upper endoscopy. Because the population of patients with compensated advanced chronic liver disease continues to grow, it is neither beneficial nor cost-effective to perform endoscopic variceal screening in all patients. Therefore, there is ongoing research into the development of methods to non-invasively risk stratify patients with cirrhosis for the presence of high-risk esophageal varices and effectively limit the population that undergoes endoscopic variceal screening. This is particularly important and timely in light of increasing healthcare reform and barriers to healthcare. In this review, we discuss and compare, with respect to test characteristics and clinical applicability, the available methods used to non-invasively predict the presence of esophageal varices.
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Affiliation(s)
- Saroja Bangaru
- Internal Medicine, Gastroenterology, University of California at Los Angeles, Los Angeles, CA 90025, United States
| | - Jihane N Benhammou
- The Vatche and Tamar Manoukian Division of Digestive Diseases, University of California at Los Angeles, Los Angeles, CA 90095, United States
| | - James H Tabibian
- Department of Medicine, Olive View-University of California at Los Angeles Medical Center, Sylmar, CA 91342, United States
- David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, United States
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23
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Ahmad AK, Atzori S, Maurice J, Taylor-Robinson SD, Lim AKP. Non-invasive splenic parameters of portal hypertension: Assessment and utility. World J Hepatol 2020; 12:1055-1066. [PMID: 33312429 PMCID: PMC7701973 DOI: 10.4254/wjh.v12.i11.1055] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 08/22/2020] [Accepted: 10/09/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Portal hypertension is a major complication of cirrhosis that is associated with significant morbidity and mortality. The present gold-standard method to risk stratify and observe cirrhosis patients with portal hypertension is hepatic venous pressure gradient measurement or esophagogastroduodenoscopy. However, these methods are invasive, carry a risk of complications and are associated with significant patient discomfort. Therefore, non-invasive splenic parameters are of clinical interest as potential useful markers in determining the presence of portal hypertension. However, diagnostic accuracy and reproducibility remains unvalidated.
AIM To assess the diagnostic accuracy of spleen stiffness, area and diameter in predicting the presence of portal hypertension.
METHODS Of 50 patients with varying liver disease pathologies were prospectively recruited from the St. Mary’s Hospital Liver Unit in London; 25 with evidence of portal hypertension and 25 with no evidence of portal hypertension. Liver stiffness, spleen stiffness, spleen diameter and spleen area were measured using the Philips Affiniti 70 elastography point quantification point shear wave elastography system. The aspartate aminotransferase-to-platelet-ratio-index (APRI) score was also calculated. Performance measures, univariate and multivariate logistic regression were used to evaluate demographic, clinical and elastography variables. Interclass correlation coefficient was used to determine the reproducibility of splenic area and diameter.
RESULTS On univariate and individual performance, platelet count [area under the receiver operating characteristic (AUROC) 0.846, P value < 0.001], spleen area (AUROC 0.828, P value = 0.002) and APRI score (AUROC 0.827, P value < 0.001) were the most accurate variables in identifying the presence of portal hypertension. On multivariate logistic regression models constructed, the combination of spleen area greater than 57.90 cm2 and platelet count less than 126 × 109 had 63.2% sensitivity and 100% specificity, 100% positive predictive value and 100% negative predictive value. An alternative combination of spleen stiffness greater than 29.99 kPa and platelet count less than 126 × 109 had 88% sensitivity, 75% specificity, 78.6% positive predictive value and 85.7% negative predictive value. An interclass correlation coefficient value of 0.98 (95%CI: 0.94-0.99, P value < 0.001) and 0.96 (95%CI: 0.91-0.99, P value < 0.001) were determined for inter-operator variability for spleen area and diameter respectively.
CONCLUSION Spleen area, spleen stiffness and platelet count may be useful markers to assess the presence of portal hypertension in patients of various etiologies.
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Affiliation(s)
- Ayesha Karim Ahmad
- Liver Unit, Department of Digestion, Metabolism & Reproduction, Faculty of Medicine, Imperial College London, London W2 1NY, United Kingdom
| | - Sebastiana Atzori
- Liver Unit, Department of Digestion, Metabolism & Reproduction, Imperial College London, London W2 1NY, United Kingdom
| | - James Maurice
- Liver Unit, Department of Digestion, Metabolism & Reproduction, Imperial College London, London W2 1NY, United Kingdom
| | - Simon D Taylor-Robinson
- Liver Unit, Department of Digestion, Metabolism & Reproduction, Imperial College London, London W2 1NY, United Kingdom
| | - Adrian KP Lim
- Liver Unit and Imaging, Department of Digestion, Metabolism & Reproduction, Imperial College London, London W2 1NY, United Kingdom
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24
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Kennedy P, Bane O, Hectors SJ, Fischman A, Schiano T, Lewis S, Taouli B. Noninvasive imaging assessment of portal hypertension. Abdom Radiol (NY) 2020; 45:3473-3495. [PMID: 32926209 PMCID: PMC10124623 DOI: 10.1007/s00261-020-02729-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 08/16/2020] [Accepted: 08/30/2020] [Indexed: 02/07/2023]
Abstract
Portal hypertension (PH) is a spectrum of complications of chronic liver disease (CLD) and cirrhosis, with manifestations including ascites, gastroesophageal varices, splenomegaly, hypersplenism, hepatic hydrothorax, hepatorenal syndrome, hepatopulmonary syndrome and portopulmonary hypertension. PH can vary in severity and is diagnosed via invasive hepatic venous pressure gradient measurement (HVPG), which is considered the reference standard. Accurate diagnosis of PH and assessment of severity are highly relevant as patients with clinically significant portal hypertension (CSPH) are at higher risk for developing acute variceal bleeding and mortality. In this review, we discuss current and upcoming noninvasive imaging methods for diagnosis and assessment of severity of PH.
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25
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Li J, Sehrawat TS, Chen J, Hilscher MB, Glaser KJ, Arab JP, De Assuncao TM, Simonetto DA, Mounajjed T, Manduca A, Ehman RL, Shah VH, Yin M. Quantitative assessment of portal hypertension with bi-parametric dual-frequency hepatic MR elastography in mouse models. Eur Radiol 2020; 31:2303-2311. [PMID: 33026502 DOI: 10.1007/s00330-020-07341-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 08/28/2020] [Accepted: 09/22/2020] [Indexed: 12/15/2022]
Abstract
OBJECTIVES To determine the potential of bi-parametric dual-frequency hepatic MR elastography (MRE) for predicting portal pressure (PP) in mouse models of portal hypertension (PHTN) with the presence of varying hepatic fibrosis. METHODS We studied 73 wild-type male mice, including 22 mice with hepatic congestion, 20 mice with cholestatic liver injury, and 31 age-matched sham mice. Hepatic shear stiffness (SS) and volumetric strain (VS) were calculated by 3D MRE acquired at 80 and 200 Hz. We measured PP immediately after MRE. Liver fibrosis was verified by hydroxyproline assay. We predicted PP by fitting generalized linear models with single- and dual-frequency SS and VS, respectively. The relationship between predicted and actual PP was evaluated by Spearman's correlation. We compared the prediction accuracy of portal hypertension for all models with DeLong tests at a significance level of 0.05. RESULTS Animals with congestive or cholestatic liver disease developed significant PHTN and hepatic fibrosis to varying degrees. In both models, SS increased, while VS decreased significantly compared with shams. All bi-parametric models had high diagnostic accuracy for PHTN. The dual-frequency models (AUCs: 0.90 [81-95%], 0.91 [81-95%]) had substantially or significantly higher accuracy than single-frequency ones (AUCs: 0.83 [71-91%], and 0.78 [66-87%]). The predicted PP of dual-frequency models also showed stronger correlations with actual PP than single-frequency predictions. CONCLUSIONS The bi-parametric dual-frequency model improved the diagnostic accuracy of liver MRE in diagnosing PHTN in preclinical models. This technical advance has the potential to monitor PHTN progression and treatment efficacy in the presence of varying fibrosis. KEY POINTS • Bi-parametric hepatic MR elastography can predict portal pressure. • The prediction models of shear stiffness and volumetric strain with dual-frequency measurements demonstrate high diagnostic accuracy (AUCs > 0.9) in two different portal hypertension mouse models with varying fibrosis.
