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Rocca A, Komici K, Brunese MC, Pacella G, Avella P, Di Benedetto C, Caiazzo C, Zappia M, Brunese L, Vallone G. Quantitative ultrasound (QUS) in the evaluation of liver steatosis: data reliability in different respiratory phases and body positions. LA RADIOLOGIA MEDICA 2024; 129:549-557. [PMID: 38512608 PMCID: PMC11021279 DOI: 10.1007/s11547-024-01786-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Accepted: 01/10/2024] [Indexed: 03/23/2024]
Abstract
Liver steatosis is the most common chronic liver disease and affects 10-24% of the general population. As the grade of disease can range from fat infiltration to steatohepatitis and cirrhosis, an early diagnosis is needed to set the most appropriate therapy. Innovative noninvasive radiological techniques have been developed through MRI and US. MRI-PDFF is the reference standard, but it is not so widely diffused due to its cost. For this reason, ultrasound tools have been validated to study liver parenchyma. The qualitative assessment of the brightness of liver parenchyma has now been supported by quantitative values of attenuation and scattering to make the analysis objective and reproducible. We aim to demonstrate the reliability of quantitative ultrasound in assessing liver fat and to confirm the inter-operator reliability in different respiratory phases. We enrolled 45 patients examined during normal breathing at rest, peak inspiration, peak expiration, and semi-sitting position. The highest inter-operator agreement in both attenuation and scattering parameters was achieved at peak inspiration and peak expiration, followed by semi-sitting position. In conclusion, this technology also allows to monitor uncompliant patients, as it grants high reliability and reproducibility in different body position and respiratory phases.
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Affiliation(s)
- Aldo Rocca
- Department of Medicine and Health Sciences "Vincenzo Tiberio", University of Molise, 86100, Campobasso, Italy
| | - Klara Komici
- Department of Medicine and Health Sciences "Vincenzo Tiberio", University of Molise, 86100, Campobasso, Italy
| | - Maria Chiara Brunese
- Department of Medicine and Health Sciences "Vincenzo Tiberio", University of Molise, 86100, Campobasso, Italy.
| | - Giulia Pacella
- Department of Medicine and Health Sciences "Vincenzo Tiberio", University of Molise, 86100, Campobasso, Italy
| | - Pasquale Avella
- Department of General Surgery, Center for Hepatobiliary and Pancreatic Surgery, Pineta Grande Hospital, Castel Volturno, CE, Italy
| | - Chiara Di Benedetto
- Department of Medicine and Health Sciences "Vincenzo Tiberio", University of Molise, 86100, Campobasso, Italy
| | - Corrado Caiazzo
- Department of Medicine and Health Sciences "Vincenzo Tiberio", University of Molise, 86100, Campobasso, Italy
| | - Marcello Zappia
- Department of Medicine and Health Sciences "Vincenzo Tiberio", University of Molise, 86100, Campobasso, Italy
| | - Luca Brunese
- Department of Medicine and Health Sciences "Vincenzo Tiberio", University of Molise, 86100, Campobasso, Italy
| | - Gianfranco Vallone
- Department of Medicine and Health Sciences "Vincenzo Tiberio", University of Molise, 86100, Campobasso, Italy
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Braun A, Mühlberg R, Fischer M, Haas NA, Meyer Z. Liver stiffness in Fontan patients: the effect of respiration and food intake. Front Med (Lausanne) 2023; 10:1192017. [PMID: 37746087 PMCID: PMC10512863 DOI: 10.3389/fmed.2023.1192017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Accepted: 08/25/2023] [Indexed: 09/26/2023] Open
Abstract
Objectives For several years, patients with single ventricle hearts have been palliated according to the Fontan principle. One well known long-term consequence in these patients is the Fontan-associated liver disease and fibrosis, which occurs due to the chronically increased Central Venous Pressure (CVP) after Fontan palliation. It carries an increased risk of liver cirrhosis and hepatocellular carcinoma over time. Liver elastography (LE) is a non-invasive, safe, and feasible ultrasound method to determine liver stiffness and the stage of liver fibrosis. Usually, this examination must be performed in a sober condition and strict inspiratory hold to optimize the results and may therefore be difficult to perform on children as a routine examination. However, the influence of food intake and respiration on these results in Fontan patients is unclear. To optimize the implementation for this examination especially in children, the effects of food intake and breathing maneuvers on liver stiffness in patients with Fontan circulation were investigated. Methods For this prospective study, 25 Fontan patients (group 1) and 50 healthy volunteers (group 2) were examined. The two groups were additionally divided into two age categories (group 1a: 10-19 years; group 1b: 20-29 years; group 2a: 15-19 years; group 2b: 20-25 years). Liver stiffness was measured by liver elastography once before food intake (=T0, with 6 h of fasting). Subsequently the participants consumed a standardized chocolate drink (500 mL) with nutritional distribution corresponding to a standardized meal (600 kcal). Liver stiffness was then determined 15, 30, 45, 60, 90, 120, 150, and 180 min after ingestion. Each measurement of liver stiffness was performed during maximal inspiratory and expiratory holds. The study was reviewed and approved by the responsible ethics committee. Results In group 2 there was a significant increase in liver stiffness after food intake at T15, T30, and T45 during inspiration measurements (T0 = 4.0 kPa vs. T15 = 4.9 kPa, difference = 22.5%; T0 = 4.0 kPa vs. T30 = 4.9 kPa difference = 22.5%; T0 = 4.0 kPa vs. T45 = 4.3 kPa difference = 7.5%), as well as during expiration at T15 and T30 (T0 = 4.5 kPa vs. T15 = 5.1 kPa, difference = 14.7%; T0 = 4.5 kPa vs. T30 = 4.9 kPa difference = 7.8%). Whereas in Fontan patients (group 1) liver stiffness did not differ significantly at any time between fasting (T0) and postprandial values. The respiratory maneuvers in the healthy subjects (group 2) differed significantly only before food intake (T0) (group 2: insp = 3.97 kPa vs. exp. = 4.48 kPa difference = 11.3%). In the Fontan group (group 1), there was no significant difference between the respiratory phases at any point. The different age categories showed no significant difference in liver stiffness. Conclusion With these results we could demonstrate for the first time that in Fontan patients the time of food intake (i.e., fasting) has no clinical significance for the values obtained in liver elastography. We could also demonstrate that the breathing maneuvers during the examination had only minimal clinical impact on the results of liver elastography in patients with normal circulation and no effect in patients with Fontan-circulation. Consequently, liver elastography for Fontan patients is reliable independently of food intake and breathing maneuvers and can also be performed on younger patients, who are unable to follow breathing commands or longer fasting periods, without any impairment of the results. These results should encourage a routine use of LE in the follow-up of Fontan patients.
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Şendur HN, Cerit MN, Fatullayeva T, Erdal ZS, Karabörk Kılıç AC, Özhan Oktar S. Do Ultrasound Based Quantitative Hepatic Fat Content Measurements Have Differences Between Respiratory Phases? Acad Radiol 2023; 30:1832-1837. [PMID: 36628802 DOI: 10.1016/j.acra.2022.12.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Revised: 12/10/2022] [Accepted: 12/13/2022] [Indexed: 01/11/2023]
Abstract
RATIONALE AND OBJECTIVES The recently developed ultrasound based tools using attenuation coefficient (AC) and scatter distribution coefficient (SDC) values can be used to quantify hepatic fat content in patients with non-alcoholic fatty liver disease (NAFLD). However, currently the impact of respiratory phase on these measurements is not known. The purpose of this study is to compare AC and SDC measurements acquired at peak inspiration and end expiration phases. MATERIALS AND METHODS AC and SDC measurements were obtained in 50 patients with NAFLD. Tissue Attenuation Imaging (TAI) and Tissue Scatter Distribution Imaging (TSI) tools were utilized to measure AC and SDC values, respectively. Five measurements were performed at respiratory phases using TAI and TSI tools and the median values were noted. Subgroup analyses were performed and Wilcoxon signed rank test was used for comparison of the measurements. RESULTS The median values of the AC measurements at peak inspiration and end expiration phases were 0.87 dB/cm/MHz and 0.89 dB/cm/MHz, respectively. The median values of the SDC measurements at peak inspiration and end expiration phases were 97.91 and 96.62, respectively. There were no statistically significant differences in AC and SDC measurements between the respiratory phases except for AC measurements in BMI <30 kg/m2 subgroup. CONCLUSION Our results revealed that respiratory phases have no impact on SDC measurements. However, while the AC measurements in BMI ≥30 kg/m2 subgroup showed no significant difference, there was a significant difference in AC measurements in BMI <30 kg/m2 subgroup between the respiratory phases.
