Liver biopsy for histological assessment: The case against

Heterogeneous Pathological Changes in Liver Lobes During Liver Disease: A Perspective Review

Liver diseases have a global prevalence of 25%, accounting for 4% of all deaths worldwide, and are associated with a 36% increased risk of fatal and nonfatal cardiovascular events. Metabolic dysfunction-associated steatotic liver disease constitutes the liver expression of metabolic syndrome and represents the primary type of liver disease. Microscopical analysis of biopsies, which allows the evaluation of a small portion of tissue with inferences made to the entire organ, is considered the gold standard for determining the presence of liver diseases. However, potential sampling errors in liver biopsies are conceivable because the obtained tissue represents only a tiny fraction of the entire liver mass and may not accurately reflect the true pathological state. Studies have demonstrated the existence of sampling errors in liver biopsies, particularly concerning the severity of inflammation, degree of fibrosis, and the presence of cirrhosis. Also, clinical studies have shown that histopathological abnormalities are better detected in humans when liver samples are collected from both the right and the left lobes. However, a gap exists in clinical investigation to clarify the role of differences between these lobes in improving the diagnostic and prognostic for liver diseases. Building upon the heterogeneous nature of pathological alterations observed in liver lobes, this perspective review provided recommendations to enhance the precision of diagnosis and prognostic accuracy of liver diseases.

Assessment of the Liver Steatosis and Fibrosis Risk in Metabolic Syndrome and Its Individual Components, Considering the Varying Definitions Used in Clinical Practice throughout Time: A Retrospective Cross-Sectional Study

Multiple modifications of metabolic syndrome diagnostic criteria have been made-NCEP: ATP III (from 2001, modified in 2004), IDF (2005), IDF Consortium (2009), or Polish Scientific Society Consortium standards (2022) are now frequently in use. Hepatosteatosis and hepatofibrosis are commonly mentioned aspects of metabolic syndrome that greatly increase the likelihood of developing complications. The objective of the study was to assess different diagnostic criteria for metabolic syndrome based on the prevalence of liver steatosis and fibrosis. A retrospective analysis was conducted on the medical data of 2102 patients. Out of all the single criteria, meeting the obesity criterion based on waist circumference showed the highest increase in the risk of hepatosteatosis (by 64-69%, depending on the definition used)-hypertriglyceridemia increased the risk of hepatofibrosis by 71%. Regardless of the specific criteria used, patients with metabolic syndrome had a 34-36% increased likelihood of developing hepatosteatosis-the probability of hepatofibrosis varied between 42% and 47% for the criteria established in 2004, 2005, and 2009, while the Polish 2022 criteria were not statistically significant (p = 0.818). It seems appropriate to establish consistent metabolic syndrome diagnostic criteria-the 2009 IDF guidelines are the most effective in assessing hepatosteatosis and fibrosis risk.

High early mortality after percutaneous liver biopsy in metastatic cancer: national analysis

OBJECTIVE

The study aimed to assess outcomes in patients undergoing liver biopsy for metastatic cancer, focusing on mortality rates and chemotherapy following their biopsy.

METHODS

Hospital Episode Statistics data from 2010 to 2019 identified 30 992 patients with metastatic cancer who underwent percutaneous liver biopsy. Primary outcomes included 14-day and 30-day mortality rates, as well as the proportion receiving chemotherapy within 6 months.

RESULTS

30 992 patients were studied (median age of 69 (IQR 59-74) years, 52% female). 28% underwent inpatient biopsy with 8% dying within 14 days and 26% within 30 days. Outpatient biopsies had lower mortality rates: 2.2% at 14 days and 8.6% at 30 days.30-day mortality was associated with: inpatient biopsy (OR 3.5 (95% CI 3.26 to 3.76)) and increasing comorbidity (Charlson score 1-4: 1.21 (95% CI 1.11 to 1.32)); but negatively with all ages under 70 (eg, for 18-29 years 0.35 (95% CI 0.20 to 0.63)) and biopsy at a radiotherapy centre (0.88 (95% CI 0.82 to 0.95)).46% of patients received chemotherapy within 6 months of biopsy (53% with outpatient biopsies but only 33% with inpatient biopsies). Receiving chemotherapy was associated with: all ages under 70 (eg, 18-29 years 3.3 (95% CI 2.62 to 5.30)), female sex (1.06 (95% CI 1.01 to 1.11)) and medium (1.13 (95% CI 1.04 to 1.22) and high (1.49 (95% CI 1.38 to 1.62)) volume liver biopsy providers; but negatively with inpatient biopsy (0.45 (95% CI 0.43 to 0.48)) and increasing comorbidity (Charlson score 1-4: 0.85 (95% CI 0.79 to 0.91)).

