Predicting gastroesophageal varices through spleen magnetic resonance elastography in pediatric liver fibrosis

Preoperative imaging findings to predict 2-year native liver survival after the Kasai procedure in patients with biliary atresia

OBJECTIVES

To investigate the feasibility of using preoperative imaging indices to predict 2-year native liver survival after the Kasai procedure in patients with biliary atresia (BA).

MATERIALS AND METHODS

The retrospective review included 190 BA patients who underwent the Kasai procedure between 2000 and 2020, with preoperative US and/or MRI, excluding cases with less than 2-year follow-up period. Multivariable logistic regression analysis was performed to identify imaging indices to predict 2-year native liver survival. Kasai failure was defined as the need for liver transplantation or death within 2 years of the Kasai procedure.

RESULTS

Of the 90 patients included, all had preoperative US, and 61 also had MRI. Kasai failure occurred in 52% (47/90). Preoperative US identified gallbladder length (OR 0.40, 95% CI 0.17-0.95, p = 0.039; cutoff 1.6 cm, AUC 67.66) and biliary cysts (OR 24.64, 95% CI 1.97-308.08, p = 0.013) as significant Kasai failure predictors, with a combined accuracy of 73% (60/82). For patients having both preoperative US and MRI, significant predictors were hepatic artery diameter (OR 6.75, 95% CI 1.31-34.88, p = 0.023; cutoff 2 mm, AUC 73.83) and biliary cysts (OR 23.89, 95% CI 1.43-398.82, p = 0.027) on US, and gallbladder length (OR 0.25, 95% CI 0.08-0.76, p = 0.014; cutoff 1.2 cm, AUC 74.72) and spleen size (OR 2.53, 95% CI 1.02-6.29, p = 0.045; cutoff 6.9 cm, AUC 73.72) on MRI, with a combined accuracy of 85% (52/61).

CONCLUSION

Preoperative US and/or MRI enhance the 2-year native liver survival prediction in BA patients after the Kasai procedure.

CLINICAL RELEVANCE STATEMENT

BA patients with hepatic artery diameter > 2 mm (US), gallbladder length < 1.6 cm (US) or < 1.2 cm (MRI), spleen size > 6.9 cm (MRI), and absence of biliary cysts (US/MRI) have a decreased likelihood of 2-year native liver survival.

KEY POINTS

• Preoperative US and/or MRI can predict the probability of achieving 2-year native liver survival following the Kasai procedure. • Combining US and MRI improved the accuracy to 85% for predicting 2-year native liver survival in BA patients. • The hepatic artery diameter > 2 mm (US), gallbladder length < 1.6 cm (US) or < 1.2 cm (MRI), spleen size > 6.9 cm (MRI), and no biliary cysts (US/MRI) are significant predictors of Kasai failure in patients with biliary atresia.

Superiority of spleen stiffness on two-dimensional magnetic resonance elastography over liver stiffness and serum tests in assessing portal hypertension in chronic liver disease

Background

The value of magnetic resonance elastography (MRE) in portal hypertension (PH) has yet to be determined in the context of chronic liver disease (CLD). This study examined the value of MRE for the prediction of hepatic venous pressure gradient (HVPG) and high-risk esophageal varices (EVs) in a CLD cohort with a generally high HVPG.

Methods

Patients with CLD who underwent both HVPG measurement and two-dimensional MRE examination at Beijing Friendship Hospital between April 2018 and March 2022 were prospectively included. Two-dimensional MRE was performed within the liver and spleen. Endoscopy results and laboratory parameters were collected. Some selected published serum markers were calculated, including fibrosis 4, aspartate aminotransferase-to-platelet ratio index, and King's score. The efficacy of the parameters for assessing PH was analyzed by using the Pearson correlation coefficient, linear and logistic regression, and receiver operating characteristic curve analyses.