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Affiliation(s)
- Halit Nahit Şendur
- Department of Radiology, Gazi University Faculty of Medicine, Yenimahalle, Ankara, Turkey.
| | - Mahi N Cerit
- Department of Radiology, Gazi University Faculty of Medicine, Yenimahalle, Ankara, Turkey
| | - Turkana Fatullayeva
- Department of Radiology, Gazi University Faculty of Medicine, Yenimahalle, Ankara, Turkey
| | - Zeynep S Erdal
- Department of Radiology, Gazi University Faculty of Medicine, Yenimahalle, Ankara, Turkey
| | | | - Suna Özhan Oktar
- Department of Radiology, Gazi University Faculty of Medicine, Yenimahalle, Ankara, Turkey
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Impact of Breathing Phase, Liver Segment, and Prandial State on Ultrasound Shear Wave Speed, Shear Wave Dispersion, and Attenuation Imaging of the Liver in Healthy Volunteers. Diagnostics (Basel) 2023; 13:diagnostics13050989. [PMID: 36900133 PMCID: PMC10001107 DOI: 10.3390/diagnostics13050989] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2023] [Revised: 02/20/2023] [Accepted: 02/28/2023] [Indexed: 03/08/2023] Open
Abstract
OBJECTIVES Measurement location and patient state can impact noninvasive liver assessment and change clinical staging in ultrasound examinations. Research into differences exists for Shear Wave Speed (SWS) and Attenuation Imaging (ATI), but not for Shear Wave Dispersion (SWD). The aim of this study is to assess the effect of breathing phase, liver lobe, and prandial state on SWS, SWD, and ATI ultrasound measurements. METHODS Two experienced examiners performed SWS, SWD, and ATI measurements in 20 healthy volunteers using a Canon Aplio i800 system. Measurements were taken in the recommended condition (right lobe, following expiration, fasting state), as well as (a) following inspiration, (b) in the left lobe, and (c) in a nonfasting state. RESULTS SWS and SWD measurements were strongly correlated (r = 0.805, p < 0.001). Mean SWS was 1.34 ± 0.13 m/s in the recommended measurement position and did not change significantly under any condition. Mean SWD was 10.81 ± 2.05 m/s/kHz in the standard condition and significantly increased to 12.18 ± 1.41 m/s/kHz in the left lobe. Individual SWD measurements in the left lobe also had the highest average coefficient of variation (19.68%). No significant differences were found for ATI. CONCLUSION Breathing and prandial state did not significantly affect SWS, SWD, and ATI values. SWS and SWD measurements were strongly correlated. SWD measurements in the left lobe showed a higher individual measurement variability. Interobserver agreement was moderate to good.
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Cha J, Kim J, Ko J, Kim J, Eom K. Effects of Confounding Factors on Liver Stiffness in Two-Dimensional Shear Wave Elastography in Beagle Dogs. Front Vet Sci 2022; 9:827599. [PMID: 35155659 PMCID: PMC8830801 DOI: 10.3389/fvets.2022.827599] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Accepted: 01/06/2022] [Indexed: 12/12/2022] Open
Abstract
Background Two-dimensional shear wave elastography (2D-SWE) is a powerful technique that can non-invasively measure liver stiffness to assess hepatic fibrosis. Purpose This study aimed to identify the effects of confounding factors, including anesthesia, breathing, and scanning approach, on liver stiffness when performing 2D-SWE in dogs. Materials and Methods Nine healthy Beagle dogs were included in this study. Hepatic 2D-SWE was performed, and liver stiffness was compared between conscious and anesthetized states, free-breathing and breath-holding conditions, and intercostal and subcostal approaches. For the anesthetized state, the breath-holding condition was subdivided into seven phases, which included forced-expiration (5 and 10 mL/kg), end-expiration (0 cm H2O), and forced-inspiration (5, 10, 15, and 20 cm H2O), and liver stiffness was compared among these phases. Changes in liver stiffness were compared between intercostal and subcostal approaches according to breathing phases. Results No significant difference was observed in liver stiffness between the conscious and anesthetized states or between the free-breathing and breath-holding conditions. No significant difference was noted in liver stiffness among the breathing phases, except for forced-inspiration with high airway pressure (15 and 20 cm H2O in the intercostal approach and 10, 15, and 20 cm H2O in the subcostal approach), which was associated with significantly higher liver stiffness (p < 0.05). Liver stiffness was significantly higher in the subcostal approach than in the intercostal approach (p < 0.05). Changes in liver stiffness were significantly higher in the subcostal approach than in the intercostal approach in all forced-inspiratory phases (p < 0.05). Conclusion In conclusion, when performing 2D-SWE in dogs, liver stiffness is unaffected by anesthesia and free-breathing. To avoid inadvertent increases in liver stiffness, the deep inspiratory phase and subcostal approach are not recommended. Thus, liver stiffness should be interpreted considering these confounding factors.
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Spleen Stiffness Probability Index (SSPI): A simple and accurate method to detect esophageal varices in patients with compensated liver cirrhosis. Ann Hepatol 2021; 19:53-61. [PMID: 31740162 DOI: 10.1016/j.aohep.2019.09.004] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Revised: 09/11/2019] [Accepted: 09/12/2019] [Indexed: 02/04/2023]
Abstract
INTRODUCTION AND OBJECTIVES Recent findings pointed out that even low-risk esophageal varices (EVs) are markers of severe prognosis. Accordingly, we analyzed spleen stiffness (SS) as a non-invasive method to predict EVs of any grade in a cohort of patients with compensated liver cirrhosis. METHOD We measured SS and liver stiffness (LS) using point-Shear-Wave Elastography (pSWE) with Philips Affiniti 70 system in 210 cirrhotic patients who had undergone endoscopic screening for EVs. We compared SS and LS predictive capability for EVs of any grade. RESULTS SS was higher in cirrhotic patients with EVs if compared to patients without EVs (p<0.001). The cut-off analysis detected 31kPa (100% sensitivity and negative predictive value) as the value to rule-out EVs and 69kPa (100% specificity and positive predictive value) to rule-in EVs. Besides, we developed the Spleen Stiffness Probability Index (SSPI), that can provide a probability of presence/absence of EVs. SSPI was the best model according to all discriminative and calibration metrics (AIC=120, BIC=127, AUROC=0.95, Pseudo-R2=0.74). SS demonstrated higher correlation with spleen bipolar diameter and spleen surface (r=0.52/0.55) if compared to LS (r=0.30/0.25) - and with platelet count as well (r=0.67 vs r=0.4). CONCLUSION SS showed significantly higher performance than other parameters, proving to be the best non-invasive test in the screening of EVs: by directly applying SS cut-off of 31kPa, our department could have safely avoided endoscopy in 36% of patients. Despite cut-off analyses, it was possible to create a probability model that could further stratify low-risk from high-risk patients (for any grade of EVs).
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Taraldsen V, Tomasgard S, Rudlang M, Gilja O, Vesterhus M, Mjelle A. Point Shear Wave Elastography and the Effect of Physical Exercise, Alcohol Consumption, and Respiration in Healthy Adults. Ultrasound Int Open 2020; 6:E54-E61. [PMID: 33305164 PMCID: PMC7723471 DOI: 10.1055/a-1298-9642] [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: 04/28/2020] [Accepted: 10/26/2020] [Indexed: 11/16/2022] Open
Abstract
Purpose
Ultrasound elastography is a noninvasive method for liver stiffness measurement (LSM) with the aim of reflecting approximate liver fibrosis load. Despite minimal evidence, current guidelines recommend 10 min of rest and breath hold prior to measurements and offer no advice concerning recent alcohol consumption, leading to challenges in clinical practice. We aimed to investigate how LSM in healthy adults is influenced by physical exercise, recent alcohol consumption, and respiration.
Materials and Methods
42 healthy subjects aged 21–36 years were included. LSM using point shear wave elastography (pSWE) was performed in five stages: baseline, after physical activity, after registration of alcohol consumption, and during breath hold compared to free breathing.
Results
LSM values were significantly increased following physical exercise compared to baseline values (4.1±0.8 vs. 3.8±0.8 kPa, p=0.01). Alcohol consumption during the last 72 h (0–27 alcohol units) did not significantly affect LSM. There was no significant difference between LSM during breath hold and free breathing.
