Fibrosis in nonalcoholic fatty liver disease: Noninvasive assessment using computed tomography volumetry

Value of gadoxetic acid-enhanced MR imaging for preoperative prediction of future liver regeneration after hemihepatectomy

PURPOSE

Liver resection is currently considered the most effective treatment for patients with liver cancer. To the best of our knowledge, no study has investigated the association between gadoxetic acid-enhanced magnetic resonance imaging (MRI) findings and liver regeneration in patients who underwent hemihepatectomy. We aimed to clarify the relationship between the signal intensity (SI) of the liver parenchyma on gadoxetic acid-enhanced MRI and the degree of liver regeneration in patients who underwent hemihepatectomy.

MATERIALS AND METHODS

Forty-one patients who underwent gadoxetic acid-enhanced MRI before hemihepatectomy were enrolled. We calculated the liver-to-erector spinae muscle SI ratio (LMR) in the hepatobiliary phase and the precontrast images. ΔLMR was calculated using the following equation: ΔLMR = (LMR in the hepatobiliary phase-LMR in the precontrast image)/LMR in the precontrast image. The preoperative and postoperative remnant liver volumes (LVs) were calculated using CT volumetry. We calculated the resection rate (RR) and liver regeneration index (LRI) using the following formulas: RR = Resected LV/Total LV × 100 and LRI = (postoperative remnant LV-preoperative remnant LV)/preoperative remnant LV × 100. The relationships among LRI, imaging, and clinicopathological factors were analyzed.

RESULTS

Univariate analysis showed RR and ΔLMR showed a positive correlation with LRI (ρ = 0.4133, p = 0.0072 and ρ = 0.7773, p < 0.001, respectively). Spleen volume showed a negative correlation with LRI (ρ = -0.3138, p = 0.0486). Stepwise multiple regression analysis showed ΔLMR and RR were independently correlated with LRI (β coefficient = 44.8771, p = 0.0198 and β coefficient = 1.9653, p < 0.001, respectively).

CONCLUSION

ΔLMR may serve as a preoperative predictor of liver regeneration in patients undergoing hemihepatectomy.

Long-term impact of replaced right hepatic artery resection in pancreaticoduodenectomy

The clinical impact of replaced right hepatic artery (rRHA) resection during pancreaticoduodenectomy (PD) has not been thoroughly investigated. We therefore assessed the short- and long-term effects of rRHA resection during PD, with special reference to alterations in the volumetric profile of the liver. Patients with rRHA were divided into two groups based on the presence (R group) or absence (nR group) of resection. The nR group included cases of rRHA resection and reconstruction. We compared the postoperative short-term complications and detailed liver volume profile by CT volumetry in the long term between the R and nR groups. Forty-seven patients were eligible for the analyses of short-term outcomes (R: n = 7, nR: n = 40), and no marked difference was observed in the incidence of short-term postoperative complications. The patient cohort for the long-term investigations included 34 cases (R: n = 6, nR: n = 28), excluding patients with early recurrence. There was no significant difference in the preoperative liver volume profiles between the two groups. At 12 postoperative months, although the whole liver (WL) volume did not significantly change in either group, the ratio of the volume of the anterior/posterior sections significantly increased in the R group (R: pre- vs. 12 months, 1.01 vs. 1.28, p < 0.05; nR: pre- vs. 12 months, 1.40 vs. 1.33, p = 0.99). Long-term rRHA resection did not significantly affect the WL volume with alteration of the liver volumetric profile of each section.

Endoscopic Ultrasound-based Shear Wave Elastography for Detection of Advanced Liver Disease

BACKGROUND AND AIMS

Endoscopic ultrasound shear wave elastography (EUS-SWE) is a novel modality for liver stiffness measurement. The aims of this study are to evaluate the performance and reliability of EUS-SWE for detecting advanced liver disease in a prospective cohort.

METHODS

EUS-SWE measurements were prospectively obtained from patients undergoing EUS between August 2020 and March 2023. Liver stiffness measurements were compared between patients with and without advanced liver disease (ALD), defined as stage ≥3, to determine diagnostic accuracy for advanced fibrosis and portal hypertension. Logistic regression was performed to identify variables that impact the reliability of EUS-SWE readings. Select patients underwent paired magnetic resonance elastography (MRE) for liver fibrosis correlation.

RESULTS

Patients with ALD demonstrated higher liver stiffness compared to healthy controls (left lobe: 17.6 vs. 12.7 kPa, P<0.001; median right lobe: 24.8 vs. 11.0 kPa, P<0.001). The area under the receiver operator characteristic (AUROC) for the detection of ALD was 0.73 and 0.80 for left and right lobe measurements, respectively. General anesthesia was associated with reliable EUS-SWE liver readings (odds ratio: 2.73, 95% CI: 1.07-7.39, P=0.040). Left lobe measurements correlated significantly with MRE with an increase of 0.11 kPa (95% CI: 0.05-0.17 kPA) for every 1 kPa increase on EUS-SWE. D.