Results

A total of 48 patients were included. The mean HVPG was 16.8±5.8 mmHg. Among these patients, 47 patients had PH (HVPG >5 mmHg), and 43 patients had clinically significant PH (HVPG ≥10 mmHg). Among the parameters associated with HVPG, the strongest correlation was found for spleen stiffness (SS) (R=0.638; P<0.001). In multiple regression analyses, SS was independently associated with an elevated HVPG and high-risk EVs. The areas under the receiver operating characteristic curve of SS for identifying patients with an HVPG ≥16 mmHg, HVPG ≥20 mmHg, and high-risk EVs were 0.790, 0.822, and 0.886, respectively, which were higher than those of liver stiffness (LS) and serum markers but slightly inferior to that of fibrosis 4 (area under the receiver operating characteristic curve =0.844) in identifying an HVPG ≥16 mmHg. SS cutoff values of 9.5, 10.05, and 9.9 kPa were selected to rule out the presence of an HVPG ≥16 mmHg, HVPG ≥20 mmHg, and high-risk EVs (sensitivity: 100%, 100%, and 100%, respectively; specificity: 45.5%, 50%, and 60%, respectively).

Conclusions

In patients with generally high HVPG, SS measured by two-dimensional MRE may be a better predictor of HVPG values and high-risk EVs than LS and serum markers.

MR and Ultrasound Elastography for Fibrosis Assessment in Children: Practical Implementation and Supporting Evidence-AJR Expert Panel Narrative Review

Quantitative MRI and ultrasound biomarkers of liver fibrosis have become important tools in the diagnosis and clinical management of children with chronic liver disease (CLD). In particular, MR elastography (MRE) is now routinely performed in clinical practice to evaluate the liver for fibrosis. Ultrasound shear-wave elastography has also become widely performed for this purpose, especially in young children. These noninvasive methods are increasingly used to replace liver biopsy for the diagnosis, quantitative staging, and treatment monitoring of patients with CLD. Although ultrasound has advantages of portability and lower equipment cost, available evidence indicates that MRI may have greater reliability and accuracy in liver fibrosis evaluation. In this AJR Expert Panel Narrative Review, we describe how, why, and when to use MRI- and ultrasound-based elastography methods for liver fibrosis assessment in children. Practical approaches are discussed for adapting and optimizing these methods in children, with consideration of clinical indications, patient preparation, equipment requirements, acquisition technique, as well as pitfalls and confounding factors. Guidance is provided for interpretation and reporting, and representative case examples are presented.

Consensus on the management of complications of cirrhosis of the liver in pediatrics

The Asociación Mexicana de Hepatología A.C. carried out the Consensus on the Management of Complications of Cirrhosis of the Liver in Pediatrics to provide physicians with useful information for treating said complications. A group of pediatric gastroenterologists and experts in nutrition, nephrology, and infectious diseases participated and reviewed the medical literature. The Delphi method was applied to obtain the level of agreement on the statements that were formulated. The statements were sent to the participants to be analyzed and voted upon, after which they were discussed in virtual sessions, and the final versions were produced. The aim of the consensus results was to issue indications for the management of pediatric patients with liver cirrhosis, to prevent or control complications.

Spleen Stiffness on Magnetic Resonance Elastography for the Detection of Portal Hypertension: A Systematic Review and Meta-Analysis

Background

Chronic liver disease, complicated by portal hypertension (PH), may alter the extra-hepatic hemodynamic condition and spleen stiffness (SS). We aimed to evaluate the diagnostic accuracy of MRI-based elastographic methods (MRE) for detecting PH.

Methods

Seven studies were included with reference to SS with regard to the prediction of PH patients. Major outcomes considered for data extraction were diagnostic parameters for MRI for concluding mild PH, clinically significant PH and severe PH. PubMed, Scopus, Google Scholar, Cochrane and Science Direct databases were used to extract the published literature through to May, 2021Using the Rayyan Zotero and R softwares.