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Affiliation(s)
- Jiahui Li
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | - Tejasav S Sehrawat
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Jingbiao Chen
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Moira B Hilscher
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Kevin J Glaser
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | - Juan P Arab
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | | | - Douglas A Simonetto
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | | | - Armando Manduca
- Department of Radiology, Mayo Clinic, Rochester, MN, USA.,Department of Physiology and Biomedical Engineering, Mayo Clinic, Rochester, MN, USA
| | | | - Vijay H Shah
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Meng Yin
- Department of Radiology, Mayo Clinic, Rochester, MN, USA.
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26
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Stefanescu H, Rusu C, Lupsor-Platon M, Nicoara Farcau O, Fischer P, Grigoras C, Horhat A, Stancu O, Ardelean A, Tantau M, Badea R, Procopet B. Liver Stiffness Assessed by Ultrasound Shear Wave Elastography from General Electric Accurately Predicts Clinically Significant Portal Hypertension in Patients with Advanced Chronic Liver Disease. ULTRASCHALL IN DER MEDIZIN (STUTTGART, GERMANY : 1980) 2020; 41:526-533. [PMID: 31476787 DOI: 10.1055/a-0965-0745] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
PURPOSE Clinically significant portal hypertension (CSPH) is responsible for most of the complications in patients with cirrhosis. Liver stiffness (LS) measurement by vibration-controlled transient elastography (VCTE) is currently used to evaluate CSPH. Bi-dimensional shear wave elastography from General Electric (2D-SWE.GE) has not yet been validated for the diagnosis of PHT. Our aims were to test whether 2D-SWE.GE-LS is able to evaluate CSPH, to determine the reliability criteria of the method and to compare its accuracy with that of VCTE-LS in this clinical setting. MATERIALS AND METHODS Patients with chronic liver disease referred to hepatic catheterization (HVPG) were consecutively enrolled. HVPG and LS by both VCTE and 2D-SWE.GE were performed on the same day. The diagnostic performance of each LS method was compared against HVPG and between each other. RESULTS 2D-SWE.GE-LS was possible in 123/127 (96.90 %) patients. The ability to record at least 5 LS measurements by 2D-SWE.GE and IQR < 30 % were the only features associated with reliable results. 2D-SWE.GE-LS was highly correlated with HVPG (r = 0.704; p < 0.0001), especially if HVPG < 10 mmHg and was significantly higher in patients with CSPH (15.52 vs. 8.14 kPa; p < 0.0001). For a cut-off value of 11.3 kPa, the AUROC of 2D-SWE.GE-LS to detect CSPH was 0.91, which was not inferior to VCTE-LS (0.92; p = 0.79). The diagnostic accuracy of LS by 2D-SWE.GE-LS to detect CSPH was similar with the one of VCTE-LS (83.74 % vs. 85.37 %; p = 0.238). The diagnostic accuracy was not enhanced by using different cut-off values which enhanced the sensitivity or the specificity. However, in the subgroup of compensated patients with alcoholic liver disease, 2D-SWE.GE-LS classified CSPH better than VCTE-LS (93.33 % vs. 85.71 %, p = 0.039). CONCLUSION 2D-SWE.GE-LS has good accuracy, not inferior to VCTE-LS, for the diagnosis of CSPH.
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Affiliation(s)
- Horia Stefanescu
- Hepatology Department, Regional Institute of Gastroenterology and Hepatology, Cluj Napoca, Romania
- Liver Research Club, Cluj-Napoca, Romania
| | - Corina Rusu
- 3rd Medical Clinic, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
- Liver Research Club, Cluj-Napoca, Romania
| | - Monica Lupsor-Platon
- Medical Imaging Department, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Oana Nicoara Farcau
- 3rd Medical Clinic, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
- Liver Research Club, Cluj-Napoca, Romania
| | - Petra Fischer
- 3rd Medical Clinic, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
- Liver Research Club, Cluj-Napoca, Romania
| | - Crina Grigoras
- Hepatology Department, Regional Institute of Gastroenterology and Hepatology, Cluj Napoca, Romania
- Liver Research Club, Cluj-Napoca, Romania
| | - Adelina Horhat
- Hepatology Department, Regional Institute of Gastroenterology and Hepatology, Cluj Napoca, Romania
- Liver Research Club, Cluj-Napoca, Romania
| | - Oana Stancu
- Central Military Hospital, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
- Liver Research Club, Cluj-Napoca, Romania
| | - Andreea Ardelean
- Hepatology Department, Regional Institute of Gastroenterology and Hepatology, Cluj Napoca, Romania
- Liver Research Club, Cluj-Napoca, Romania
| | - Marcel Tantau
- 3rd Medical Clinic, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Radu Badea
- Medical Imaging Department, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Bogdan Procopet
- Hepatology Department, Regional Institute of Gastroenterology and Hepatology, Cluj Napoca, Romania
- 3rd Medical Clinic, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
- Liver Research Club, Cluj-Napoca, Romania
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27
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Diagnostic accuracy of spleen stiffness to evaluate portal hypertension and esophageal varices in chronic liver disease: a systematic review and meta-analysis. Eur Radiol 2020; 31:2392-2404. [PMID: 32974686 PMCID: PMC7979650 DOI: 10.1007/s00330-020-07223-8] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2020] [Revised: 06/25/2020] [Accepted: 08/21/2020] [Indexed: 02/06/2023]
Abstract
Objectives To systematically review studies on the diagnostic accuracy of spleen stiffness measurement (SSM) for the detection of clinical significant portal hypertension (CSPH), severe portal hypertension (SPH), esophageal varices (EV), and high-risk esophageal varices (HREV) in patients with chronic liver diseases (CLD). Methods Through a systematic search, we identified 32 studies reporting the accuracy of SSM for the diagnosis of portal hypertension (PH) and/or EV in adults with CLD. A bivariate random-effects model was performed to estimate pooled sensitivity, specificity, likelihood ratio, positive predictive value (PPV), negative predictive value (NPV), and diagnostic odds ratios (DOR). The clinical utility of SSM was evaluated by Fagan plot. Results A total of 32 studies assessing 3952 patients were included in this meta-analysis. The pooled sensitivities of SSM were 0.85 (95% confidence interval (CI), 0.69–0.93) for CSPH; 0.84 (95% CI, 0.75–0.90) for SPH; 0.90 (95% CI, 0.83–0.94) for any EV; and 0.87 (95% CI, 0.77–0.93) for HREV. The pooled specificities of SSM were 0.86 (95% CI, 0.74–0.93) for CSPH; 0.84 (95% CI, 0.72–0.91) for SPH; 0.73 (95% CI, 0.66–0.79) for EV; and 0.66 (95% CI, 0.53–0.77) for HREV. Summary PPV and NPV of SSM for detecting HREV were 0.54 (95% CI, 0.47–0.62) and 0.88 (95% CI, 0.81–0.95), respectively. Conclusions Our meta-analysis suggests that SSM could be used as a helpful surveillance tool in management of CLD patients and was quite useful for ruling out the presence of HREV thereby avoiding unnecessary endoscopy. Key Points • SSM could be used to rule out the presence of HREV in patients with CLD thereby avoiding unnecessary endoscopy. • SSM has significant diagnostic value for CSPH and SPH with high sensitivity and specificity in patients with CLD. • SSM could be used as a helpful surveillance tool for clinicians managing CLD patients. Electronic supplementary material The online version of this article (10.1007/s00330-020-07223-8) contains supplementary material, which is available to authorized users.
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Mandorfer M, Hernández-Gea V, García-Pagán JC, Reiberger T. Noninvasive Diagnostics for Portal Hypertension: A Comprehensive Review. Semin Liver Dis 2020; 40:240-255. [PMID: 32557480 DOI: 10.1055/s-0040-1708806] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Noninvasive diagnostics for portal hypertension include imaging and functional tests, as well as blood-based biomarkers, and capture different features of the portal hypertensive syndrome. Definitive conclusions regarding their clinical utility require assessment of their diagnostic value in specific clinical settings (i.e., diagnosing a particular hemodynamic condition within a well-defined target population). Several noninvasive methods are predictive of clinically significant portal hypertension (CSPH; hepatic venous pressure gradient [HVPG] ≥ 10 mm Hg; the threshold for complications of portal hypertension); however, only a minority of them have been evaluated in compensated advanced chronic liver disease (i.e., the target population). Importantly, most methods correlate only weakly with HVPG at high values (i.e., in patients with CSPH). Nevertheless, selected methods show promise for diagnosing HVPG ≥ 16 mm Hg (the cut-off for increased risks of hepatic decompensation and mortality) and monitoring HVPG changes in response to nonselective beta-blockers or etiological treatments. Finally, we review established and potential future clinical applications of noninvasive methods.