Conclusion
In healthy subjects, LSM increased after recent physical exercise, while alcohol consumption 24–72 h prior to examination did not have a significant impact. There was no clinically significant effect of breath hold on LSM. Our study supports present guidelines recommending rest prior to LSM, while indicating that breath hold may not be mandatory. Recent moderate alcohol exposure may affect LSM to a lesser extent than commonly believed.
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Affiliation(s)
- Victoria Taraldsen
- Department of Clinical Science, University of Bergen Faculty of Medicine and Dentistry, Bergen, Norway
| | - Sunneva Tomasgard
- Department of Clinical Science, University of Bergen Faculty of Medicine and Dentistry, Bergen, Norway
| | - MargretheThune Rudlang
- Department of Clinical Science, University of Bergen Faculty of Medicine and Dentistry, Bergen, Norway
| | - OddHelge Gilja
- Department of Clinical Science, University of Bergen Faculty of Medicine and Dentistry, Bergen, Norway.,Haukeland University Hospital, National Centre for Ultrasound in Gastroenterology, Bergen, Norway
| | - Mette Vesterhus
- Department of Clinical Science, University of Bergen Faculty of Medicine and Dentistry, Bergen, Norway.,Department of Medicine, Haraldsplass Deaconess Hospital Bergen, Norway.,Norwegian PSC Research Center (NoPSC), Division of Surgery, Inflammatory medicine and transplantation, Oslo Universitetssykehus Rikshospitalet, Oslo, Norway
| | - AndersBatman Mjelle
- Department of Clinical Science, University of Bergen Faculty of Medicine and Dentistry, Bergen, Norway.,Department of Clinical Medicine, Haukeland University Hospital, National Centre for Ultrasound in Gastroenterology, Bergen, Norway
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Giuffrè M, Macor D, Masutti F, Abazia C, Tinè F, Patti R, Buonocore MR, Colombo A, Visintin A, Campigotto M, Crocè LS. Evaluation of spleen stiffness in healthy volunteers using point shear wave elastography. Ann Hepatol 2020; 18:736-741. [PMID: 31054978 DOI: 10.1016/j.aohep.2019.03.004] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2018] [Revised: 03/07/2019] [Accepted: 03/07/2019] [Indexed: 02/08/2023]
Abstract
INTRODUCTION AND OBJECTIVES This study aims to measure the values of spleen stiffness (SS) in healthy subjects, the inter-operator agreement in SS measurement, and to detect statistically significant correlations between SS and age, sex, weight, BMI, portal vein dynamics and splenic dimensions. MATERIALS AND METHODS The study included 100 healthy volunteers who had no substantial alcohol intake (<30g/daily for man, <20g/daily women), were negative on hepatitis B, hepatitis C, HIV blood serology, and had any history of lymphoproliferative disorders. Abdominal ultrasound, liver and spleen elastography were performed on each patient to search for focal splenic lesions, bile tract or portal vein dilatation, moderate/severe liver steatosis, and to measure liver and spleen stiffness. RESULTS The mean value was 18.14 (±3.08) kPa. In the group of men (n=49), the mean was 17.73 (±2.91) kPa, whereas in the group of women (n=51) it was 16.72 (±3.32) kPa. Statistical analyses showed no correlation between spleen stiffness and sex, age, weight, and BMI. Regarding their splenoportal axis, statistically significant differences in SS were found in the means of the two subgroups of subjects stratified by their portal flow velocity (p=0.003) and spleen area (p<0.001). Spearman's rank showed a weak association between SS and portal flow velocty (r=0.271) and splenic area (r=-0.237). ICC showed excellent (0.96) inter-operator agreement and Bland-Altman plot demonstrated no systematic over/under-estimation of spleen stiffness values. CONCLUSIONS Our results may serve as a reference point in the evaluation of SS especially in patients affected by advanced liver disease.
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Affiliation(s)
- Mauro Giuffrè
- Dipartimento Universitario Clinico Di Scienze Mediche Chirurgiche e Della Salute, Università Degli Studi Di Trieste, Italy.
| | - Daniele Macor
- Dipartimento Universitario Clinico Di Scienze Mediche Chirurgiche e Della Salute, Università Degli Studi Di Trieste, Italy
| | - Flora Masutti
- Clinica Patologie Fegato, Azienda Sanitaria Universitaria Integrata Di Trieste, Italy
| | - Cristiana Abazia
- Clinica Patologie Fegato, Azienda Sanitaria Universitaria Integrata Di Trieste, Italy
| | - Fabio Tinè
- Clinica Patologie Fegato, Azienda Sanitaria Universitaria Integrata Di Trieste, Italy
| | - Riccardo Patti
- Clinica Patologie Fegato, Azienda Sanitaria Universitaria Integrata Di Trieste, Italy
| | - Matteo Rossano Buonocore
- Dipartimento Universitario Clinico Di Scienze Mediche Chirurgiche e Della Salute, Università Degli Studi Di Trieste, Italy
| | - Anna Colombo
- Dipartimento Universitario Clinico Di Scienze Mediche Chirurgiche e Della Salute, Università Degli Studi Di Trieste, Italy
| | - Alessia Visintin
- Dipartimento Universitario Clinico Di Scienze Mediche Chirurgiche e Della Salute, Università Degli Studi Di Trieste, Italy
| | - Michele Campigotto
- Dipartimento Universitario Clinico Di Scienze Mediche Chirurgiche e Della Salute, Università Degli Studi Di Trieste, Italy
| | - Lory Saveria Crocè
- Dipartimento Universitario Clinico Di Scienze Mediche Chirurgiche e Della Salute, Università Degli Studi Di Trieste, Italy; Clinica Patologie Fegato, Azienda Sanitaria Universitaria Integrata Di Trieste, Italy; Fondazione Italiana Fegato, Italy
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Villani R, Cavallone F, Romano AD, Bellanti F, Serviddio G. Two-Dimensional Shear Wave Elastography versus Transient Elastography: A Non-Invasive Comparison for the Assessment of Liver Fibrosis in Patients with Chronic Hepatitis C. Diagnostics (Basel) 2020; 10:diagnostics10050313. [PMID: 32429410 PMCID: PMC7277963 DOI: 10.3390/diagnostics10050313] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Revised: 05/12/2020] [Accepted: 05/13/2020] [Indexed: 02/05/2023] Open
Abstract
In recent years, several non-invasive methods have been developed for staging liver fibrosis in patients with chronic hepatitis C. A 2D-Shear wave elastography (SWE) technique has been recently introduced on the EPIQ 7 US system (ElastQ), but its accuracy has not been validated in patients with chronic hepatitis C virus (HCV) infection. We enrolled 178 HCV patients to assess their liver fibrosis stage with ElastQ software using transient elastography as a reference standard. The best cut-off values to diagnose ³ F2, ³ F3, and F4 were 8.15, 10.31, and 12.65 KPa, respectively. Liver stiffness values had a positive correlation with transient elastography (r = 0.57; p < 0.001). The area under the receiver operating characteristics (AUROC) was 0.899 for ³ F2 (moderate fibrosis), 0.900 for ³ F3 (severe fibrosis), and 0.899 for cirrhosis. 2D-SWE has excellent accuracy in assessing liver fibrosis in patients with chronic hepatitis C and an excellent correlation with transient elastography.
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Hou Z, Okamoto RJ, Bayly PV. Shear Wave Propagation and Estimation of Material Parameters in a Nonlinear, Fibrous Material. J Biomech Eng 2020; 142:958441. [PMID: 31513702 DOI: 10.1115/1.4044504] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Indexed: 11/08/2022]
Abstract
This paper describes the propagation of shear waves in a Holzapfel-Gasser-Ogden (HGO) material and investigates the potential of magnetic resonance elastography (MRE) for estimating parameters of the HGO material model from experimental data. In most MRE studies the behavior of the material is assumed to be governed by linear, isotropic elasticity or viscoelasticity. In contrast, biological tissue is often nonlinear and anisotropic with a fibrous structure. In such materials, application of a quasi-static deformation (predeformation) plays an important role in shear wave propagation. Closed form expressions for shear wave speeds in an HGO material with a single family of fibers were found in a reference (undeformed) configuration and after imposed predeformations. These analytical expressions show that shear wave speeds are affected by the parameters (μ0, k1, k2, κ) of the HGO model and by the direction and amplitude of the predeformations. Simulations of corresponding finite element (FE) models confirm the predicted influence of HGO model parameters on speeds of shear waves with specific polarization and propagation directions. Importantly, the dependence of wave speeds on the parameters of the HGO model and imposed deformations could ultimately allow the noninvasive estimation of material parameters in vivo from experimental shear wave image data.