Results

Out of 587 studies extracted, 7 were selected based on inclusion and exclusion criteria. A QUADAS-2 assessment showed that all studies were clear in terms of patient selection and reference standard. A funnel plot showed that all the selected studies were outliers, indicating a low level of accuracy for the studies included. Subgroup analysis, with reference to SS as a predictor of PH, revealed raw mean difference (RMD) of 7.78% (95% CI 5.23-10.34, P<0.01). The corresponding RMD observed for <60 years and >60 yr were 34.26% (95% CI 9.33- 59.20, I²=100%, τ²=646.7688, P=0), and 46.92% (95% CI 20-59.33, I²=97%, τ²=1003.023, P=0) respectively. The specificity and sensitivity noted for MRI in determining SS were 0.721 and 0.747, respectively with an area-under the curve of 0.788. The estimated random effect models for specificity and sensitivity were 0.938 and 0.842, respectively.

Conclusion

The real-time MRE has acceptable specificity and sensitivity for diagnosing SS.

Clinical utility of 3D magnetic resonance elastography in patients with biliary obstruction

OBJECTIVES

Three-dimensional magnetic resonance elastography (3D-MRE) allows for multiparametric modeling of both elastic and viscous tissue characteristics. Our aim was to compare 3D-MRE with conventional liver shear stiffness assessment in gauging obstructive jaundice (OJ), predicting the adequacy of biliary decompression after drainage, and discriminating OJ from liver fibrosis.

METHODS

Patients with no histories of liver disease (n = 201) were studied in retrospect, grouped by bilirubin levels as no jaundice (NJ ≤ 2 mg/dL; n = 75), mild OJ (>2 mg/dL and ≤ 4 mg/dL; n = 56), and severe OJ (> 4 mg/dL; n = 70). For comparison, another 75 patients with chronic hepatitis B and C infections and histologically proven liver fibrosis were similarly analyzed. Each patient underwent spin-echo echo-planar-imaging MRE at 60 Hz with 3D wave postprocessing. Logistic regression and ordinary regression models were used to compare the 3D-MRE model with liver shear stiffness.

RESULTS

Liver shear stiffness, loss modulus, and damping ratio were incorporated into a 3D-MRE model, which significantly outperformed shear stiffness in predicting OJ severity (accuracy: 0.801 vs 0.672; p < 0.001). Both the 3D-MRE model and liver shear stiffness performed equally well in predicting the outcome of biliary drainage procedure (C-statistics: 0.852 vs 0.847; p = 0.48). The 3D-MRE model also demonstrated significantly better C-statistics than that of liver shear stiffness in discriminating mild OJ from F1-F2 liver fibrosis (0.765 vs 0.641; p = 0.005) and severe OJ from F3-F4 liver fibrosis (0.750 vs 0.635; p = 0.031).

CONCLUSIONS

3D-MRE is an innovative imaging method for gauging OJ severity, predicting the outcome of biliary drainage procedure, and discriminating OJ from liver fibrosis.

KEY POINTS

• 3D-MR elastography achieved promising results for predicting the severity of obstructive jaundice. • Advanced parameters of 3D-MR elastography demonstrated significantly better performance than that of shear stiffness of 2D-MR elastography in discriminating obstructive jaundice from liver fibrosis caused by chronic hepatitis B/C. • Both 3D-MR elastography and 2D-MR elastography were equivalent in predicting the outcome of biliary drainage procedure.

Noninvasive assessment of clinically significant portal hypertension using ΔT1 of the liver and spleen and ECV of the spleen on routine Gd-EOB-DTPA liver MRI

PURPOSE

To analyze the predictive value of ΔT1 of the liver and spleen as well as the extracellular volume fraction (ECV) of the spleen as noninvasive biomarkers for the determination of clinically significant portal hypertension (CSPH) on routine Gd-EOB-DTPA liver MRI.