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Affiliation(s)
- Mattias Mandorfer
- Vienna Hepatic Hemodynamic Lab, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria.,Barcelona Hepatic Hemodynamic Lab, Liver Unit, Hospital Clínic, Barcelona, Spain
| | - Virginia Hernández-Gea
- Barcelona Hepatic Hemodynamic Lab, Liver Unit, Hospital Clínic, Barcelona, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - Juan Carlos García-Pagán
- Barcelona Hepatic Hemodynamic Lab, Liver Unit, Hospital Clínic, Barcelona, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - Thomas Reiberger
- Vienna Hepatic Hemodynamic Lab, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
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29
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Garcovich M, Di Stasio E, Zocco MA, Riccardi L, Ainora ME, Annicchiarico BE, Gibiino G, Santopaolo F, Gasbarrini A, Pompili M. Assessing Baveno VI criteria with liver stiffness measured using a new point-shear wave elastography technique (BAVElastPQ study). Liver Int 2020; 40:1952-1960. [PMID: 32510772 DOI: 10.1111/liv.14558] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2019] [Revised: 05/21/2020] [Accepted: 05/31/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND AND AIMS To date, no study has explored the potential role of ElastPQ, a novel point-SWE technique, in the assessment of clinically significant portal hypertension. The aim of our study was to determine a liver stiffness (LS) cut-off value measured by ElastPQ and laboratory parameters that could help to identify those patients who can safely avoid screening endoscopy. METHODS Data were collected on 1422 patients who underwent ElastPQ measurement from January 2013 to January 2016 in our Department. Inclusion criteria were a LS value of ≥7 kPa, an upper gastrointestinal endoscopy within 12 months and a diagnosis of compensated chronic liver disease. Exclusion criteria were history of decompensated liver disease, evidence of porto-spleno-mesenteric vein thrombosis and non-cirrhotic portal hypertension. Varices were graded as low-risk varices (grade <2) or varices needing treatment (VNT, grade ≥2). RESULTS The study included 195 patients (120 [61%] HCV, 171 [88%] Child-Pugh A). Varices were present in 35% cases, with 10% prevalence of VNT. According to ROC curve analysis, LS measurement and platelet count were evaluated as predictors of VNT. Overall, 75/195 (38%) met the 'BAVElastPQ' criteria (that is, LS < 12 kPa and platelet count >150 000/μL). Within this group, 11/75 (15%) had any grade of varices and only 1/75 (1%) had VNT. The BAVElastPQ criteria gave sensitivity of 0.95, specificity of 0.42, positive predictive value of 0.15 and negative predictive value of 0.99. CONCLUSIONS The BAVElastPQ criteria correctly identified 99% of patients without VNT. By applying such criteria, we could have potentially avoided 38% of surveillance endoscopies in our cohort.
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Affiliation(s)
- Matteo Garcovich
- Department of Internal Medicine, Gastroenterology and Liver Diseases, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Enrico Di Stasio
- Department of Internal Medicine, Gastroenterology and Liver Diseases, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Institute of Biochemistry and Clinical Biochemistry, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Maria A Zocco
- Department of Internal Medicine, Gastroenterology and Liver Diseases, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Laura Riccardi
- Department of Internal Medicine, Gastroenterology and Liver Diseases, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Maria E Ainora
- Department of Internal Medicine, Gastroenterology and Liver Diseases, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Brigida E Annicchiarico
- Department of Internal Medicine, Gastroenterology and Liver Diseases, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Giulia Gibiino
- Department of Internal Medicine, Gastroenterology and Liver Diseases, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Francesco Santopaolo
- Department of Internal Medicine, Gastroenterology and Liver Diseases, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Antonio Gasbarrini
- Department of Internal Medicine, Gastroenterology and Liver Diseases, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Maurizio Pompili
- Department of Internal Medicine, Gastroenterology and Liver Diseases, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
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Barr RG, Wilson SR, Rubens D, Garcia-Tsao G, Ferraioli G. Update to the Society of Radiologists in Ultrasound Liver Elastography Consensus Statement. Radiology 2020; 296:263-274. [PMID: 32515681 DOI: 10.1148/radiol.2020192437] [Citation(s) in RCA: 176] [Impact Index Per Article: 44.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
This multidisciplinary update of the Society of Radiologists in Ultrasound consensus statement on liver elastography incorporates the large volume of new information available in the literature since the initial publication. The recommended procedure for acquiring stiffness measurements is reviewed. There has been substantial improvement in the acoustic radiation force impulse (ARFI) technology-most notably the addition of a quality assessment of the shear wave propagation. Due to the efforts of the Quantitative Imaging Biomarkers Alliance, or QIBA, the variability of liver stiffness measurements between systems had decreased. There are now effective treatments for hepatitis B and hepatitis C, and follow-up after effective treatment should be based on the use of the delta change of the value obtained at viral eradication or suppression. Because the detection of compensated advanced chronic liver disease (cACLD) is very important, the new guidelines are made based on the probability of cACLD for given stiffness values. The panel recommends a vendor-neutral rule of four for interpretation for ARFI techniques. This new method simplifies interpretation of liver stiffness results and is more clinically relevant.
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Affiliation(s)
- Richard G Barr
- From the Department of Radiology, Northeastern Ohio Medical University, Rootstown, Ohio (R.G.B.); Department of Radiology, University of Calgary, Calgary, Canada (S.R.W.); Departments of Imaging Science, Oncology, and Biomedical Engineering, University of Rochester Medical Center, Rochester, NY (D.R.); Section of Digestive Diseases, Department of Medicine, Yale University, New Haven, Conn (G.G.T.); and Ultrasound Unit, Department of Clinical Sciences and Infectious Diseases, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy (G.F.)
| | - Stephanie R Wilson
- From the Department of Radiology, Northeastern Ohio Medical University, Rootstown, Ohio (R.G.B.); Department of Radiology, University of Calgary, Calgary, Canada (S.R.W.); Departments of Imaging Science, Oncology, and Biomedical Engineering, University of Rochester Medical Center, Rochester, NY (D.R.); Section of Digestive Diseases, Department of Medicine, Yale University, New Haven, Conn (G.G.T.); and Ultrasound Unit, Department of Clinical Sciences and Infectious Diseases, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy (G.F.)
| | - Deborah Rubens
- From the Department of Radiology, Northeastern Ohio Medical University, Rootstown, Ohio (R.G.B.); Department of Radiology, University of Calgary, Calgary, Canada (S.R.W.); Departments of Imaging Science, Oncology, and Biomedical Engineering, University of Rochester Medical Center, Rochester, NY (D.R.); Section of Digestive Diseases, Department of Medicine, Yale University, New Haven, Conn (G.G.T.); and Ultrasound Unit, Department of Clinical Sciences and Infectious Diseases, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy (G.F.)
| | - Guadalupe Garcia-Tsao
- From the Department of Radiology, Northeastern Ohio Medical University, Rootstown, Ohio (R.G.B.); Department of Radiology, University of Calgary, Calgary, Canada (S.R.W.); Departments of Imaging Science, Oncology, and Biomedical Engineering, University of Rochester Medical Center, Rochester, NY (D.R.); Section of Digestive Diseases, Department of Medicine, Yale University, New Haven, Conn (G.G.T.); and Ultrasound Unit, Department of Clinical Sciences and Infectious Diseases, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy (G.F.)
| | - Giovanna Ferraioli
- From the Department of Radiology, Northeastern Ohio Medical University, Rootstown, Ohio (R.G.B.); Department of Radiology, University of Calgary, Calgary, Canada (S.R.W.); Departments of Imaging Science, Oncology, and Biomedical Engineering, University of Rochester Medical Center, Rochester, NY (D.R.); Section of Digestive Diseases, Department of Medicine, Yale University, New Haven, Conn (G.G.T.); and Ultrasound Unit, Department of Clinical Sciences and Infectious Diseases, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy (G.F.)