CONCLUSIONS

SWE is a promising technology that can readily be incorporated into standard EUS examinations for the assessment of ALD.

Variation in hepatic segmental portal venous pulsed wave Doppler flow distribution in patients with NAFLD: A pilot study

Purpose

To evaluate the segmental variations in portal venous pulsed wave colour Doppler flow velocity in patients with moderate to severe non-alcoholic fatty liver disease in comparison with healthy controls.

Materials and Methods

In this prospective, observational, case-control study, the maximum velocity of all the segmental branches of portal vein were evaluated on colour Doppler in patients with moderate to severe non-alcoholic fatty liver disease, and the values were compared between three groups (1) Healthy controls (n = 30), (2) non-alcoholic fatty liver disease group, that is moderate to severe fatty liver without features of portal hypertension (n = 32) and (3) non-alcoholic steatohepatitis-portal hypertension group, that is those non-alcoholic fatty liver disease patients with features of portal hypertension (n = 13).

Results

Compared to controls, non-alcoholic fatty liver disease group showed a lower velocity in all the eight segments of liver. The ratio of segment 2 to segment 7 peak portal vein maximum velocity was significantly higher in non-alcoholic fatty liver disease (1.03 ± 0.21) compared to controls (0.90 ± 0.17) and even higher in non-alcoholic steatohepatitis-Portal hypertension group (1.83 ± 0.40) with p value of 0.003.

Conclusion

Our study demonstrates the occurrence of flow redistribution occurring in cases of non-alcoholic fatty liver disease patients with the left lobe receiving higher portal venous flow. This flow redistribution was even more pronounced in a subset of non-alcoholic fatty liver disease patients who developed features of portal hypertension.

Spleen to non-cancerous liver volume ratio predicts liver cirrhosis in hepatocellular carcinoma patients

PURPOSE

To investigate the performance of spleen to non-cancerous liver volume ratio (STnLR) for diagnosing liver cirrhosis in patients with hepatocellular carcinoma (HCC) during preoperative evaluation.

METHODS

Patients were randomly divided into experiment group and validation group. Patients were grouped into cirrhosis group and non-cirrhosis group according to Scheuer staging. Patients' routine image data were reconstructed using a three-dimensional system. STnLR, spleen to liver volume ratio (STLR), spleen volume, aspartate aminotransferase to platelet ratio index (APRI), and fibrosis index based on the four factors (FIB-4) were calculated. Correlations between indices and cirrhosis were measured by Spearman correlation analysis. Diagnostic performance was assessed and compared using receiver operating characteristic analysis. Accuracies of the models were analyzed in validation group.

RESULTS

No statistical difference in demographic and clinical characteristics was observed between groups. In experiment group, STnLR had the strongest correlation (r = 0.5399, P < 0.0001), and STLR, spleen volume, APRI, and FIB-4 had moderate correlations (r = 0.4583, 0.4123, 0.3648, and 0.3405, P < 0.0001, < 0.0001, < 0.0001, and = 0.0002) with liver cirrhosis stage. AUROC of STnLR (0.8326) was not statistically higher than that for spleen volume (0.7542, P = 0.09832) and STLR (0.8046, P = 0.3034), but was significantly higher than that for APRI (0.7099, P = 0.02046) and FIB-4 (0.7294, P = 0.03987). In validation group, STnLR showed the highest AUROC value (0.8538) and highest Youden index (0.5869) among all models.

CONCLUSION

STnLR is an accurate and stable volumetric model to diagnose hepatic cirrhosis in the HCC population, which is superior to APRI and FIB-4.

Ultrasound-Based Hepatic Elastography in Non-Alcoholic Fatty Liver Disease: Focus on Patients with Type 2 Diabetes

Non-alcoholic fatty liver disease (NAFLD) is the most prevalent liver disease and is the hepatic expression of metabolic syndrome. The development of non-invasive methods for the diagnosis of hepatic steatosis and advanced fibrosis in high-risk patients, especially those with type 2 diabetes mellitus, is highly needed to replace the invasive method of liver biopsy. Elastographic methods can bring significant added value to screening and diagnostic procedures for NAFLD in patients with diabetes, thus contributing to improved NAFLD management. Pharmacological development and forthcoming therapeutic measures that address NAFLD should also be based on new, non-invasive, and reliable tools that assess NAFLD in at-risk patients and be able to properly guide treatment in individuals with both diabetes and NAFLD. This is the first review aiming to outline and discuss recent studies on ultrasound-based hepatic elastography, focusing on NAFLD assessment in patients with diabetes.

Non-invasive diagnosis of non-alcoholic fatty liver disease using an algorithm combining clinical indexes and ultrasonographic measures

INTRODUCTION AND OBJECTIVE

Non-Alcoholic Fatty Liver Disease (NAFLD) is a metabolic liver disease related to insulin resistance, which requires invasive methods for diagnosis. The aim of this study was to analyze whether the use of an algorithm involving both clinical indices and hepatic ultrasound measurements improves the accuracy for the non-invasive diagnosis of NAFLD.