METHOD

195 consecutive patients with known or suspected chronic liver disease from 9/2018 to 7/2019 with Gd-EOB-DTPA liver MRI and abdominal T1 mapping were retrospectively included. Based on the presence of splenomegaly with thrombocytopenia, ascites and portosystemic collaterals, the patients were divided into noCSPH (n = 113), compensated CSPH (cCSPH, ≥1 finding without ascites; n = 55) and decompensated CSPH (dCSPH, ascites ± other findings; n = 27). T1 times were measured in the liver, spleen and abdominal aorta in the unenhanced and contrast-enhanced T1 maps. Native T1 times and ΔT1 of the liver and spleen as well as ECV of the spleen were compared between groups using the Kruskal-Wallis test with Dunn's post hoc test. Furthermore, cutoff values for group differentiation were calculated using ROC analysis with Youden's index.

RESULTS

ΔT1 of the liver was significantly lower in patients with cCSPH and dCSPH (p < 0.001) compared to patients with noCSPH. In the ROC analyses for differentiation between noCSPH and CSPH (cCSPH + dCSPH), a cutoff of < 0.67 for ΔT1 of the liver (AUC = 0.79) performed better than ΔT1 (AUC = 0.69) and ECV (AUC = 0.63) of the spleen with cutoffs of > 0.29 and > 41.9, respectively.

CONCLUSION

ΔT1 of the liver and spleen in addition to ECV of the spleen allow for determination of CSPH on routine Gd-EOB-DTPA liver MRI.

Three-dimensional MR Elastography Depicts Liver Inflammation, Fibrosis, and Portal Hypertension in Chronic Hepatitis B or C

Background The value of measuring mechanical properties to categorize various pathophysiologic states of the liver is as yet undetermined in chronic hepatitis B (CHB) or C (CHC). Purpose To evaluate multiparametric three-dimensional (3D) MR elastography as a means of detecting early necroinflammation, distinguishing necroinflammation from fibrosis, and gauging the severity of portal hypertension (PH) in CHB or CHC. Materials and Methods From January 2015 to September 2019, participants with CHB or CHC were prospectively enrolled from a single institution and were divided into two groups: those with liver biopsy and no evidence of PH (group 1) and those with PH and a hepatic venous pressure gradient (HVPG) measurement (group 2). For group 3, healthy volunteers were separately recruited from a nearby community. Multiple viscoelastic parameters (shear stiffness [SS], storage modulus, loss modulus, and damping ratio [DR]) were determined at 3D MR elastography at 60 Hz, and multivariable logistic or linear regression analysis was used to assess associations of mechanical parameters with histologic scores and HVPG. Results A total of 155 participants (median age, 41 years [interquartile range, 32-48 years]; 85 women) were in group 1 (training set: n = 78, validation set: n = 77), 85 participants (median age, 57 years [interquartile range, 43-61 years]; 51 women) in group 2, and 60 healthy volunteers (median age, 49 years [interquartile range, 27-64 years]; 38 men) in group 3. The liver DR was higher in participants with necroinflammation (DR, 0.13 ± 0.03) versus those without (at liver fibrosis stage F0) (DR, 0.10 ± 0.02; P < .001). Liver DR and SS together performed well in the diagnosis of necroinflammation (area under the receiver operating characteristic curve [AUC], 0.88 [95% CI: 0.79, 0.96]) and the scoring of moderate to severe activity (AUC, 0.88 [95% CI: 0.81, 0.95]) in the validation data set. Liver DR (regression coefficient [β] = -30.3 [95% CI: -58.0, -2.5]; P = .03) and splenic SS (β = 2.3 [95% CI: 1.7, 2.9]; P < .001) were independently associated with HVPG. Conclusion Three-dimensional MR elastography may detect early necroinflammation, distinguish necroinflammation from liver fibrosis, and correlate with hepatic venous pressure gradient in chronic hepatitis B and C. © RSNA, 2021 Online supplemental material is available for this article. See also the editorial by Reeder in this issue.