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Li J, Venkatesh SK, Yin M. Advances in Magnetic Resonance Elastography of Liver. Magn Reson Imaging Clin N Am 2020; 28:331-340. [PMID: 32624152 DOI: 10.1016/j.mric.2020.03.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
Abstract
Magnetic resonance elastography (MRE) is the most accurate noninvasive technique in diagnosing fibrosis and cirrhosis in patients with chronic liver disease (CLD). The accuracy of hepatic MRE in distinguishing the severity of disease has been validated in studies of patients with various CLDs. Advanced hepatic MRE is a reliable, comfortable, and inexpensive alternative to liver biopsy for disease diagnosing, progression monitoring, and clinical decision making in patients with CLDs. This article summarizes current knowledge of the technical advances and innovations in hepatic MRE, and the clinical applications in various hepatic diseases.
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Affiliation(s)
- Jiahui Li
- Department of Radiology, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA
| | | | - Meng Yin
- Department of Radiology, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA.
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Can Non-Invasive Methods Be Clinically Useful for Diagnosis and Severity of Portal Hypertension? HEPATITIS MONTHLY 2020. [DOI: 10.5812/hepatmon.99974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/13/2023]
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The role of spleen stiffness using ARFI in predicting esophageal varices in patients with Hepatitis B and C virus-related cirrhosis. ACTA ACUST UNITED AC 2020; 57:334-340. [PMID: 31301679 DOI: 10.2478/rjim-2019-0017] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Current guidelines recommend that all patients with cirrhosis undergo upper gastrointestinal endoscopy (UGE) screening for esophageal varices (EV). Unfortunately, UGE has a lot of disadvantages, consequently various non-invasive methods of diagnosing EV have been proposed. We evaluated if spleen stiffness (SS) measured by Acoustic Radiation Force Impulse (ARFI) is a viable technique in diagnosing EV. METHODS We recruited 178 patients with cirrhosis caused by Hepatitis B and C who underwent biochemical tests, abdominal ultrasound, UGE, LS and SS measurements using ARFI elastography. Based on the endoscopic results the patients were divided in 3 groups: without EV, with small EV (<5 mm) and with large EV (>5 mm). RESULTS ARFI SS was the only non-invasive parameter associated with the presence of EV (2.7±0.30 vs. 3.4±0.52, p<0.001) and large EV (2.91±0.36 vs. 3.86±0.37, p=0.001) after multivariate logistic regression (p<0.001). ARFI SS for predicting EV showed an AUROC of 0.872 (CI 95%: 0.799-0.944), for a cut-off value of 2.89 m/s: Sensitivity (Se) 91.4% (CI 95%: 81-97%), Specificity (Sp) 67.7% (CI 95%: 51-85%). ARFI SS for diagnosing large EV (>5mm) had better results with an AUROC 0.969 (CI 95%:0.935-0.99), and for a cut-off of 3.30 m/s: Se 96.4% (CI 95%: 82-99.9%), Sp 88.5% (CI 95%: 78-95%). CONCLUSIONS SS measured using ARFI is a good method of detecting EV and is an excellent method of diagnosing large EV in patients with virus-related cirrhosis.
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Fierbinteanu-Braticevici C, Tribus L, Peagu R, Petrisor A, Baicus C, Cretoiu D, Pasternak A, Oprea G, Purcareanu A, Moldoveanu AC. Spleen Stiffness as Predictor of Esophageal Varices in Cirrhosis of Different Etiologies. Sci Rep 2019; 9:16190. [PMID: 31700031 PMCID: PMC6838194 DOI: 10.1038/s41598-019-52407-y] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Accepted: 10/09/2019] [Indexed: 02/06/2023] Open
Abstract
The purpose of this study is to determine whether esophageal varices (EV) can be identified through the evaluation of spleen stiffness (SSM) via acoustic radiation force impulse (ARFI). A total of 135 patients suffering from cirrhosis underwent a clinical exam, laboratory tests, abdominal ultrasound, liver stiffness (LSM) measurement, SSM evaluation and upper gastrointestinal endoscopy. Based on the endoscopy results, the patients were classified into three groups: those with no evident EV, those with small EV and those with varices needing treatment (VNT). Patients with EV of any grade had significantly higher average SSM values over those with no EV (3.37 m/s versus 2.79 m/s, p-value < 0.001), while patients with VNT showed an even greater difference (3.96 m/s versus 2.93 m/s, p-value < 0.001). SSM proved to be an excellent method of predicting patients with VNT.
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Affiliation(s)
- Carmen Fierbinteanu-Braticevici
- Medical Clinic II and Gastroenterology, Carol Davila University of Medicine and Pharmacy, Bucharest, 050474, Romania.,Department of Gastroenterology, Bucharest Emergency University Hospital, Bucharest, 050098, Romania
| | - Laura Tribus
- Medical Clinic II and Gastroenterology, Carol Davila University of Medicine and Pharmacy, Bucharest, 050474, Romania.,Department of Gastroenterology, Bucharest Emergency University Hospital, Bucharest, 050098, Romania
| | - Razvan Peagu
- Medical Clinic II and Gastroenterology, Carol Davila University of Medicine and Pharmacy, Bucharest, 050474, Romania.,Department of Gastroenterology, Bucharest Emergency University Hospital, Bucharest, 050098, Romania
| | - Ana Petrisor
- Medical Clinic II and Gastroenterology, Carol Davila University of Medicine and Pharmacy, Bucharest, 050474, Romania.,Department of Gastroenterology, Bucharest Emergency University Hospital, Bucharest, 050098, Romania
| | - Cristian Baicus
- Department of Clinical Epidemiology and Biostatistics, Carol Davila University of Medicine and Pharmacy Bucharest, Bucharest, 050474, Romania
| | - Dragos Cretoiu
- Department of Cellular and Molecular Biology and Histology, Carol Davila University of Medicine and Pharmacy, Bucharest, 050474, Romania. .,Fetal Medicine Excellence Research Center, Alessandrescu-Rusescu National Institute for Mother and Child Health, Bucharest, 011062, Romania.
| | - Artur Pasternak
- Department of Anatomy, Jagiellonian University Medical College, Krakow, 31-008, Poland
| | - Gabriela Oprea
- Medical Clinic II and Gastroenterology, Carol Davila University of Medicine and Pharmacy, Bucharest, 050474, Romania.,Department of Gastroenterology, Bucharest Emergency University Hospital, Bucharest, 050098, Romania
| | - Adina Purcareanu
- Medical Clinic II and Gastroenterology, Carol Davila University of Medicine and Pharmacy, Bucharest, 050474, Romania.,Department of Internal Medicine, Bucharest Emergency University Hospital, Bucharest, 050098, Romania
| | - Alexandru C Moldoveanu
- Medical Clinic II and Gastroenterology, Carol Davila University of Medicine and Pharmacy, Bucharest, 050474, Romania.,Department of Gastroenterology, Bucharest Emergency University Hospital, Bucharest, 050098, Romania
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Ahmad AK, Atzori S, Taylor-Robinson SD, Maurice JB, Cooke GS, Garvey L. Spleen stiffness measurements using point shear wave elastography detects noncirrhotic portal hypertension in human immunodeficiency virus. Medicine (Baltimore) 2019; 98:e17961. [PMID: 31764798 PMCID: PMC6882591 DOI: 10.1097/md.0000000000017961] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
To assess the utility of spleen stiffness as a diagnostic tool in individuals with human immunodeficiency virus (HIV) and non-cirrhotic portal hypertension (NCPH).The Philips EPIQ7, a new point shearwave elastography (pSWE) technique, was used to assess liver and spleen stiffness in 3 patient groups. Group 1: HIV and NCPH (n = 11); Group 2: HIV with past didanosine (ddI) exposure without known liver disease or NCPH (n = 5); Group 3: HIV without known liver disease or ddI exposure (n = 9).Groups were matched for age, HIV chronicity, and antiretroviral treatment (including cumulative ddI exposure in Groups 1 and 2). Differences in liver and spleen stiffness (in kPa) between groups were analyzed using the Mann-Whiney U test.Liver and spleen stiffness were both significantly higher in NCPH versus ddI-exposed (P = .019 and P = .006) and ddI-unexposed controls (P = .038 and P < .001). Spleen stiffness was more effective than liver stiffness at predicting NCPH, area under receiver operating characteristic (AUROC) 0.812 versus 0.948. Combining the 2 variables improved the diagnostic performance, AUROC 0.961. The optimal cut-off for predicting NCPH using splenic stiffness was 25.4 kPa, with sensitivity 91%, specificity 93%, positive predictive value (PPV) 91%, negative predictive value (NPV) 93%, positive likelihood ratio 12.73, negative likelihood ratio 0.10. Spleen and liver stiffness scores were strongly correlated (P = .0004, 95% confidence interval [CI] 18, 59).Elevated spleen stiffness is observed in HIV with NCPH and can be quantified easily using pSWE with high diagnostic accuracy. Novel strategies such as pSWE for longitudinal monitoring of patients with HIV and NCPH should be considered.