PATIENTS AND METHODS

Cross-sectional study with patients undergoing elective cholecystectomy. We collected anthropometric, metabolic, liver biopsy, and liver ultrasonography data. We calculated unpaired t-test and Pearson's coefficient, and areas under the receiver-operating characteristic curves (AUROC) for the Fatty Liver Index (FLI), Lipid Accumulation Product (LAP) indexes, right liver index diameter, and for predictive models constructed with discriminant analysis.

RESULTS

One hundred patients in groups with and without NAFLD. FLI, LAP, right and caudate liver lobe diameters, and congestion index were higher in NAFLD group (p = 0.011, p = 0.011, p = 0.001, p = 0.027, p = 0.009). The right liver lobe diameter had the highest AUROC. Predictive models that combined sensitivity and specificity for the clinical indexes and liver ultrasound had an AUROC over 0.7.

CONCLUSION

The ultrasonography measure of right liver lobe diameter by itself can reliably identify patients with NAFLD with a good sensitivity and specificity, however, this can be improved by adding the LAP mathematical index in our population.

Understanding the association of polycystic ovary syndrome and non-alcoholic fatty liver disease

Polycystic ovary syndrome (PCOS) is the most common endocrine disorder among reproductive-age women. Patients with non-alcoholic fatty liver disease (NAFLD) often suffer from metabolic syndrome, atherosclerosis, ischemic heart disease, and extrahepatic tumors, conferring a lower survival than the general population; therefore it is crucial to study the association between NAFLD and PCOS since it remains poorly understood. Insulin resistance (IR) plays a central role in the pathogenesis of NAFLD and PCOS; also, hyperandrogenism enhances IR in these patients. IR, present in the NAFLD-PCOS association could decrease the hepatic production of sex hormone-binding globulin through a possible regulation mediated by hepatocyte nuclear factor 4 alpha. On the other hand, apoptotic processes initiated by androgens actively contribute to the progression of NAFLD. Considering the association between the two conditions, the screening of women with PCOS for the presence of NAFLD appears reasonable. The pathophysiological mechanisms of PCOS-NAFLD association and the initial approach will be reviewed here.

The diagnostic and initial approach of the patient with non-alcoholic fatty liver disease: role of the primary care provider

Non-alcoholic fatty liver disease (NAFLD) represents a broad spectrum of liver damage, ranging from simple steatosis to steatohepatitis and fibrosis; as well, there is a close association between NAFLD, obesity, metabolic syndrome and type 2 diabetes mellitus. There is a certain degree of uncertainty regarding the natural history and prognosis of NAFLD; however, several methods are currently used for its diagnostic approach. In the first instance, non-invasive tests could be used to identify patients at low risk of developing fibrosis and to establish more easily the need for a liver biopsy, whose accuracy in the evaluation of fibrosis has been questioned, mainly due to errors of intra and interobserver sampling, technical problems and cost, which limits its use. Therefore, it is essential to determine the diagnostic strategy for patients with NAFLD.

A novel, non-invasive model for diagnosing liver fibrosis stage in patients with hepatocellular carcinoma

The aim of this study was to investigate the diagnostic value of the platelet count-to-spleen volume ratio (PSR) for diagnosing hepatic fibrosis in patients with hepatocellular carcinoma (HCC). In this interim analysis of an on-going prospective study, 117 patients with HCC and with or without cirrhosis or fibrosis in different stages were analyzed. Fibrosis staging negatively correlated with PSR and the liver volume-to-spleen volume ratio (LSR), while it positively correlated with aspartate aminotransferase-to-platelet ratio index (APRI), Frons' index, S-index and a fibrosis index based on four factors (FIB-4). The area under the receiver operating characteristic curve (AUROC) was significantly larger for PSR (0.777) than LSR (0.633, P = 0.002). Among patients with significant fibrosis, AUROC for PSR did not differ significantly from the AUROCs for APRI (0.789, P = 0.825), Frons' index (0.674, P = 0.102), FIB-4 (0.704, P = 0.251) or S-index (0.696, P = 0.204). Among patients with severe fibrosis, AUROC was significantly higher for PSR (0.808) than for LSR (0.685, P = 0.003), Frons' index (0.673, P = 0.014), FIB-4 (0.684, P = 0.029), or S-index (0.672, P = 0.016); in contrast, the AUROC for PSR was not significantly different from that for APRI (0.739, P = 0.215). Among patients with cirrhosis, AUROC was significantly higher for PSR (0.814) than for LSR (0.671, P = 0.001) or S-index (0.679, P = 0.022), while the AUROC for PSR did not differ significantly from those for APRI (0.711, P = 0.105), Frons' index (0.722, P = 0.061) or FIB-4 (0.708, P = 0.079). Our results suggest that PSR may be a useful non-invasive model for diagnosing liver fibrosis stage in patients with HCC in China.