Diffusion tensor imaging of the spleen in prediction and grading of esophageal varices in cirrhotic children with portal hypertension

PURPOSE

To assess diffusion tensor imaging (DTI) of spleen in prediction and grading of esophageal varices (OV) in cirrhotic children.

METHODS

This prospective study was conducted upon 30 children with cirrhotic children with OV and 10 age-gender matched controls that underwent DTI of abdomen. Mean diffusivity (MD) and fractional anisotropy (FA) of spleen were calculated and matched with the grading of OV at endoscopy and laboratory biomarkers of portal hypertension.

RESULTS

Mean ADC of spleen in patient was significantly different (p = 0.001) from that of controls by both reviewers respectively. The cutoff ADC measurement of the spleen used for prediction of OV was ≥ 0.75 and ≥ 0.76 × 10^-3mm²/s with AUC was 0.993 and 0.997 for both reviewers respectively. The FA of the spleen in patient was different (p = 0.01) from of controls of both reviewers respectively. Cutoff FA of spleen used for prediction of OV was ≤ 0.35 and ≤ 0.36 for both observers respectively. ADC and FA of spleen was correlated with platelets count (r =  - 0.713, 0.392; p = 0.001, 0.012) and prothrombin time (r = 0.518, - 0.380; p = 0.001, 0.016).

CONCLUSION

DTI metrics of spleen can predict and grade OV and correlated with laboratory biomarkers of portal hypertension.

Accuracy of liver and spleen stiffness on magnetic resonance elastography for detecting portal hypertension: a systematic review and meta-analysis

INTRODUCTION

The purpose of this systematic review and meta-analysis was to evaluate the diagnostic accuracy of liver and spleen stiffness on magnetic resonance elastography (MRE) for detecting clinically significant portal hypertension.

METHODS

A systematic review of MEDLINE, EMBASE, Scopus, the Cochrane Library, and the Grey Literature through to 15 August 2019 was performed. Original articles with >10 patients evaluating liver and/or spleen stiffness on MRE using a reference standard of portal hypertension defined as intractable ascites, esophageal varices, encephalopathy and/or death were included in analysis. Patient, clinical, MRI, and diagnostic performance was independently acquired by two reviewers. Meta-analysis was performed using a bivariate mixed-effects regression model.

RESULTS

Fourteen studies were included with 12 studies evaluating liver stiffness and eight studies evaluating spleen stiffness. The pooled and weighted sensitivity, specificity, and area under the curve (AUC) values for liver stiffness on MRE were 83% [95% confidence interval (CI) 72-90%], 80% (95% CI 70-88%), and 88% (95% CI 85-91%), respectively. The pooled and weighted sensitivity, specificity, and AUC values for spleen stiffness on MRE were 79% (95% CI 61-90%), 90% (95% CI 80-95%), and 92% (95% CI 89-94%), respectively. The liver and spleen stiffness sensitivity and specificity values were comparable when evaluating for esophageal varices only at of 80% (95% CI 66-89%) and 76% (95% CI 62-86%) for liver stiffness, and 75% (95% CI 52-90%) and 89% (95% CI 70-96%) for spleen stiffness.

DISCUSSION

Liver and spleen stiffness on MRE can serve as a supplemental noninvasive assessment tools for detecting clinically significant portal hypertension. Spleen stiffness may be more specific and accurate than liver stiffness for detecting portal hypertension.

Multiparametric MR mapping in clinical decision-making for diffuse liver disease

Accurate diagnosis, monitoring and treatment decisions in patients with chronic liver disease currently rely on biopsy as the diagnostic gold standard, and this has constrained early detection and management of diseases that are both varied and can be concurrent. Recent developments in multiparametric magnetic resonance imaging (mpMRI) suggest real potential to bridge the diagnostic gap between non-specific blood-based biomarkers and invasive and variable histological diagnosis. This has implications for the clinical care and treatment pathway in a number of chronic liver diseases, such as haemochromatosis, steatohepatitis and autoimmune or viral hepatitis. Here we review the relevant MRI techniques in clinical use and their limitations and describe recent potential applications in various liver diseases. We exemplify case studies that highlight how these techniques can improve clinical practice. These techniques could allow clinicians to increase their arsenals available to utilise on patients and direct appropriate treatments.