CONCLUSIONS

Mortality rates following liver biopsy for metastatic cancer are notably higher among patients undergoing emergency inpatient procedures. Clinicians should carefully weigh the risks and benefits of biopsy in elderly, comorbid or poor performance status patients. Multidisciplinary approaches involving palliative care may aid in decision-making for these patients.

Mistakes in utilising histopathology for the management of liver disease

INTRODUCTION

Liver biopsy has become selective due to its invasiveness, potential adverse effects, patient acceptance and cost. Furthermore, the emergence of noninvasive tests (NITs) has challenged the necessity of liver biopsies in specific clinical situations. However, liver biopsy continues to play a crucial role in disease diagnosis, prognosis, and evaluating treatment compliance and response in selected patients.

AREAS COVERED

In this narrative review, we discuss the errors and the shortcomings that can occur at various stages, from the initial patient selection for a liver biopsy to the final reporting phase, and strategies to address them. Clinicians and pathologists must take all necessary precautions to mitigate potential shortcomings that could compromise the value of liver biopsies.

EXPERT OPINION

The increasing sophistication of NITs offers a safer, more convenient, and potentially more cost-effective approach to diagnosing chronic liver disease, especially for assessing the degree of liver fibrosis. As NITs continue to evolve, liver biopsy will likely transition to a more targeted role, ensuring optimal patient care in the ever-changing field of hepatology. However, liver biopsy will continue to have a pivotal role in assessing acute liver disease where the diagnostic yield of the liver biopsy still outweighs that of NITs.

Photon-counting CT using multi-material decomposition algorithm enables fat quantification in the presence of iron deposits

PURPOSE

A new generation of CT detectors were recently developed with the ability to measure individual photon's energy and thus provide spectral information. The aim of this work was to assess the performance of simultaneous fat and iron quantification using a clinical photon-counting CT (PCCT) and its comparison to dual-energy CT (DECT), MRS and MRI at 3 T.

METHODS

Two 3D printed cylindrical phantoms with 32 samples (n = 12 fat fractions between 0 % and 100 %, n = 20 with mixtures of fat and iron) were scanned with PCCT and DECT scanners for comparison. A three-material decomposition approach was used to estimate the volume fractions of fat (FF), iron and soft tissue. The same phantoms were examined by MRI (6-echo DIXON, a.k.a. Q-DIXON) and MRS (multi-echo STEAM, a.k.a. HISTO) at 3 T for comparison.

RESULTS

PCCT, DECT, MRI and MRS computed FFs showed correlation with reference fat fraction values in samples with no iron (r > 0.98). PCCT decomposition showed slightly weaker correlation with FFref in samples with added iron (r = 0.586) compared to MRI (r = 0.673) and MRS (r = 0.716) methods. On the other hand, it showed no systematic over- or underestimation. Surprisingly, DECT decomposition-derived FF showed strongest correlation (r = 0.758) in these samples, however systematic overestimation was observed. FF values computed by three-material PCCT decomposition, DECT decomposition, MRI and MRS were unaffected by iron concentration.

CONCLUSIONS

This in-vitro study shows for the first time that photon-counting computed tomography may be used for quantification of fat content in the presence of iron deposits.

Synthesis and preclinical evaluation of a 89Zr-labelled human single chain antibody for non-invasive detection of hepatic myofibroblasts in acute liver injury