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Affiliation(s)
| | | | | | | | - Graham S. Cooke
- Department of Infectious Diseases, Imperial College, St Mary's Hospital Campus, London W2 1PG
| | - Lucy Garvey
- Jefferiss Wing, Department of HIV Medicine, Imperial College Healthcare NHS Trust, St Mary's Hospital, London W2 1NY
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Rana R, Wang S, Li J, Basnet S, Zheng L, Yang C. Diagnostic accuracy of non-invasive methods detecting clinically significant portal hypertension in liver cirrhosis: a systematic review and meta-analysis. Minerva Med 2019; 111:266-280. [PMID: 31638361 DOI: 10.23736/s0026-4806.19.06143-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
INTRODUCTION We attempted to investigate non-invasive techniques and their diagnostic performances for evaluating clinically significant portal hypertension. EVIDENCE ACQUISITION The systematic search was performed on PubMed, Embase, Scopus, and Web of Science TM core index databases before 13 December 2018 restricted to English language and human studies. EVIDENCE SYNTHESIS Thirty-two studies were included, with total populations of 3,987. The overall pooled analysis was performed by bivariate random effect model, which revealed significantly higher sensitivity and specificity of 77.1% (95% confidence interval, 76.8-78.5%) and 80.1% (95% confidence interval, 78.2-81.9%), respectively; positive likelihood ratio (3.67), negative likelihood ratio (0.26); and diagnostic odd ratio (16.24). Additionally, the area under curve exhibited significant diagnostic accuracy of 0.871. However, notable heterogeneity existed in between studies (I2=87.1%), therefore, further subgroup analysis was performed. It demonstrated ultrasonography, elastography, biomarker, and computed tomography scan had a significant overall summary sensitivity (specificity) of 89.6% (78.9%), 81.7% (83.2%), 72.2% (76.8%), and 77.2% (81.2%), respectively. Moreover, the areas under curve values were significantly higher in elastography (0.906), followed by computed tomography scan (0.847), biomarker (0.825), and ultrasonography (0.803). CONCLUSIONS In future, non-invasive techniques could be the future choice of investigations for screening and diagnosis of clinically significant portal hypertension in cirrhosis. However, standardization of diagnostic indices and their cut-off values in each non-invasive method needs to be addressed.
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Affiliation(s)
- Ramesh Rana
- Division of Gastroenterology and Hepatology, Digestive Disease Institute, Shanghai Tongji Hospital, Tongji University School of Medicine, Shanghai, China.,Department of Internal Medicine, Gautam Buddha Community Heart Hospital, Butwal, Nepal
| | - Shenglan Wang
- Division of Gastroenterology and Hepatology, Digestive Disease Institute, Shanghai Tongji Hospital, Tongji University School of Medicine, Shanghai, China
| | - Jing Li
- Division of Gastroenterology and Hepatology, Digestive Disease Institute, Shanghai Tongji Hospital, Tongji University School of Medicine, Shanghai, China
| | - Shiva Basnet
- Department of Gastrointestinal Surgery, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China
| | - Liang Zheng
- Research Center for Translational Medicine, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China
| | - Changqing Yang
- Division of Gastroenterology and Hepatology, Digestive Disease Institute, Shanghai Tongji Hospital, Tongji University School of Medicine, Shanghai, China -
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Xu G, Li F, Mao Y. Portal pressure monitoring-state-of-the-art and future perspective. ANNALS OF TRANSLATIONAL MEDICINE 2019; 7:583. [PMID: 31807564 DOI: 10.21037/atm.2019.09.22] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Portal hypertension is a serious symptom of chronic liver diseases, which can lead to many critical complications, such as the formation of varices related to upper digestive bleeding, ascites, infection, hepatic encephalopathy, renal failure, and even death. As a result, portal pressure monitoring has important prognostic and clinical implications. The hepatic venous pressure gradient measurement, a gold-standard method applied to monitor portal pressure, is invasive and only available in experienced centers. Over the past decade, noninvasive methods aimed at monitoring the portal pressure have been increasingly investigated, including serum markers, radiological features, ultrasound elastography, doppler and contrast-enhanced ultrasonography. In this study, we focused on both invasive and noninvasive methods for portal pressure monitoring and explored their roles in clinical setting. The advantages and limitations of various techniques for future research are also discussed.
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Affiliation(s)
- Gang Xu
- Department of Liver Surgery, Peking Union Medical College (PUMC) Hospital, PUMC and Chinese Academy of Medical Sciences, Beijing 100730, China.,Paul C. Lauterbur Research Center for Biomedical Imaging, Shenzhen Institutes of Advanced Technology, Chinese Academy of Sciences, Shenzhen 518055, China
| | - Fei Li
- Paul C. Lauterbur Research Center for Biomedical Imaging, Shenzhen Institutes of Advanced Technology, Chinese Academy of Sciences, Shenzhen 518055, China.,Shenzhen Key Laboratory of Ultrasound Imaging and Therapy, Shenzhen 518055, China
| | - Yilei Mao
- Department of Liver Surgery, Peking Union Medical College (PUMC) Hospital, PUMC and Chinese Academy of Medical Sciences, Beijing 100730, China
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Yu JB, Xiong H, Yuan XC, Zhou AY. Liver Stiffness Detected by Shear Wave Elastography Predicts Esophageal Varices in Cirrhotic Patients. Ultrasound Q 2019; 37:118-122. [PMID: 31299039 DOI: 10.1097/ruq.0000000000000466] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
ABSTRACT Ultrasound elastography has become a promising noninvasive approach for assessing liver fibrosis. The purpose of this study was to evaluate the diagnosis ability of liver stiffness detected by shear wave elastography (SWE) for predicting the presence of esophageal varices (EVs) in cirrhotic patients. Four hundred sixty-eight cirrhotic patients were enrolled consecutively. Liver stiffness and EVs were detected by SWE and endoscopy, respectively. The baseline characteristics were recorded, and areas under the receiver operating characteristic curves (AUROCs) were used to compare the diagnosis accuracy. Multivariate analysis was used to identify the risk factors for EVs in cirrhosis. The mean liver stiffness was 18.4 kPa with a range of 6.8 to 52.5 kPa. Two hundred seventy-one patients had no EVs (57.9%), 139 patients had F1 EVs (29.7%), and 58 patients had high-risk EVs (12.4%). The optimal cutoff values of SWE for predicting EVs and high-risk varices were 18.5 and 20.4 kPa, respectively. The AUROCs for predicting the incidence of EVs were 0.792 (95% confidence interval [CI], 0.884-0.842), 0.814 (95% CI, 0.658-0.875), and 0.895 (95% CI, 0.813-0.918) for platelet, platelet count-to-spleen diameter ratio, and liver stiffness, respectively. For predicting the presence of high-risk varices, liver stiffness again had the highest AUROC. Multivariate analysis identified liver stiffness and platelet count-to-spleen diameter ratio as independent predictive factors for EVs in cirrhosis. Liver stiffness measured by SWE is an effective diagnostic tool for predicting EVs with greater accuracy, and SWE value is an independent factor for predicting high-risk EVs.