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Affiliation(s)
- Zuoxian Hou
- Department of Mechanical Engineering and Materials Science, Washington University, St. Louis, MO, 63130
| | - Ruth J Okamoto
- Department of Mechanical Engineering and Materials Science, Washington University, St. Louis, MO, 63130
| | - Philip V Bayly
- Department of Mechanical Engineering and Materials Science, Washington University, St. Louis, MO, 63130
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Sugimoto K, Moriyasu F, Oshiro H, Takeuchi H, Yoshimasu Y, Kasai Y, Itoi T. Clinical utilization of shear wave dispersion imaging in diffuse liver disease. Ultrasonography 2019; 39:3-10. [PMID: 31645092 PMCID: PMC6920618 DOI: 10.14366/usg.19031] [Citation(s) in RCA: 60] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Accepted: 07/26/2019] [Indexed: 12/31/2022] Open
Abstract
Shear wave (SW) dispersion imaging is a newly developed imaging technology for assessing the dispersion slope of SWs, which is related to tissue viscosity in diffuse liver disease. Our preclinical and preliminary clinical studies have shown that SW speed is more useful than dispersion slope for predicting the degree of fibrosis and that dispersion slope is more useful than SW speed for predicting the degree of necroinflammation. Thus, dispersion slope, which reflects viscosity, may provide additional pathophysiological insight into diffuse liver disease.
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Affiliation(s)
- Katsutoshi Sugimoto
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Fuminori Moriyasu
- Department of Gastroenterology and Hepatology, International University of Health and Welfare, Sanno Hospital, Tokyo, Japan
| | - Hisashi Oshiro
- Department of Pathology, Jichi Medical University, Shimotsuke, Japan
| | - Hirohito Takeuchi
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Yu Yoshimasu
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Yoshitaka Kasai
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Takao Itoi
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
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Dhyani M, Xiang F, Li Q, Chen L, Li C, Bhan AK, Anthony B, Grajo JR, Samir AE. Ultrasound Shear Wave Elastography: Variations of Liver Fibrosis Assessment as a Function of Depth, Force and Distance from Central Axis of the Transducer with a Comparison of Different Systems. ULTRASOUND IN MEDICINE & BIOLOGY 2018; 44:2209-2222. [PMID: 30143339 PMCID: PMC6594152 DOI: 10.1016/j.ultrasmedbio.2018.07.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/15/2017] [Revised: 06/25/2018] [Accepted: 07/05/2018] [Indexed: 05/10/2023]
Abstract
We evaluated variation in fibrosis staging caused by depth, pre-load force and measurement off-axis distance on different ultrasound shear wave elastography (SWE) systems prospectively in 20 patients with diffuse liver disease. Shear wave speed (SWS) was measured with transient elastography, acoustic radiation force impulse (ARFI) and 2-D shear wave elastography (SWE). ARFI and 2-D-SWE measurements were obtained at different depths (3, 5 and 7 cm), with different pre-load forces (4, 7 and 10N and variable) and at 0, 2 and 4cm off the central axis of the transducer. A single, blinded pathologist staged fibrosis using the METAVIR system (F0-F4). Area under the receiver operating characteristic curve was charted to differentiate significant fibrosis (F ≥ 2). Depth was the only factor found to influence ARFI-derived values; no acquisition factors were found to affect 2-D-SWE SWS values. ARFI and 2-D-SWE for diagnosis of significant fibrosis at a depth of 7cm along the central axis had good diagnostic performance (areas under the receiver operating characteristic curve: 0.92 and 0.82, respectively), comparable to that of transient elastography. Further investigation of this finding will likely be of interest.
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Affiliation(s)
- Manish Dhyani
- Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Feixiang Xiang
- Department of Ultrasound, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China; Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China.
| | - Qian Li
- Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Luzeng Chen
- Peking University First Hospital Ultrasound Center, Beijing, China
| | - Changtian Li
- Department of Ultrasound, The Southern Building, Chinese PLA General Hospital, Beijing, China
| | - Atul K Bhan
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Brian Anthony
- Department of Mechanical Engineering, Massachusetts Institute of Technology, Cambridge, Massachusetts, USA
| | - Joseph R Grajo
- Department of Radiology, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Anthony E Samir
- Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts, USA
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Kennedy P, Wagner M, Castéra L, Hong CW, Johnson CL, Sirlin CB, Taouli B. Quantitative Elastography Methods in Liver Disease: Current Evidence and Future Directions. Radiology 2018; 286:738-763. [PMID: 29461949 DOI: 10.1148/radiol.2018170601] [Citation(s) in RCA: 185] [Impact Index Per Article: 30.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Chronic liver diseases often result in the development of liver fibrosis and ultimately, cirrhosis. Treatment strategies and prognosis differ greatly depending on the severity of liver fibrosis, thus liver fibrosis staging is clinically relevant. Traditionally, liver biopsy has been the method of choice for fibrosis evaluation. Because of liver biopsy limitations, noninvasive methods have become a key research interest in the field. Elastography enables the noninvasive measurement of tissue mechanical properties through observation of shear-wave propagation in the tissue of interest. Increasing fibrosis stage is associated with increased liver stiffness, providing a discriminatory feature that can be exploited by elastographic methods. Ultrasonographic (US) and magnetic resonance (MR) imaging elastographic methods are commercially available, each with their respective strengths and limitations. Here, the authors review the technical basis, acquisition techniques, and results and limitations of US- and MR-based elastography techniques. Diagnostic performance in the most common etiologies of chronic liver disease will be presented. Reliability, reproducibility, failure rate, and emerging advances will be discussed. © RSNA, 2018 Online supplemental material is available for this article.
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Affiliation(s)
- Paul Kennedy
- From the Translational and Molecular Imaging Institute (P.K., B.T.) and Department of Radiology (B.T.), Icahn School of Medicine at Mount Sinai, 1470 Madison Ave, New York, NY 10029; Department of Radiology, Sorbonne Universités, UPMC, Hôpital Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Paris, France (M.W.); Department of Hepatology, University Paris-VII, Hôpital Beaujon, Clichy, France (L.C.); Liver Imaging Group, Department of Radiology, University of California-San Diego, San Diego, Calif (C.W.H., C.B.S.); Department of Biomedical Engineering, University of Delaware, Newark, Del (C.L.J.)
| | - Mathilde Wagner
- From the Translational and Molecular Imaging Institute (P.K., B.T.) and Department of Radiology (B.T.), Icahn School of Medicine at Mount Sinai, 1470 Madison Ave, New York, NY 10029; Department of Radiology, Sorbonne Universités, UPMC, Hôpital Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Paris, France (M.W.); Department of Hepatology, University Paris-VII, Hôpital Beaujon, Clichy, France (L.C.); Liver Imaging Group, Department of Radiology, University of California-San Diego, San Diego, Calif (C.W.H., C.B.S.); Department of Biomedical Engineering, University of Delaware, Newark, Del (C.L.J.)
| | - Laurent Castéra
- From the Translational and Molecular Imaging Institute (P.K., B.T.) and Department of Radiology (B.T.), Icahn School of Medicine at Mount Sinai, 1470 Madison Ave, New York, NY 10029; Department of Radiology, Sorbonne Universités, UPMC, Hôpital Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Paris, France (M.W.); Department of Hepatology, University Paris-VII, Hôpital Beaujon, Clichy, France (L.C.); Liver Imaging Group, Department of Radiology, University of California-San Diego, San Diego, Calif (C.W.H., C.B.S.); Department of Biomedical Engineering, University of Delaware, Newark, Del (C.L.J.)
| | - Cheng William Hong
- From the Translational and Molecular Imaging Institute (P.K., B.T.) and Department of Radiology (B.T.), Icahn School of Medicine at Mount Sinai, 1470 Madison Ave, New York, NY 10029; Department of Radiology, Sorbonne Universités, UPMC, Hôpital Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Paris, France (M.W.); Department of Hepatology, University Paris-VII, Hôpital Beaujon, Clichy, France (L.C.); Liver Imaging Group, Department of Radiology, University of California-San Diego, San Diego, Calif (C.W.H., C.B.S.); Department of Biomedical Engineering, University of Delaware, Newark, Del (C.L.J.)