Synaptophysin is expressed on fibrogenic hepatic myofibroblasts. C1-3 is a single chain human antibody (scAb) that binds specifically to synaptophysin on hepatic myofibroblasts, providing a targeting vector for novel in vivo imaging agents of chronic liver disease. C1-3 and a negative control scAb, CSBD9, were radiolabelled with zirconium-89 via desferrioxamine chelation to enable non-invasive molecular imaging with positron emission tomography (PET). DFO-scAb conjugates were characterised by gel electrophoresis (SDS-PAGE) and MALDI-TOF spectrometry, and 89Zr-labelled with high radiolabelling efficiency (99%). [89Zr]Zr-DFO-C1-3 exhibited high in vitro stability (> 99%) in mouse and human sera over 3 days at 25 and 37 °C. Activated hepatic myofibroblasts incubated with [89Zr]Zr-DFO-C1-3 displayed significantly higher internalised activity (59.46%, P = 0.001) compared to the [89Zr]Zr-DFO-CSBD9 control, indicating synaptophysin-mediated uptake and high binding specificity of [89Zr]Zr-DFO-C1-3. Mice with CCl4-induced acute liver damage exhibited significantly higher liver uptake of [89Zr]Zr-DFO-C1-3, compared to controls, confirmed by both Cerenkov imaging and ex vivo gamma counting (4.41 ± 0.19%ID/g, P < 0.0001). CCl4-induced liver damage and the number of hepatic myofibroblasts was confirmed by αSMA staining of liver sections. These findings indicate that [89Zr]Zr-DFO-C1-3 has promising utility as a PET imaging agent for non-invasive detection of hepatic myofibroblasts following acute liver injury.

Prevalence of metabolic dysfunction-associated steatotic liver disease (MASLD) in a middle-aged population with overweight and normal liver enzymes, and diagnostic accuracy of noninvasive proxies

The prevalence of metabolic dysfunction-associated steatotic liver disease (MASLD) is increasing at an alarming rate. Elevated liver enzymes are a primary reason to refer patients for further testing. However, liver enzymes within the normal range do not exclude the presence of MASLD. We examined the prevalence of MASLD in a middle-aged population with overweight and normal liver enzymes. In addition, we examined the accuracy of 4 sets of noninvasive proxies for MASLD. We included 1017 participants from the Netherlands epidemiology of obesity cohort study with body mass index ≥25 kg/m2 and liver enzymes (asparate aminotransferase, alanine aminotransferase, gamma-glutamyltranspeptidase) within normal range. The diagnostic accuracy of biomarker scores (fatty liver index, liver fat score [LFS], STEATO-ELSA, and hepatic steatosis index) was determined against elevated hepatic triglyceride content measured by 1proton magnetic resonance spectroscopy. Participants (mean age 56 years, 49% women), had a median body mass index of 29.6 kg/m2 and a median hepatic triglyceride content of 4.4%. MASLD was present in 42% of participants and was more common in men than women, with respectively 47% and 36% being affected. The LFS showed the highest accuracy with an area under the curve of 0.72. We identified metabolic syndrome as the prime predictor for MASLD with an odds ratio of 2.95 (95% confidence interval 2.20-3.98). The prevalence of MASLD in middle-aged men and women with overweight and liver enzymes within the normal range is over 40%. LFS showed the highest accuracy to detect MASLD, but, overall, biomarker scores performed relatively poor. The presence of metabolic syndrome was the prime predictor of MASLD.

Vibration Controlled Transient Elastography in Screening for Silent Liver Diseases

OBJECTIVES

The objective of this study was to screen for significant hepatic fibrosis or steatosis in asymptomatic, apparently healthy subjects by using Vibration-controlled transient elastography and controlled attenuation parameter (CAP).

METHODS

Prospectively, 433 asymptomatic apparently healthy adults were included. Fibroscan/CAP examination was performed for all of them. Subjects with liver stiffness measurement > 6 kPa or CAP >248 dB/m were further evaluated to assess underlying chronic liver disease.

RESULTS

According to fibroscan/CAP examination, subjects were classified into four subgroups: normal (119) with CAP score of 215.85 ± 24.81 dB/m and fibrosis score of 4.47 ± 0.81 kPa, subjects with steatosis only 133 with CAP score of 309.41 ± 42.6 dB/m and fibrosis score of 4.74 ± 0.82 kPa, subjects with both steatosis and fibrosis 95 with CAP score of 318.20 ± 39.89 dB/m and fibrosis score of 7.92 ± 2.58 kPaand subjects with fibrosis only 86 with CAP score of 213.48 ± 22.62 dB/m and fibrosis score of 6.96 ± 1.11 kPa. S0 was present in 205 (47.3%), S1 in 48 (10.2%), S2 in 16 (3.7%) and S3 in 168 (38.8%) of studied subjects, whereas F0-1 was present in 371 (85.7%), F2 in 44 (10.16%), F3 in 16 (3.7%) subjects and F4 in only one (0.23%) subject. Subjects with both steatosis and fibrosis showed significantly higher transaminases, triglycerides and total cholesterol levels than other subgroups.