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Affiliation(s)
| | | | - Xin-Chun Yuan
- The First Affiliated Hospital of Nanchang University, Nanchang, People's Republic of China
| | - Ai-Yun Zhou
- The First Affiliated Hospital of Nanchang University, Nanchang, People's Republic of China
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Zhu YL, Ding H, Fu TT, Peng SY, Chen SY, Luo JJ, Wang WP. Portal hypertension in hepatitis B-related cirrhosis: Diagnostic accuracy of liver and spleen stiffness by 2-D shear-wave elastography. Hepatol Res 2019; 49:540-549. [PMID: 30597744 DOI: 10.1111/hepr.13306] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2018] [Revised: 11/28/2018] [Accepted: 12/22/2018] [Indexed: 02/08/2023]
Abstract
AIM To assess the diagnostic accuracy of liver and spleen stiffness measured by 2-D shear-wave elastography (SWE) in evaluation of clinically significant and severe portal hypertension (CSPH and SPH, respectively). METHODS Clinical data of 155 hepatitis B-related cirrhosis patients and their liver and spleen stiffness (L-SWE and S-SWE, respectively) were collected. The diagnostic performances of L-SWE, S-SWE, the liver stiffness-spleen diameter to platelet ratio score (LSPS) and portal hypertension risk score were evaluated. RESULTS One hundred and four patients were eligible for analysis. Clinically significant and severe PH were detected in 84 and 74 patients, respectively. Liver and spleen stiffness were significantly correlated with hepatic venous pressure gradient in overall, CSPH, and SPH groups (rL = 0.607, 0.554, and 0.412; rS = 0.665, 0.566, and 0.467, respectively; all P < 0.05). The area under the receiver operating characteristic curves of L-SWE, S-SWE, LSPS, and PH risk score were 0.72 (95% confidence interval [CI], 0.49-0.95), 0.81 (95% CI, 0.55-0.97), 0.76 (95% CI, 0.51-0.96), and 0.73 (95% CI, 0.55-0.88) for CSPH, and 0.77 (95% CI, 0.51-0.93), 0.85 (95% CI, 0.59-0.96), 0.80 (95% CI, 0.58-0.98), and 0.80 (95% CI, 0.59-0.93) for SPH. The best cut-off of L-SWE for determining CSPH and SPH were 16.1 kPa (sensitivity, 78%; specificity, 72%) and 23.5 kPa (sensitivity, 81%; specificity, 79%). For S-SWE, the best cut-offs were 25.3 kPa (sensitivity, 85%; specificity, 79%) and 33.4 kPa (sensitivity, 74%; specificity, 70%). A cut-off of L-SWE <13.2 kPa or S-SWE <23.2 kPa was able to rule out CSPH, whereas a cut-off of L-SWE >24.9 kPa or S-SWE >34.2 kPa was able to rule in CSPH. CONCLUSIONS Liver and spleen stiffness measured by 2-D SWE are reliable and promising non-invasive parameters to assess CSPH and SPH.
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Affiliation(s)
- Yu-Li Zhu
- Department of Ultrasound, Zhongshan Hospital, Fudan University, Shanghai, China.,Shanghai Institute of Medical Imaging, Fudan University, Shanghai, China
| | - Hong Ding
- Department of Ultrasound, Zhongshan Hospital, Fudan University, Shanghai, China.,Shanghai Institute of Medical Imaging, Fudan University, Shanghai, China
| | - Tian-Tian Fu
- Department of Ultrasound, Zhongshan Hospital, Fudan University, Shanghai, China.,Shanghai Institute of Medical Imaging, Fudan University, Shanghai, China
| | - Shi-Yun Peng
- Department of Ultrasound, Zhongshan Hospital, Fudan University, Shanghai, China.,Shanghai Institute of Medical Imaging, Fudan University, Shanghai, China
| | - Shi-Yao Chen
- Shanghai Institute of Medical Imaging, Fudan University, Shanghai, China.,Department of Gastroenterology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Jian-Jun Luo
- Shanghai Institute of Medical Imaging, Fudan University, Shanghai, China.,Department of Interventional Radiology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Wen-Ping Wang
- Department of Ultrasound, Zhongshan Hospital, Fudan University, Shanghai, China.,Shanghai Institute of Medical Imaging, Fudan University, Shanghai, China
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Qi X, Berzigotti A, Cardenas A, Sarin SK. Emerging non-invasive approaches for diagnosis and monitoring of portal hypertension. Lancet Gastroenterol Hepatol 2019; 3:708-719. [PMID: 30215362 DOI: 10.1016/s2468-1253(18)30232-2] [Citation(s) in RCA: 85] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Revised: 05/13/2018] [Accepted: 06/25/2018] [Indexed: 02/08/2023]
Abstract
Clinically significant portal hypertension is associated with an increased risk of developing gastro-oesophageal varices and hepatic decompensation. Hepatic venous pressure gradient measurement and oesophagogastroduodenoscopy are the gold-standard methods for assessing clinically significant portal hypertension (hepatic venous pressure gradient ≥10 mm Hg) and gastro-oesophageal varices, respectively. However, invasiveness, cost, and feasibility limit their widespread use, especially if repeated and serial evaluations are required to assess the efficacy of pharmacotherapy. Although new techniques for non-invasive portal pressure measurement have been pursued for many decades, only recently have new tools been assessed and validated for larger clinical application. This Review focuses on the recent advances in non-invasive approaches for the diagnosis and serial monitoring of portal hypertension and varices for clinical practice.
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Affiliation(s)
- Xiaolong Qi
- CHESS Group, Hepatic Hemodynamic Lab, Institute of Hepatology, Nanfang Hospital, Southern Medical University, Guangzhou, China; CHESS Frontier Center, Lanzhou University, Lanzhou, China.
| | - Annalisa Berzigotti
- Hepatology Group, Swiss Liver Center, University Clinic for Visceral Surgery and Medicine, Inselspital, University of Bern, Bern, Switzerland
| | - Andres Cardenas
- GI/Liver Unit, Institute of Digestive Diseases and Metabolism, Hospital Clinic, University of Barcelona, Barcelona, Spain
| | - Shiv Kumar Sarin
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
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Attia D, Rodt T, Marquardt S, Hinrichs J, Meyer BC, Gebel M, Wacker F, Manns MP, Potthoff A. Shear wave elastography prior to transjugular intrahepatic portosystemic shunt may predict the decrease in hepatic vein pressure gradient. Abdom Radiol (NY) 2019; 44:1127-1134. [PMID: 30288582 DOI: 10.1007/s00261-018-1795-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Transjugular intrahepatic portosystemic shunt (TIPS) is a procedure used to treat portal hypertension complications. Our aim was to evaluate liver and spleen stiffness measurement (LSM and SSM, respectively) changes using acoustic radiation force impulse imaging (ARFI) in comparison to Child-Pugh scores for predicting hepatic venous pressure gradient (HVPG) decreases after TIPS implantation. METHODS This prospective study included 31 consecutive clinically significant portal hypertension patients with TIPS indication. All patients received LSM and SSM before TIPS, at baseline, 2 days (follow-up 1) and 6 weeks (follow-up 2) post-implantation. HVPG was performed during the TIPS procedure. RESULTS The mean decrease in HVPG after TIPS was 63%. LSM and SSM decreased significantly between baseline and follow-up 2 (p < 0.001 and p < 0.001, respectively). At baseline, follow-up 1 and follow-up 2, significant correlations were detected between mean SSM and mean HVPG (p = 0.026; p = 0.018; p = 0.002, respectively). HVPG decreased to ≤ 10 mmHg in 61% of patients for which LSM, SSM, and Child-Pugh score were predictors (p = 0.033, p = 0.002 and p = 0.030, respectively). The area under the curve (AUC) for LSM, SSM, and Child-Pugh was 0.88, 0.90, and 0.84, respectively, with close sensitivity and specificity. SSM had the highest diagnostic accuracy for predicting an HVPG decrease to ≤ 10 mmHg in comparison to LSM and Child-Pugh score. CONCLUSION Spleen stiffness is superior to liver stiffness and Child-Pugh score as a non-invasive surveillance tool for evaluating patients with clinically significant portal hypertension (HVPG ≥ 10 mmHg) prior to TIPS.
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Affiliation(s)
- Dina Attia
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany.
- Department of Gastroenterology, Hepatology and Endemic Medicine, Faculty of Medicine, Beni-Suef University, Mokbel Street, Beni-Suef, 62511, Egypt.
| | - Thomas Rodt
- Department of Diagnostic and Interventional Radiology, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - Steffen Marquardt
- Department of Diagnostic and Interventional Radiology, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - Jan Hinrichs
- Department of Diagnostic and Interventional Radiology, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - Bernhard C Meyer
- Department of Diagnostic and Interventional Radiology, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - Michael Gebel
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - Frank Wacker
- Department of Diagnostic and Interventional Radiology, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - Michael P Manns
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - Andrej Potthoff
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
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Paternostro R, Reiberger T, Bucsics T. Elastography-based screening for esophageal varices in patients with advanced chronic liver disease. World J Gastroenterol 2019; 25:308-329. [PMID: 30686900 PMCID: PMC6343095 DOI: 10.3748/wjg.v25.i3.308] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Revised: 11/27/2018] [Accepted: 12/20/2018] [Indexed: 02/06/2023] Open
Abstract
Elastography-based liver stiffness measurement (LSM) is a non-invasive tool for estimating liver fibrosis but also provides an estimate for the severity of portal hypertension in patients with advanced chronic liver disease (ACLD). The presence of varices and especially of varices needing treatment (VNT) indicates distinct prognostic stages in patients with compensated ACLD (cACLD). The Baveno VI guidelines suggested a simple algorithm based on LSM < 20 kPa (by transient elastography, TE) and platelet count > 150 G/L for ruling-out VNT in patients with cACLD. These (and other) TE-based LSM cut-offs have been evaluated for VNT screening in different liver disease etiologies. Novel point shear-wave elastography (pSWE) and two-dimensional shear wave elastography (2D-SWE) methodologies for LSM have also been evaluated for their ability to screen for “any” varices and for VNT. Finally, the measurement of spleen stiffness (SSM) by elastography (mainly by pSWE and 2D-SWE) may represent another valuable screening tool for varices. Here, we summarize the current literature on elastography-based prediction of “any” varices and VNT. Finally, we have summarized the published LSM and SSM cut-offs in clinically useful scale cards.