| | - Curtis L Johnson
- From the Translational and Molecular Imaging Institute (P.K., B.T.) and Department of Radiology (B.T.), Icahn School of Medicine at Mount Sinai, 1470 Madison Ave, New York, NY 10029; Department of Radiology, Sorbonne Universités, UPMC, Hôpital Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Paris, France (M.W.); Department of Hepatology, University Paris-VII, Hôpital Beaujon, Clichy, France (L.C.); Liver Imaging Group, Department of Radiology, University of California-San Diego, San Diego, Calif (C.W.H., C.B.S.); Department of Biomedical Engineering, University of Delaware, Newark, Del (C.L.J.)
| | - Claude B Sirlin
- From the Translational and Molecular Imaging Institute (P.K., B.T.) and Department of Radiology (B.T.), Icahn School of Medicine at Mount Sinai, 1470 Madison Ave, New York, NY 10029; Department of Radiology, Sorbonne Universités, UPMC, Hôpital Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Paris, France (M.W.); Department of Hepatology, University Paris-VII, Hôpital Beaujon, Clichy, France (L.C.); Liver Imaging Group, Department of Radiology, University of California-San Diego, San Diego, Calif (C.W.H., C.B.S.); Department of Biomedical Engineering, University of Delaware, Newark, Del (C.L.J.)
| | - Bachir Taouli
- From the Translational and Molecular Imaging Institute (P.K., B.T.) and Department of Radiology (B.T.), Icahn School of Medicine at Mount Sinai, 1470 Madison Ave, New York, NY 10029; Department of Radiology, Sorbonne Universités, UPMC, Hôpital Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Paris, France (M.W.); Department of Hepatology, University Paris-VII, Hôpital Beaujon, Clichy, France (L.C.); Liver Imaging Group, Department of Radiology, University of California-San Diego, San Diego, Calif (C.W.H., C.B.S.); Department of Biomedical Engineering, University of Delaware, Newark, Del (C.L.J.)
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Pellot-Barakat C, Chami L, Correas JM, Lefort M, Lucidarme O. Does motion affect liver stiffness estimates in shear wave elastography? Phantom and clinical study. Eur J Radiol 2016; 85:1645-50. [PMID: 27501901 DOI: 10.1016/j.ejrad.2016.07.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2016] [Revised: 07/07/2016] [Accepted: 07/11/2016] [Indexed: 12/16/2022]
Abstract
This study was undertaken to evaluate the impact of free-breathing (FB) vs. Apnea on Shear-wave elastography (SWE) measurements. Quantitative liver-stiffness measurements were obtained during FB and Apnea for 97 patients with various body-morphologies and liver textures. Quality indexes of FB and Apnea elasticity maps (percentage of non-filling (PNF), temporal (TV) and spatial (SV) variabilities) were computed. SWE measurements were also obtained from an homogeneous phantom at rest and during a mechanically-induced motion. Liver-stiffness values estimated from FB and Apnea acquisitions were correlated, particularly for homogeneous livers (r=0.76, P<0.001) and favorable body-morphologies (r=0.68, P<0.001). However FB values were consistently 20-25% lower than Apnea ones (P<0.001). FB also systematically resulted in degradation of TV (P<0.005) and PNF (P<0.001) compared to Apnea but had no impact on SV. With the phantom, no differences between SWE measurements at rest and during motion were observed. Apnea and FB measurements are highly correlated, although FB data quality is degraded compared to Apnea and estimated stiffness in FB is systematically lower than in Apnea. These discrepancies between rest and motion states were observed for patients but not for phantom data, suggesting that patient breath-holding impacts liver stiffness.
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Affiliation(s)
- Claire Pellot-Barakat
- Laboratoire Imagerie Moléculaire In Vivo (IMIV), UMR 1023 Inserm/CEA/Université Paris Sud - ERL 9218 CNRS, CEA/I2BM/SHFJ, Orsay, France.
| | - Linda Chami
- Radiology department, Hôpital Pitié-Salpétrière, APHP, Paris, France; Sorbonne Universités, UPMC Univ Paris 06, CNRS, INSERM, Laboratoire d'Imagerie Biomédicale (LIB), 75006 (ou 75013), Paris, France.
| | | | - Muriel Lefort
- Sorbonne Universités, UPMC Univ Paris 06, CNRS, INSERM, Laboratoire d'Imagerie Biomédicale (LIB), 75006 (ou 75013), Paris, France.
| | - Olivier Lucidarme
- Radiology department, Hôpital Pitié-Salpétrière, APHP, Paris, France; Sorbonne Universités, UPMC Univ Paris 06, CNRS, INSERM, Laboratoire d'Imagerie Biomédicale (LIB), 75006 (ou 75013), Paris, France.
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Barr RG, Ferraioli G, Palmeri ML, Goodman ZD, Garcia-Tsao G, Rubin J, Garra B, Myers RP, Wilson SR, Rubens D, Levine D. Elastography Assessment of Liver Fibrosis: Society of Radiologists in Ultrasound Consensus Conference Statement. Radiology 2015; 276:845-61. [PMID: 26079489 DOI: 10.1148/radiol.2015150619] [Citation(s) in RCA: 391] [Impact Index Per Article: 43.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The Society of Radiologists in Ultrasound convened a panel of specialists from radiology, hepatology, pathology, and basic science and physics to arrive at a consensus regarding the use of elastography in the assessment of liver fibrosis in chronic liver disease. The panel met in Denver, Colo, on October 21-22, 2014, and drafted this consensus statement. The recommendations in this statement are based on analysis of current literature and common practice strategies and are thought to represent a reasonable approach to the noninvasive assessment of diffuse liver fibrosis.
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Affiliation(s)
- Richard G Barr
- From the Department of Radiology, Northeastern Ohio Medical University, Rootstown, Ohio (R.G.B.); Southwoods Imaging, 7623 Market St, Boardman, OH 44512 (R.G.B.); Ultrasound Unit, Department of Infectious Diseases, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy (G.F.); Department of Biomedical Engineering, Pratt School of Engineering, Duke University, Durham, NC (M.L.P.); Center for Liver Diseases, Inova Fairfax Hospital, Falls Church, Va (Z.D.G.); Section of Digestive Diseases, Department of Medicine, Yale University, New Haven, Conn (G.G.T.); VA Connecticut Healthcare System, West Haven, Conn (G.G.T.); Department of Radiology, University of Michigan Medical Center, Ann Arbor, Mich (J.R.); Department of Radiology, Washington DC VA Medical Center, Washington, DC (B.G.); Division of Imaging, Diagnostics and Software Reliability, Office of Science and Engineering Laboratories, Center for Devices and Radiological Health, Food and Drug Administration, Silver Spring, Md (B.G.); Departments of Hepatology (R.P.M.) and Radiology (S.R.W.), University of Calgary, Calgary, Alberta, Canada; Departments of Imaging Science, Oncology, and Biomedical Engineering, University of Rochester Medical Center, Rochester, NY (D.R.); and Department of Radiology, Beth Israel Deaconess Medical Center, Boston, Mass (D.L.)
| | - Giovanna Ferraioli
- From the Department of Radiology, Northeastern Ohio Medical University, Rootstown, Ohio (R.G.B.); Southwoods Imaging, 7623 Market St, Boardman, OH 44512 (R.G.B.); Ultrasound Unit, Department of Infectious Diseases, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy (G.F.); Department of Biomedical Engineering, Pratt School of Engineering, Duke University, Durham, NC (M.L.P.); Center for Liver Diseases, Inova Fairfax Hospital, Falls Church, Va (Z.D.G.); Section of Digestive Diseases, Department of Medicine, Yale University, New Haven, Conn (G.G.T.); VA Connecticut Healthcare System, West Haven, Conn (G.G.T.); Department of Radiology, University of Michigan Medical Center, Ann Arbor, Mich (J.R.); Department of Radiology, Washington DC VA Medical Center, Washington, DC (B.G.); Division of Imaging, Diagnostics and Software Reliability, Office of Science and Engineering Laboratories, Center for Devices and Radiological Health, Food and Drug Administration, Silver Spring, Md (B.G.); Departments of Hepatology (R.P.M.) and Radiology (S.R.W.), University of Calgary, Calgary, Alberta, Canada; Departments of Imaging Science, Oncology, and Biomedical Engineering, University of Rochester Medical Center, Rochester, NY (D.R.); and Department of Radiology, Beth Israel Deaconess Medical Center, Boston, Mass (D.L.)