CONCLUSIONS

Most asymptomatic, apparently healthy subjects (72%) have significant steatosis and fibrosis. Liver stiffness measurement and CAP might represent promising first-line noninvasive procedures to screen for silent liver diseases in the general population.

Imaging of fibrogenesis in the liver by [18F]TZ-Z09591, an Affibody molecule targeting platelet derived growth factor receptor β

BACKGROUND

Platelet-derived growth factor receptor beta (PDGFRβ) is a receptor overexpressed on activated hepatic stellate cells (aHSCs). Positron emission tomography (PET) imaging of PDGFRβ could potentially allow the quantification of fibrogenesis in fibrotic livers. This study aims to evaluate a fluorine-18 radiolabeled Affibody molecule ([18F]TZ-Z09591) as a PET tracer for imaging liver fibrogenesis.

RESULTS

In vitro specificity studies demonstrated that the trans-Cyclooctenes (TCO) conjugated Z09591 Affibody molecule had a picomolar affinity for human PDGFRβ. Biodistribution performed on healthy rats showed rapid clearance of [18F]TZ-Z09591 through the kidneys and low liver background uptake. Autoradiography (ARG) studies on fibrotic livers from mice or humans correlated with histopathology results. Ex vivo biodistribution and ARG revealed that [18F]TZ-Z09591 binding in the liver was increased in fibrotic livers (p = 0.02) and corresponded to binding in fibrotic scars.

CONCLUSIONS

Our study highlights [18F]TZ-Z09591 as a specific tracer for fibrogenic cells in the fibrotic liver, thus offering the potential to assess fibrogenesis clearly.

Liver Mass Caused by Mycobacterium fortuitum: A Rare Case Diagnosed by EUS-FNA

Mycobacterium fortuitum is associated with skin and soft-tissue infections, yet isolated liver involvement is rare. A 67-year-old asymptomatic man was referred for endoscopic ultrasound (EUS) to evaluate a gastric lesion and an incidental liver mass. EUS revealed a heterogeneous liver mass that was sampled. Pathology revealed necrotic granulomatous inflammation and positive acid-fast bacilli stain with M. fortuitum deoxyribonucleic acid. Levofloxacin plus trimethoprim and sulfamethoxazole for 3 months were used for complete resolution of liver lesion. Isolated nontuberculous liver involvement is uncommon. We report the first case of a liver mass caused by M. fortuitum diagnosed by EUS-fine needle aspiration.

Current Status of Biomarkers and Molecular Diagnostic Tools for Rejection in Liver Transplantation: Light at the End of the Tunnel?

Strategies to minimize immune-suppressive medications after liver transplantation are limited by allograft rejection. Biopsy of liver is the current standard of care in diagnosing rejection. However, it adds to physical and economic burden to the patient and has diagnostic limitations. In this review, we aim to highlight the different biomarkers to predict and diagnose acute rejection. We also aim to explore recent advances in molecular diagnostics to improve the diagnostic yield of liver biopsies.

Trends in indirect liver function marker testing in Wales from 2000 to 2017 and their association with age and sex: an observational study

Objective

If non-invasive markers of liver fibrosis were recorded frequently enough in clinical practice, it might be feasible to use them for opportunistic community screening for liver disease. We aimed to determine their current pattern of usage in the national primary care population in Wales.

Design

Using the Secure Anonymised Information Linkage (SAIL) Databank at Swansea University (2000–2017), we quantified the frequency of common liver blood tests (aspartate aminotransferase (AST), alanine aminotransferase (ALT), platelet count and albumin) used in fibrosis marker algorithms. We examined measurement variation by age and sex.

Results

During the 18-year study period, there were 2 145 178 adult patients with at least one blood test available for analysis. Over the study period, the percentage of SAIL patients receiving an ALT test in each year increased from 2% to 33%, with platelet count and albumin measurement increasing by a similar factor. AST testing, although initially rising, had decreased to 1% by the end of the study. AST and ALT values varied by age and sex, particularly in males with the upper normal range of ALT values decreasing rapidly from 90 U/L at age 30 to 45 U/L by age 80.

Conclusion

The reduction in AST testing to only 1% of the adult population limits the use of many non-invasive liver marker algorithms. To enable widespread screening, alternative algorithms for liver fibrosis that do not depend on AST should be developed. Liver fibrosis markers should be modified to include age-specific and sex-specific normal ranges.