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Affiliation(s)
- Rafael Paternostro
- Department of Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna A-1090, Austria
| | - Thomas Reiberger
- Department of Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna A-1090, Austria
| | - Theresa Bucsics
- Department of Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna A-1090, Austria
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Ferraioli G, Wong VWS, Castera L, Berzigotti A, Sporea I, Dietrich CF, Choi BI, Wilson SR, Kudo M, Barr RG. Liver Ultrasound Elastography: An Update to the World Federation for Ultrasound in Medicine and Biology Guidelines and Recommendations. ULTRASOUND IN MEDICINE & BIOLOGY 2018; 44:2419-2440. [PMID: 30209008 DOI: 10.1016/j.ultrasmedbio.2018.07.008] [Citation(s) in RCA: 293] [Impact Index Per Article: 48.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/01/2018] [Revised: 07/02/2018] [Accepted: 07/13/2018] [Indexed: 06/08/2023]
Abstract
The World Federation for Ultrasound in Medicine and Biology has produced these guidelines for the use of elastography techniques in liver diseases. For each available technique, the reproducibility, results and limitations are analyzed, and recommendations are given. This set of guidelines updates the first version, published in 2015. Since the prior guidelines, there have been several advances in technology. The recommendations are based on the international published literature, and the strength of each recommendation is judged according to the Oxford Centre for Evidence-Based Medicine. The document has a clinical perspective and is aimed at assessing the usefulness of elastography in the management of liver diseases.
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Affiliation(s)
- Giovanna Ferraioli
- Ultrasound Unit, Department of Clinical Sciences and Infectious Diseases, Fondazione IRCCS Policlinico San Matteo, School of Medicine, University of Pavia, Pavia, Italy
| | - Vincent Wai-Sun Wong
- Department of Medicine and Therapeutics, Chinese University of Hong Kong, Hong Kong
| | - Laurent Castera
- Service d'Hepatologie, Hopital Beaujon, Clichy, Assistance Publique-Hopitaux de Paris, INSERM UMR 1149 CRI, Universite Denis Diderot Paris-VII, Paris, France
| | - Annalisa Berzigotti
- Swiss Liver Center, Hepatology, University Clinic for Visceral Surgery and Medicine, Inselspital, University of Bern, Switzerland
| | - Ioan Sporea
- Department of Gastroenterology and Hepatology, University of Medicine and Pharmacy, Timisoara, Romania
| | | | - Byung Ihn Choi
- Department of Radiology, Seoul National University Hospital, Seoul, South Korea
| | - Stephanie R Wilson
- Department of Diagnostic Imaging, Foothills Medical Centre, University of Calgary, Calgary, Alberta, Canada
| | - Masatoshi Kudo
- Department of Gastroenterology and Hepatology, Kindai University School of Medicine, Osaka Sayama, Japan
| | - Richard G Barr
- Department of Radiology, Northeastern Ohio Medical University and Southwoods Imaging, Youngstown, Ohio, USA.
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Lipinski M, Saborowski M, Heidrich B, Attia D, Kasten P, Manns MP, Gebel M, Potthoff A. Clinical characteristics of patients with liver cirrhosis and spontaneous portosystemic shunts detected by ultrasound in a tertiary care and transplantation centre. Scand J Gastroenterol 2018; 53:1107-1113. [PMID: 30270689 DOI: 10.1080/00365521.2018.1498913] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
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.
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Affiliation(s)
- Michael Lipinski
- a Department of Gastroenterology, Hepatology and Endocrinology , Hannover Medical School , Hannover , Germany
| | - Michael Saborowski
- a Department of Gastroenterology, Hepatology and Endocrinology , Hannover Medical School , Hannover , Germany
| | - Benjamin Heidrich
- a Department of Gastroenterology, Hepatology and Endocrinology , Hannover Medical School , Hannover , Germany
| | - Dina Attia
- a Department of Gastroenterology, Hepatology and Endocrinology , Hannover Medical School , Hannover , Germany
| | - Philipp Kasten
- a Department of Gastroenterology, Hepatology and Endocrinology , Hannover Medical School , Hannover , Germany
| | - Michael P Manns
- a Department of Gastroenterology, Hepatology and Endocrinology , Hannover Medical School , Hannover , Germany
| | - Michael Gebel
- a Department of Gastroenterology, Hepatology and Endocrinology , Hannover Medical School , Hannover , Germany
| | - Andrej Potthoff
- a Department of Gastroenterology, Hepatology and Endocrinology , Hannover Medical School , Hannover , Germany
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Achilles tendon elastic properties remain decreased in long term after rupture. Knee Surg Sports Traumatol Arthrosc 2018; 26:2080-2087. [PMID: 29147741 DOI: 10.1007/s00167-017-4791-4] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2017] [Accepted: 11/06/2017] [Indexed: 01/03/2023]
Abstract
PURPOSE Rupture of the Achilles tendon results in inferior scar tissue formation. Elastography allows a feasible in vivo investigation of biomechanical properties of the Achilles tendon. The purpose of this study is to investigate the biomechanical properties of healed Achilles tendons in the long term. MATERIALS AND METHODS Patients who suffered from Achilles tendon rupture were recruited for an elastographic evaluation. Unilateral Achilles tendon ruptures were included and scanned in the mid-substance and calcaneal insertion at least 2 years after rupture using shear wave elastography. Results were compared to patients' contralateral non-injured Achilles tendons and additionally to a healthy population. Descriptive statistics, reliability analysis, and correlation analysis with clinical scores were performed. RESULTS Forty-one patients were included in the study with a mean follow-up-time of 74 ± 30; [26-138] months after rupture. Significant differences were identified in shear wave elastography in the mid-substance of healed tendons (shear wave velocity 1.2 ±1.5 m/s) compared to both control groups [2.5 ±1.5 m/s (p < 0.01) and 2.8 ±1.6 m/s (p < 0.0001) contralateral and healthy population, respectively]. There was no correlation between the measurements and the clinical outcome. CONCLUSIONS This study shows that the healed Achilles tendon after rupture has inferior elastic properties even after a long-term healing phase. Differences in elastic properties after rupture mainly originate from the mid-substance of the Achilles tendon, in which most of the ruptures occur. Elastographic results do not correspond with subjective perception. Clinically, sonoelastographical measurements of biomechanical properties can be useful to provide objective insights in tendon recovery.
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Noninvasive Assessment of Portal Hypertension in Advanced Chronic Liver Disease: An Update. Gastroenterol Res Pract 2018; 2018:4202091. [PMID: 29977287 PMCID: PMC6011072 DOI: 10.1155/2018/4202091] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Accepted: 04/30/2018] [Indexed: 12/14/2022] Open
Abstract
The assessment of portal hypertension is a relevant step in the evaluation of newly diagnosed advanced chronic liver disease (ACLD). The current gold standard includes the invasive evaluation of hepatic venous pressure gradient (HVPG) and endoscopy. However, noninvasive or minimally invasive techniques to assess portal hypertension have been proposed and well established. In the present manuscript, we review clinical studies on the use of noninvasive or minimally invasive techniques to assess portal hypertension in ACLD patients.