| | - Mark L Palmeri
- From the Department of Radiology, Northeastern Ohio Medical University, Rootstown, Ohio (R.G.B.); Southwoods Imaging, 7623 Market St, Boardman, OH 44512 (R.G.B.); Ultrasound Unit, Department of Infectious Diseases, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy (G.F.); Department of Biomedical Engineering, Pratt School of Engineering, Duke University, Durham, NC (M.L.P.); Center for Liver Diseases, Inova Fairfax Hospital, Falls Church, Va (Z.D.G.); Section of Digestive Diseases, Department of Medicine, Yale University, New Haven, Conn (G.G.T.); VA Connecticut Healthcare System, West Haven, Conn (G.G.T.); Department of Radiology, University of Michigan Medical Center, Ann Arbor, Mich (J.R.); Department of Radiology, Washington DC VA Medical Center, Washington, DC (B.G.); Division of Imaging, Diagnostics and Software Reliability, Office of Science and Engineering Laboratories, Center for Devices and Radiological Health, Food and Drug Administration, Silver Spring, Md (B.G.); Departments of Hepatology (R.P.M.) and Radiology (S.R.W.), University of Calgary, Calgary, Alberta, Canada; Departments of Imaging Science, Oncology, and Biomedical Engineering, University of Rochester Medical Center, Rochester, NY (D.R.); and Department of Radiology, Beth Israel Deaconess Medical Center, Boston, Mass (D.L.)
| | - Zachary D Goodman
- From the Department of Radiology, Northeastern Ohio Medical University, Rootstown, Ohio (R.G.B.); Southwoods Imaging, 7623 Market St, Boardman, OH 44512 (R.G.B.); Ultrasound Unit, Department of Infectious Diseases, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy (G.F.); Department of Biomedical Engineering, Pratt School of Engineering, Duke University, Durham, NC (M.L.P.); Center for Liver Diseases, Inova Fairfax Hospital, Falls Church, Va (Z.D.G.); Section of Digestive Diseases, Department of Medicine, Yale University, New Haven, Conn (G.G.T.); VA Connecticut Healthcare System, West Haven, Conn (G.G.T.); Department of Radiology, University of Michigan Medical Center, Ann Arbor, Mich (J.R.); Department of Radiology, Washington DC VA Medical Center, Washington, DC (B.G.); Division of Imaging, Diagnostics and Software Reliability, Office of Science and Engineering Laboratories, Center for Devices and Radiological Health, Food and Drug Administration, Silver Spring, Md (B.G.); Departments of Hepatology (R.P.M.) and Radiology (S.R.W.), University of Calgary, Calgary, Alberta, Canada; Departments of Imaging Science, Oncology, and Biomedical Engineering, University of Rochester Medical Center, Rochester, NY (D.R.); and Department of Radiology, Beth Israel Deaconess Medical Center, Boston, Mass (D.L.)
| | - Guadalupe Garcia-Tsao
- From the Department of Radiology, Northeastern Ohio Medical University, Rootstown, Ohio (R.G.B.); Southwoods Imaging, 7623 Market St, Boardman, OH 44512 (R.G.B.); Ultrasound Unit, Department of Infectious Diseases, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy (G.F.); Department of Biomedical Engineering, Pratt School of Engineering, Duke University, Durham, NC (M.L.P.); Center for Liver Diseases, Inova Fairfax Hospital, Falls Church, Va (Z.D.G.); Section of Digestive Diseases, Department of Medicine, Yale University, New Haven, Conn (G.G.T.); VA Connecticut Healthcare System, West Haven, Conn (G.G.T.); Department of Radiology, University of Michigan Medical Center, Ann Arbor, Mich (J.R.); Department of Radiology, Washington DC VA Medical Center, Washington, DC (B.G.); Division of Imaging, Diagnostics and Software Reliability, Office of Science and Engineering Laboratories, Center for Devices and Radiological Health, Food and Drug Administration, Silver Spring, Md (B.G.); Departments of Hepatology (R.P.M.) and Radiology (S.R.W.), University of Calgary, Calgary, Alberta, Canada; Departments of Imaging Science, Oncology, and Biomedical Engineering, University of Rochester Medical Center, Rochester, NY (D.R.); and Department of Radiology, Beth Israel Deaconess Medical Center, Boston, Mass (D.L.)
| | - Jonathan Rubin
- From the Department of Radiology, Northeastern Ohio Medical University, Rootstown, Ohio (R.G.B.); Southwoods Imaging, 7623 Market St, Boardman, OH 44512 (R.G.B.); Ultrasound Unit, Department of Infectious Diseases, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy (G.F.); Department of Biomedical Engineering, Pratt School of Engineering, Duke University, Durham, NC (M.L.P.); Center for Liver Diseases, Inova Fairfax Hospital, Falls Church, Va (Z.D.G.); Section of Digestive Diseases, Department of Medicine, Yale University, New Haven, Conn (G.G.T.); VA Connecticut Healthcare System, West Haven, Conn (G.G.T.); Department of Radiology, University of Michigan Medical Center, Ann Arbor, Mich (J.R.); Department of Radiology, Washington DC VA Medical Center, Washington, DC (B.G.); Division of Imaging, Diagnostics and Software Reliability, Office of Science and Engineering Laboratories, Center for Devices and Radiological Health, Food and Drug Administration, Silver Spring, Md (B.G.); Departments of Hepatology (R.P.M.) and Radiology (S.R.W.), University of Calgary, Calgary, Alberta, Canada; Departments of Imaging Science, Oncology, and Biomedical Engineering, University of Rochester Medical Center, Rochester, NY (D.R.); and Department of Radiology, Beth Israel Deaconess Medical Center, Boston, Mass (D.L.)
| | - Brian Garra
- From the Department of Radiology, Northeastern Ohio Medical University, Rootstown, Ohio (R.G.B.); Southwoods Imaging, 7623 Market St, Boardman, OH 44512 (R.G.B.); Ultrasound Unit, Department of Infectious Diseases, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy (G.F.); Department of Biomedical Engineering, Pratt School of Engineering, Duke University, Durham, NC (M.L.P.); Center for Liver Diseases, Inova Fairfax Hospital, Falls Church, Va (Z.D.G.); Section of Digestive Diseases, Department of Medicine, Yale University, New Haven, Conn (G.G.T.); VA Connecticut Healthcare System, West Haven, Conn (G.G.T.); Department of Radiology, University of Michigan Medical Center, Ann Arbor, Mich (J.R.); Department of Radiology, Washington DC VA Medical Center, Washington, DC (B.G.); Division of Imaging, Diagnostics and Software Reliability, Office of Science and Engineering Laboratories, Center for Devices and Radiological Health, Food and Drug Administration, Silver Spring, Md (B.G.); Departments of Hepatology (R.P.M.) and Radiology (S.R.W.), University of Calgary, Calgary, Alberta, Canada; Departments of Imaging Science, Oncology, and Biomedical Engineering, University of Rochester Medical Center, Rochester, NY (D.R.); and Department of Radiology, Beth Israel Deaconess Medical Center, Boston, Mass (D.L.)
| | - Robert P Myers
- From the Department of Radiology, Northeastern Ohio Medical University, Rootstown, Ohio (R.G.B.); Southwoods Imaging, 7623 Market St, Boardman, OH 44512 (R.G.B.); Ultrasound Unit, Department of Infectious Diseases, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy (G.F.); Department of Biomedical Engineering, Pratt School of Engineering, Duke University, Durham, NC (M.L.P.); Center for Liver Diseases, Inova Fairfax Hospital, Falls Church, Va (Z.D.G.); Section of Digestive Diseases, Department of Medicine, Yale University, New Haven, Conn (G.G.T.); VA Connecticut Healthcare System, West Haven, Conn (G.G.T.); Department of Radiology, University of Michigan Medical Center, Ann Arbor, Mich (J.R.); Department of Radiology, Washington DC VA Medical Center, Washington, DC (B.G.); Division of Imaging, Diagnostics and Software Reliability, Office of Science and Engineering Laboratories, Center for Devices and Radiological Health, Food and Drug Administration, Silver Spring, Md (B.G.); Departments of Hepatology (R.P.M.) and Radiology (S.R.W.), University of Calgary, Calgary, Alberta, Canada; Departments of Imaging Science, Oncology, and Biomedical Engineering, University of Rochester Medical Center, Rochester, NY (D.R.); and Department of Radiology, Beth Israel Deaconess Medical Center, Boston, Mass (D.L.)