Quantitative assessment of portal hypertension with bi-parametric dual-frequency hepatic MR elastography in mouse models

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.

Quantitative Imaging in Pediatric Hepatobiliary Disease

Pediatric hepatobiliary imaging is important for evaluation of not only congenital or structural disease but also metabolic or diffuse parenchymal disease and tumors. A variety of ultrasonography and magnetic resonance imaging (MRI) techniques can be used for these assessments. In ultrasonography, conventional ultrasound imaging as well as vascular imaging, elastography, and contrast-enhanced ultrasonography can be used, while in MRI, fat quantification, T2/T2^* mapping, diffusion-weighted imaging, magnetic resonance elastography, and dynamic contrast-enhanced MRI can be performed. These techniques may be helpful for evaluation of biliary atresia, hepatic fibrosis, nonalcoholic fatty liver disease, sinusoidal obstruction syndrome, and hepatic masses in children. In this review, we discuss each tool in the context of management of hepatobiliary disease in children, and cover various imaging techniques in the context of the relevant physics and their clinical applications for patient care.

Periportal thickening on magnetic resonance imaging for hepatic fibrosis in infantile cholestasis

BACKGROUND

Untreated neonatal cholestasis can progress to liver cirrhosis and end stage liver disease in infancy due to prolonged hepatocyte and biliary tree injury and may require liver transplantation. Therefore, non-invasive evaluation of hepatic fibrosis is important in infants with cholestasis.

AIM

To investigate the usefulness of periportal thickening (PT) measured on liver magnetic resonance imaging (MRI) for the assessment of hepatic fibrosis in infants with cholestasis including biliary atresia (BA).

METHODS

This retrospective study included infants less than 6 mo who underwent liver MRI and biopsy for the evaluation of infantile cholestasis. PT and spleen size were measured on MRI. Serologic assessment was based on aspartate transaminase to platelet ratio index (APRI). The grade of histopathologic fibrosis was assessed by the METAVIR grading system. Correlation and diagnostic performance of PT, normalized spleen size ratio (SR, using the upper normal size limit), and APRI for diagnosing hepatic fibrosis were obtained by receiver-operating characteristic (ROC) curve analysis.

RESULTS

A total of 155 patients were included, 110 of which were diagnosed with BA. Mean age at the time of MRI was 57.6 ± 34.4 d. There were positive correlations between fibrosis grade and PT and SR, even after adjusting age (all, P < 0.001). For the diagnosis of significant fibrosis (METAVIR grade F2-F4), the area under the ROC curve was 0.899 (95%CI: 0.840–0.941) for PT (cutoff, 4.2 mm), which was higher than 0.741 (95%CI: 0.664–0.808) for SR and 0.712 (95%CI: 0.634–0.782) for APRI (both, P < 0.001). For the diagnosis of cirrhosis (F4), the area under the ROC curve was the highest with SR as 0.790 (95%CI: 0.718–0.852).

CONCLUSION

Liver MRI findings of PT and SR are useful to assess clinically significant hepatic fibrosis (F2 and higher) in infants with cholestasis including BA.

Assessment of liver fibrosis with liver and spleen magnetic resonance elastography, serum markers in chronic liver disease

Background

The accurate assessment of liver fibrosis is essential for patients with chronic liver disease. A liver biopsy is an invasive procedure that has many potential defects and complications. Therefore, noninvasive assessment techniques are of considerable value for clinical diagnosis. Liver and spleen magnetic resonance elastography (MRE) and serum markers have been proposed for quantitative and noninvasive assessment of liver fibrosis. This study aims to compare the diagnostic performance of liver and spleen stiffness measured by MRE, fibrosis index based on the 4 factors (FIB-4), aspartate aminotransferase-to-platelet ratio index (APRI), and their combined models for staging hepatic fibrosis.