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Performance of spleen stiffness measurement in prediction of clinical significant portal hypertension: A meta-analysis. Clin Res Hepatol Gastroenterol 2018; 42:216-226. [PMID: 29223365 DOI: 10.1016/j.clinre.2017.11.002] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2017] [Revised: 10/13/2017] [Accepted: 11/13/2017] [Indexed: 02/05/2023]
Abstract
AIM Our purpose was to evaluate the correlation between spleen stiffness (SS) measured by ultrasound-based elastography and hepatic venous pressure gradient (HVPG) and assess the accuracy of SS in detecting clinical significant portal hypertension (CSPH) and severe portal hypertension. METHOD Nine studies were included from thorough literature research and selection processes. A random model was used to analyze the correlation between HVPG and SS. We adopted the bivariate mixed effects model to assess the diagnostic performance. RESULTS Regarding to correlation between SS and HVPG, the summary correlation coefficient was 0.72 (95% confidence interval [CI], 0.63-0.80). In detection of CSPH, the sensitivity, specificity, AUC and DOR were: 0.88 (0.70-0.96), 0.84 (0.72-0.92), 0.92 (0.89-0.94) and 38 (17-84) for CSPH, respectively; and 0.92 (0.82-0.96), 0.79 (0.72-0.85), 0.87 (0.84-0.90) and 41 (17-100) for severe portal hypertension, respectively. CONCLUSION Correlation between SS and HVPG was good. Although SS showed good sensitivity and specificity, the different cut-off values and techniques among studies might limit the impact of our results on clinical practice. Therefore, more high-quality prospective studies are required to evaluate the role of SS in predicting portal hypertension.
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Karatzas A, Konstantakis C, Aggeletopoulou I, Kalogeropoulou C, Thomopoulos K, Triantos C. Νon-invasive screening for esophageal varices in patients with liver cirrhosis. Ann Gastroenterol 2018; 31:305-314. [PMID: 29720856 PMCID: PMC5924853 DOI: 10.20524/aog.2018.0241] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2017] [Accepted: 01/26/2018] [Indexed: 12/11/2022] Open
Abstract
Esophageal varices are one of the main complications of liver cirrhosis. Upper gastrointestinal endoscopy is the gold standard for the detection of esophageal varices. Many less invasive methods for screening of varices have been investigated and the most recent Baveno VI guidelines suggest that endoscopy is not necessary in patients with liver stiffness <20 kPa and platelets >150,000/μL. A critical review of the literature was performed concerning non-invasive or minimally invasive methods of screening for esophageal varices. Liver and spleen elastography, imaging methods including computed tomography, magnetic resonance imaging and ultrasound, laboratory tests and capsule endoscopy are discussed. The accuracy of each method, and its advantages and limitations compared to endoscopy are analyzed. There are data to support the Baveno VI guidelines, but there is still a lack of large prospective studies and low specificity has been reported for the liver stiffness and platelet count combination. Spleen elastography has shown promising results, as there are data to support its superiority to liver elastography, but it needs further assessment. Computed tomography has shown high diagnostic accuracy and can be part of the diagnostic work up of cirrhotic patients in the future, including screening for varices.
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Affiliation(s)
- Andreas Karatzas
- Department of Radiology, Olympion Therapeutirio (Andreas Karatzas)
| | | | - Ioanna Aggeletopoulou
- Department of Gastroenterology, University Hospital of Patras (Ioanna Aggeletopoulou, Konstantinos Thomopoulos, Christos Triantos)
| | - Christina Kalogeropoulou
- Department of Radiology, University Hospital of Patras (Christina Kalogeropoulou), Patras, Achaia, Greece
| | - Konstantinos Thomopoulos
- Department of Gastroenterology, University Hospital of Patras (Ioanna Aggeletopoulou, Konstantinos Thomopoulos, Christos Triantos)
| | - Christos Triantos
- Department of Gastroenterology, University Hospital of Patras (Ioanna Aggeletopoulou, Konstantinos Thomopoulos, Christos Triantos)
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Tsukano N, Miyase S, Saeki T, Mizobe K, Iwashita H, Arima N, Fujiyama S. Usefulness of virtual touch quantification for staging liver fibrosis in patients with hepatitis C, and factors affecting liver stiffness measurement failure compared with liver biopsy. Hepatol Res 2018; 48:373-382. [PMID: 29226524 DOI: 10.1111/hepr.13041] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2017] [Revised: 11/10/2017] [Accepted: 12/02/2017] [Indexed: 02/08/2023]
Abstract
AIM The assessment of liver fibrosis in patients with hepatitis C is important to predict carcinogenesis. In this study, we evaluated the usefulness of virtual touch quantification (VTQ) for staging liver fibrosis, and investigated factors causing discrepancies between the estimated fibrosis stage using VTQ and the pathological fibrosis stage. METHODS Patients with hepatitis C (n = 302) were assessed using VTQ and underwent pathological liver investigation within 1 week before and after VTQ. A receiver operator characteristic (ROC) curve was obtained for VTQ, fibrosis-4 (FIB-4) index, and aspartate aminotransferase-to-platelet ratio index (APRI), and each area under the ROC curve (AUROC) was compared to predict fibrosis stage. We used univariate and multivariate analyses to investigate the factors related to the discrepancy between the estimated fibrosis stage using VTQ and the pathological fibrosis stage. RESULTS At any stage, VTQ was the most accurate for staging liver fibrosis. The VTQ cut-off values were 1.33 m/s (AUROC = 0.822) for ≥F2, 1.51 m/s (AUROC = 0.836) for ≥F3, and 1.92 m/s (AUROC = 0.890) for F4. Skin liver capsule distance (SCD) was the most relevant factor for the discrepancy between the estimated fibrosis stage using VTQ and the pathological fibrosis stage. The SCD cut-off value was 17.5 mm. CONCLUSIONS Virtual touch quantification is a non-invasive, simple method that is more accurate for staging liver fibrosis than the FIB-4 index and APRI. However, when the SCD is longer than 17.5 mm, there may be measurement failures.
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Affiliation(s)
- Natsumi Tsukano
- Department of Gastroenterology and Hepatology, Kumamoto Shinto General Hospital, Kumamoto, Japan
| | - Shiho Miyase
- Department of Gastroenterology and Hepatology, Kumamoto Shinto General Hospital, Kumamoto, Japan
| | - Tatsuhiko Saeki
- Department of Gastroenterology and Hepatology, Kumamoto Shinto General Hospital, Kumamoto, Japan
| | - Keiko Mizobe
- Department of Gastroenterology and Hepatology, Kumamoto Shinto General Hospital, Kumamoto, Japan
| | - Hirofumi Iwashita
- Department of Gastroenterology and Hepatology, Kumamoto Shinto General Hospital, Kumamoto, Japan
| | - Nobuyuki Arima
- Department of Gastroenterology and Hepatology, Kumamoto Shinto General Hospital, Kumamoto, Japan
| | - Shigetoshi Fujiyama
- Department of Gastroenterology and Hepatology, Kumamoto Shinto General Hospital, Kumamoto, Japan
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Shear Wave Elastography as a Quantitative Biomarker of Clinically Significant Portal Hypertension: A Systematic Review and Meta-Analysis. AJR Am J Roentgenol 2018; 210:W185-W195. [PMID: 29570374 DOI: 10.2214/ajr.17.18367] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To qualify shear wave elastography (SWE) as a biomarker for clinically significant portal hypertension (CSPH) beyond proof of concept, we aimed to accumulate and summarize the current evidence through systematic review and meta-analysis. MATERIALS AND METHODS A computerized literature search was performed to identify studies from MEDLINE and EMBASE up to February 9, 2017. Studies on the diagnostic performance of liver stiffness measurements using SWE for CSPH with hepatic venous pressure gradient (HVPG) as the reference standard were included. Various aspects of SWE were comprehensively assessed. The summary diagnostic performance of SWE for the diagnosis of CSPH and the summary correlation coefficient between liver stiffness measured using SWE and HVPG were evaluated through a meta-analysis. RESULTS Nine articles (including 746 patients) were retrieved. The diagnostic performance of SWE for the diagnosis of CSPH was fairly good, with a summary sensitivity of 85% (95% CI, 75-91%; I2 = 78.56%) and summary specificity of 85% (95% CI, 77-90%; I2 = 0%); the area under the ROC curve was 0.88 (95% CI, 0.85-0.91). The summary correlation coefficient between liver stiffness and HVPG measurements was 0.741 (95% CI, 0.658-0.825; I2 = 0%). These results support the value of SWE as a diagnostic biomarker for CSPH. However, there was significant heterogeneity in the imaging devices, protocols, liver stiffness measurement methods, and cutoff values used, which suggests that standardization is required. CONCLUSION The consistent evidence favoring SWE as a biomarker for CSPH should be considered in the biomarker qualification process and management of patients with CSPH.
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