| | - Stephanie R Wilson
- From the Department of Radiology, Northeastern Ohio Medical University, Rootstown, Ohio (R.G.B.); Southwoods Imaging, 7623 Market St, Boardman, OH 44512 (R.G.B.); Ultrasound Unit, Department of Infectious Diseases, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy (G.F.); Department of Biomedical Engineering, Pratt School of Engineering, Duke University, Durham, NC (M.L.P.); Center for Liver Diseases, Inova Fairfax Hospital, Falls Church, Va (Z.D.G.); Section of Digestive Diseases, Department of Medicine, Yale University, New Haven, Conn (G.G.T.); VA Connecticut Healthcare System, West Haven, Conn (G.G.T.); Department of Radiology, University of Michigan Medical Center, Ann Arbor, Mich (J.R.); Department of Radiology, Washington DC VA Medical Center, Washington, DC (B.G.); Division of Imaging, Diagnostics and Software Reliability, Office of Science and Engineering Laboratories, Center for Devices and Radiological Health, Food and Drug Administration, Silver Spring, Md (B.G.); Departments of Hepatology (R.P.M.) and Radiology (S.R.W.), University of Calgary, Calgary, Alberta, Canada; Departments of Imaging Science, Oncology, and Biomedical Engineering, University of Rochester Medical Center, Rochester, NY (D.R.); and Department of Radiology, Beth Israel Deaconess Medical Center, Boston, Mass (D.L.)
| | - Deborah Rubens
- From the Department of Radiology, Northeastern Ohio Medical University, Rootstown, Ohio (R.G.B.); Southwoods Imaging, 7623 Market St, Boardman, OH 44512 (R.G.B.); Ultrasound Unit, Department of Infectious Diseases, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy (G.F.); Department of Biomedical Engineering, Pratt School of Engineering, Duke University, Durham, NC (M.L.P.); Center for Liver Diseases, Inova Fairfax Hospital, Falls Church, Va (Z.D.G.); Section of Digestive Diseases, Department of Medicine, Yale University, New Haven, Conn (G.G.T.); VA Connecticut Healthcare System, West Haven, Conn (G.G.T.); Department of Radiology, University of Michigan Medical Center, Ann Arbor, Mich (J.R.); Department of Radiology, Washington DC VA Medical Center, Washington, DC (B.G.); Division of Imaging, Diagnostics and Software Reliability, Office of Science and Engineering Laboratories, Center for Devices and Radiological Health, Food and Drug Administration, Silver Spring, Md (B.G.); Departments of Hepatology (R.P.M.) and Radiology (S.R.W.), University of Calgary, Calgary, Alberta, Canada; Departments of Imaging Science, Oncology, and Biomedical Engineering, University of Rochester Medical Center, Rochester, NY (D.R.); and Department of Radiology, Beth Israel Deaconess Medical Center, Boston, Mass (D.L.)
| | - Deborah Levine
- From the Department of Radiology, Northeastern Ohio Medical University, Rootstown, Ohio (R.G.B.); Southwoods Imaging, 7623 Market St, Boardman, OH 44512 (R.G.B.); Ultrasound Unit, Department of Infectious Diseases, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy (G.F.); Department of Biomedical Engineering, Pratt School of Engineering, Duke University, Durham, NC (M.L.P.); Center for Liver Diseases, Inova Fairfax Hospital, Falls Church, Va (Z.D.G.); Section of Digestive Diseases, Department of Medicine, Yale University, New Haven, Conn (G.G.T.); VA Connecticut Healthcare System, West Haven, Conn (G.G.T.); Department of Radiology, University of Michigan Medical Center, Ann Arbor, Mich (J.R.); Department of Radiology, Washington DC VA Medical Center, Washington, DC (B.G.); Division of Imaging, Diagnostics and Software Reliability, Office of Science and Engineering Laboratories, Center for Devices and Radiological Health, Food and Drug Administration, Silver Spring, Md (B.G.); Departments of Hepatology (R.P.M.) and Radiology (S.R.W.), University of Calgary, Calgary, Alberta, Canada; Departments of Imaging Science, Oncology, and Biomedical Engineering, University of Rochester Medical Center, Rochester, NY (D.R.); and Department of Radiology, Beth Israel Deaconess Medical Center, Boston, Mass (D.L.)
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Moon KM, Kim G, Baik SK, Choi E, Kim MY, Kim HA, Cho MY, Shin SY, Kim JM, Park HJ, Kwon SO, Eom YW. Ultrasonographic scoring system score versus liver stiffness measurement in prediction of cirrhosis. Clin Mol Hepatol 2013. [PMID: 24459644 DOI: 10.3350/cmh.2013.19.4.3890] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND/AIMS We compared the cirrhosis-prediction accuracy of an ultrasonographic scoring system (USSS) combining six representative sonographic indices with that of liver stiffness measurement (LSM) by transient elastography, and prospectively investigated the correlation between the USSS score and LSM in predicting cirrhosis. METHODS Two hundred and thirty patients with chronic liver diseases (187 men, 43 women; age, 50.4±9.5 y, mean±SD) were enrolled in this prospective study. The USSS produces a combined score for nodularity of the liver surface and edge, parenchyma echogenicity, presence of right-lobe atrophy, spleen size, splenic vein diameter, and abnormality of the hepatic vein waveform. The correlations of the USSS score and LSM with that of a pathological liver biopsy (METAVIR scoring system: F0-F4) were evaluated. RESULTS The mean USSS score and LSM were 7.2 and 38.0 kPa, respectively, in patients with histologically overt cirrhosis (F4, P=0.017) and 4.3 and 22.1 kPa in patients with fibrotic change without overt cirrhosis (F0-F3) (P=0.025). The areas under the receiver operating characteristic (ROC) curves of the USSS score and LSM for F4 patients were 0.849 and 0.729, respectively. On the basis of ROC curves, criteria of USSS ≥6: LSM ≥17.4 had a sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of 89.2%:77.6%, 69.4%:61.4%, 86.5%:83.7%, 74.6%:51.9% and 0.83:0.73, respectively, in predicting F4. CONCLUSIONS The results indicate that this USSS has comparable efficacy to LSM in the diagnosis of cirrhosis.
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Affiliation(s)
- Kyoung Min Moon
- Department of Internal Medicine, Konyang University College of Medicine, Daejeon, Korea
| | - Gaeun Kim
- Department of Nursing, Keimyung University College of Nursing, Daegu, Korea
| | - Soon Koo Baik
- Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea. ; Cell Therapy and Tissue Engineering Center, Yonsei University Wonju College of Medicine, Wonju, Korea. ; Institute of Lifestyle Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Eunhee Choi
- Institute of Lifestyle Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Moon Young Kim
- Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea. ; Cell Therapy and Tissue Engineering Center, Yonsei University Wonju College of Medicine, Wonju, Korea. ; Institute of Lifestyle Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Hyoun A Kim
- Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Mee Yon Cho
- Department of Pathology, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Seung Yong Shin
- Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Jung Min Kim
- Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Hong Jun Park
- Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Sang Ok Kwon
- Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Young Woo Eom
- Cell Therapy and Tissue Engineering Center, Yonsei University Wonju College of Medicine, Wonju, Korea
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19
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Moon KM, Kim G, Baik SK, Choi E, Kim MY, Kim HA, Cho MY, Shin SY, Kim JM, Park HJ, Kwon SO, Eom YW. Ultrasonographic scoring system score versus liver stiffness measurement in prediction of cirrhosis. Clin Mol Hepatol 2013; 19:389-98. [PMID: 24459644 PMCID: PMC3894439 DOI: 10.3350/cmh.2013.19.4.389] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2013] [Revised: 11/06/2013] [Accepted: 11/12/2013] [Indexed: 12/17/2022] Open
Abstract
Background/Aims We compared the cirrhosis-prediction accuracy of an ultrasonographic scoring system (USSS) combining six representative sonographic indices with that of liver stiffness measurement (LSM) by transient elastography, and prospectively investigated the correlation between the USSS score and LSM in predicting cirrhosis. Methods Two hundred and thirty patients with chronic liver diseases (187 men, 43 women; age, 50.4±9.5 y, mean±SD) were enrolled in this prospective study. The USSS produces a combined score for nodularity of the liver surface and edge, parenchyma echogenicity, presence of right-lobe atrophy, spleen size, splenic vein diameter, and abnormality of the hepatic vein waveform. The correlations of the USSS score and LSM with that of a pathological liver biopsy (METAVIR scoring system: F0-F4) were evaluated. Results The mean USSS score and LSM were 7.2 and 38.0 kPa, respectively, in patients with histologically overt cirrhosis (F4, P=0.017) and 4.3 and 22.1 kPa in patients with fibrotic change without overt cirrhosis (F0-F3) (P=0.025). The areas under the receiver operating characteristic (ROC) curves of the USSS score and LSM for F4 patients were 0.849 and 0.729, respectively. On the basis of ROC curves, criteria of USSS ≥6: LSM ≥17.4 had a sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of 89.2%:77.6%, 69.4%:61.4%, 86.5%:83.7%, 74.6%:51.9% and 0.83:0.73, respectively, in predicting F4. Conclusions The results indicate that this USSS has comparable efficacy to LSM in the diagnosis of cirrhosis.