Methods

One hundred and twenty patients with chronic liver disease underwent MRE scans. Liver and spleen stiffness were measured by the MRE stiffness maps. Serum markers were collected to calculate FIB-4 and APRI. Liver biopsies were used to identify pathologic grading. Spearman's rank correlation analysis evaluated the correlation between the parameters and fibrosis stages. Receiver operating characteristic (ROC) analysis evaluated the performance of the four individual parameters, a liver and spleen stiffness combined model, and an all-parameters combined model in assessing liver fibrosis.

Results

Liver stiffness, spleen stiffness, FIB-4, and APRI were all correlated with fibrosis stage (r=0.87, 0.64, 0.65, and 0.51, respectively, all P<0.001). Among the 4 individual diagnostic markers, liver stiffness showed the highest values in staging F1-4, F2-4, F3-4 and F4 (AUC =0.89, 0. 97, 0.95, and 0.95, all P<0.001). The AUCs of the liver and spleen stiffness combined model in the F1-4, F2-4, F3-4, and F4 staging groups were 0.89, 0.97, 0.95, and 0.96, respectively (all P<0.001). The corresponding AUCs of the all-parameters combined model were 0.90, 0.97, 0.95, and 0.96 (all P<0.001). The AUCs of the liver and spleen stiffness combined model were significantly higher than those of APRI, FIB-4 in the F2-4, F3-4, and F4 staging groups (all P<0.05). Both combined models were not significantly different from liver stiffness in staging liver fibrosis (all P>0.05).

Conclusions

Liver stiffness measured with MRE had better diagnostic performance than spleen stiffness, APRI, and FIB-4 for fibrosis staging. The combined models did not significantly improve the diagnostic value compared with liver stiffness in staging fibrosis.

Spleen and Liver Stiffness to Detect Esophageal Varices in Children with Biliary Atresia

OBJECTIVES

The aim of the study was to determine the accuracy of noninvasive parameters, such as liver (LS) and spleen stiffness (SS) to detect esophageal varices (EV) in children with biliary atresia (BA).

METHODS

Children with BA between 2000 and 2015 were recruited. All underwent esophagogastroduodenoscopy and transient elastography. Demographic data, laboratory investigations, alanine transferase-to-platelet ratio index (APRI), and Varices Prediction Rule (VPR) score were collected.

RESULTS

A total of 51 children (mean age 10.63 years, standard deviation (SD) = 6.08 years; 53% boys) were enrolled. There were differences in onset and outcome of portoenterostomy, spleen palpablility, platelet count, albumin, LS, SS, and VPR between the varice and varice-free groups (P < 0.05). In the varice group, the median LS was 18.12 (interquartile ratio, IQR 13.15-19.12) and the median SS was 46.85 (IQR 25.95-54.55) kPa. In the varice-free group, the median LS was 7.85 (IQR 5.88-16.75) and the median SS was 16.54 (IQR 11.75-21.75) kPa. Both LS and SS were higher in the varice than the varice-free group (P < 0001). The area under the receiver operating characteristic curve of LS, SS, spleen palpability, platelet count, APRI, and VPR were 0.734, 0.870, 0.817, 0.810, 0.751, and 0.794, respectively. Using a cut-off value of 12.5 kPa for LS, the sensitivity and specificity were 80 and 70%, respectively. Using a cut-off value of 28.9 kPa for SS, the sensitivity and specificity were 75 and 87%, respectively. Combination of LS and SS to diagnose varices increased the specificity to 93%.

CONCLUSIONS

SS as a single marker had the best diagnostic value to predict esophageal varices in children with BA. The combination of SS and LS furthermore, increased the diagnostic yield.