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Affiliation(s)
- Kyoung Min Moon
- Department of Internal Medicine, Konyang University College of Medicine, Daejeon, Korea
| | - Gaeun Kim
- Department of Nursing, Keimyung University College of Nursing, Daegu, Korea
| | - Soon Koo Baik
- Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea. ; Cell Therapy and Tissue Engineering Center, Yonsei University Wonju College of Medicine, Wonju, Korea. ; Institute of Lifestyle Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Eunhee Choi
- Institute of Lifestyle Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Moon Young Kim
- Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea. ; Cell Therapy and Tissue Engineering Center, Yonsei University Wonju College of Medicine, Wonju, Korea. ; Institute of Lifestyle Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Hyoun A Kim
- Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Mee Yon Cho
- Department of Pathology, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Seung Yong Shin
- Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Jung Min Kim
- Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Hong Jun Park
- Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Sang Ok Kwon
- Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Young Woo Eom
- Cell Therapy and Tissue Engineering Center, Yonsei University Wonju College of Medicine, Wonju, Korea
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Cui XW, Friedrich-Rust M, Molo CD, Ignee A, Schreiber-Dietrich D, Dietrich CF. Liver elastography, comments on EFSUMB elastography guidelines 2013. World J Gastroenterol 2013; 19:6329-6347. [PMID: 24151351 PMCID: PMC3801303 DOI: 10.3748/wjg.v19.i38.6329] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2013] [Revised: 08/11/2013] [Accepted: 09/17/2013] [Indexed: 02/06/2023] Open
Abstract
Recently the European Federation of Societies for Ultrasound in Medicine and Biology Guidelines and Recommendations have been published assessing the clinical use of ultrasound elastography. The document is intended to form a reference and to guide clinical users in a practical way. They give practical advice for the use and interpretation. Liver disease forms the largest section, reflecting published experience to date including evidence from meta-analyses with shear wave and strain elastography. In this review comments and illustrations on the guidelines are given.
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Trabut JB, Thépot V, Nalpas B, Lavielle B, Cosconea S, Corouge M, Vallet-Pichard A, Fontaine H, Mallet V, Sogni P, Pol S. Rapid decline of liver stiffness following alcohol withdrawal in heavy drinkers. Alcohol Clin Exp Res 2012; 36:1407-11. [PMID: 22404692 DOI: 10.1111/j.1530-0277.2012.01737.x] [Citation(s) in RCA: 68] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2011] [Accepted: 12/05/2011] [Indexed: 12/11/2022]
Abstract
BACKGROUND Measurement of liver stiffness (LS) using real-time elastography appears as a promising tool to evaluate the severity of chronic liver diseases. Previous studies in patients with alcoholic liver disease have suggested that fibrosis was the only histological parameter to influence LS. To challenge this hypothesis, we have prospectively tested the short-term impact of alcohol withdrawal on LS value. METHODS Patients hospitalized for alcohol withdrawal in our Liver and Addiction Unit between 2007 and 2010 had an LS determination at entry (D0) and 7 days after alcohol withdrawal (D7). LS value was given as the median of 10 measurements performed with a FibroScan(®) device. For a given patient, variation of LS was considered as significant when the comparison of the 10 measurements at D0 and at D7 yielded a p-value under 0.05 (Wilcoxon test). RESULTS One hundred and thirty-seven patients were included in the study (median alcohol consumption: 150 g/d; hepatitis C: n = 21 [15.6%]). Considering all patients, median LS value decreased from 7.2 to 6.1 kPa between D0 and D7 (p = 0.00001, paired Wilcoxon test). LS decreased significantly in 62 patients (45.3%), and there was a reduction in the estimated stage of fibrosis in 32 (23.3%). LS increased significantly in 16 patients (11.7%). Subgroup analyses revealed that the decrease in LS was still significant in patients with or without hepatitis C infection, and aspartate transaminase level below or above 100 UI/l. CONCLUSIONS LS decreases significantly in nearly half of heavy drinkers after only 7 days of abstinence. This result strongly suggests that nonfibrotic lesions (such as the presence of alcoholic hepatitis) may influence LS. From a practical point of view, it also shows that variation of alcohol consumption must be taken into account for the interpretation of LS value.
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Affiliation(s)
- Jean-Baptiste Trabut
- Unité d'Hépatologie et d'Addictologie, Hôpital Cochin, Assitance Publique - Hôpitaux de Paris, France.
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22
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Kim SU, Kim JK, Park YN, Han KH. Discordance between liver biopsy and Fibroscan® in assessing liver fibrosis in chronic hepatitis b: risk factors and influence of necroinflammation. PLoS One 2012; 7:e32233. [PMID: 22384189 PMCID: PMC3285687 DOI: 10.1371/journal.pone.0032233] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2011] [Accepted: 01/25/2012] [Indexed: 12/15/2022] Open
Abstract
Background Few studies have investigated predictors of discordance between liver biopsy (LB) and liver stiffness measurement (LSM) using FibroScan®. We assessed predictors of discordance between LB and LSM in chronic hepatitis B (CHB) and investigated the effects of necroinflammatory activity. Methods In total, 150 patients (107 men, 43 women) were prospectively enrolled. Only LSM with ≥10 valid measurements was considered reliable. Liver fibrosis was evaluated using the Laennec system. LB specimens <15 mm in length were considered ineligible. Reference cutoff LSM values to determine discordance were calculated from our cohort (6.0 kPa for ≥F2, 7.5 kPa for ≥F3, and 9.4 kPa for F4). Results A discordance, defined as a discordance of at least two stages between LB and LSM, was identified in 21 (14.0%) patients. In multivariate analyses, fibrosis stages F3–4 and F4 showed independent negative associations with discordance (P = 0.002; hazard ratio [HR], 0.073; 95% confidence interval [CI], 0.014–0.390 for F3–4 and P = 0.014; HR, 0.067; 95% CI, 0.008–0.574 for F4). LSM values were not significantly different between maximal activity grades 1–2 and 3–4 in F1 and F2 fibrosis stages, whereas LSM values were significantly higher in maximal activity grade 3–4 than 1–2 in F3 and F4 fibrosis stage (median 8.6 vs. 11.3 kPa in F3, P = 0.049; median 11.9 vs. 19.2 kPa in F4, P = 0.009). Conclusion Advanced fibrosis stage (F3–4) or cirrhosis (F4) showed a negative correlation with discordance between LB and LSM in patients with CHB, and maximal activity grade 3–4 significantly influenced LSM values in F3 and F4.
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Affiliation(s)
- Seung Up Kim
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
- Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
- Liver Cirrhosis Clinical Research Center, Seoul, Korea
| | - Ja Kyung Kim
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
- Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
- Liver Cirrhosis Clinical Research Center, Seoul, Korea
| | - Young Nyun Park
- Department of Pathology, Yonsei University College of Medicine, Seoul, Korea
- Center for Chronic Metabolic Disease, Yonsei University College of Medicine, Seoul, Korea
- Liver Cirrhosis Clinical Research Center, Seoul, Korea
- Brain Korea 21 Project for Medical Science, Seoul, Korea
- * E-mail: (YNP); (K-HH)
| | - Kwang-Hyub Han
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
- Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
- Liver Cirrhosis Clinical Research Center, Seoul, Korea
- Brain Korea 21 Project for Medical Science, Seoul, Korea
- * E-mail: (YNP); (K-HH)
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