Multi-scale information with attention integration for classification of liver fibrosis in B-mode US image

BACKGROUND AND OBJECTIVE

Chronic hepatitis B (CHB) is one of the most common liver diseases in the world, which threats a lot to people's usual life. The increased deposition of fibrotic tissues in livers for patients with CHB may lead to the development of liver cirrhosis, hepatocellular carcinoma, or even liver failure. Accurate fibrosis staging is very important for the targeted treatment of liver fibrosis and its recovery.

METHODS

In this paper, we propose a new deep convolutional neural network (DCNN) with functions of multi-scale information extraction and attention integration for more accurate liver fibrosis classification from ultrasound (US) images. The proposed network uses two pyramid-structured CNN elements to extract multi-scale features from US images. Such a design significantly enlarges the receptive field of the convolution layer, such that more useful information can be explored by the neural network to associate with the final classification. Based on this, a new feature distillation method is also proposed to enhance the ability of deep features derived from multi-scale information. The proposed distillation method employs attention maps to automatically extract class-related features from multi-scale information, which effectively suppress the influence of potential distractors.

RESULTS

Experimental results on the US liver fibrosis dataset collected from 286 participants show that the proposed deep framework achieves promising classification performance. The proposed method achieves a classification accuracy of 95.66% on the test dataset.

CONCLUSION

Our proposed framework could stage liver fibrosis highly accurately. It might provide effective suggestions for the clinical treatment of liver fibrosis that can facilitate its recovery.

Development and multicenter validation of FIB-6: A novel, machine learning, simple bedside score to rule out liver cirrhosis and compensated advanced chronic liver disease in patients with chronic hepatitis C

BACKGROUND

Non-invasive tests (NITs), such as Fibrosis-4 index (FIB-4) and the aspartate aminotransferase-to-platelet ratio index (APRI), developed using classical statistical methods, are increasingly used for determining liver fibrosis stages and recommended in treatment guidelines replacing the liver biopsy. Application of conventional cutoffs of FIB-4 and APRI resulted in high rates of misclassification of fibrosis stages.

AIM

There is an unmet need for more accurate NITs that can overcome the limitations of FIB-4 and APRI.

PATIENTS AND METHODS

Machine learning with the random forest algorithm was used to develop a non-invasive index using retrospective data of 7238 patients with biopsy-proven chronic hepatitis C from two centers in Egypt; derivation dataset (n = 1821) and validation set in the second center (n = 5417). Receiver operator curve analysis was used to define cutoffs for different stages of fibrosis. Performance of the new score was externally validated in cohorts from two other sites in Egypt (n = 560) and seven different countries (n = 1317). Fibrosis stages were determined using the METAVIR score. Results were also compared with three established tools (FIB-4, APRI, and the aspartate aminotransferase-to-alanine aminotransferase ratio [AAR]).

RESULTS

Age in addition to readily available laboratory parameters such as aspartate, and alanine aminotransferases, alkaline phosphatase, albumin (g/dl), and platelet count (/cm³ ) correlated with the biopsy-derived stage of liver fibrosis in the derivation cohort and were used to construct the model for predicting the fibrosis stage by applying the random forest algorithm, resulting in an FIB-6 index, which can be calculated easily at http://fib6.elriah.info. Application of the cutoff values derived from the derivation group on the validation groups yielded very good performance in ruling out cirrhosis (negative predictive value [NPV] = 97.7%), compensated advance liver disease (NPV = 90.2%), and significant fibrosis (NPV = 65.7%). In the external validation groups from different countries, FIB-6 demonstrated higher sensitivity and NPV than FIB-4, APRI, and AAR.

CONCLUSION

FIB-6 score is a non-invasive, simple, and accurate test for ruling out liver cirrhosis and compensated advance liver disease in patients with chronic hepatitis C and performs better than APRI, FIB-4, and AAR.

Arginase-1 and P-glycoprotein are downregulated in canine hepatocellular carcinoma

Background

Hepatocellular carcinoma is the most common primary hepatic malignancy in humans and dogs. Several differentially expressed molecules have been studied and reported in human hepatocellular carcinoma and non-neoplastic liver lesions. However, studies on the features of canine hepatocellular carcinoma are limited, especially related to the differential characteristics of neoplastic and non-neoplastic lesions.

Objectives

The study's objective was 1) to examine and evaluate the expression of arginase-1, P-glycoprotein, and cytokeratin 19 in canine liver tissues and 2) to investigate the differential features of hepatocellular carcinomas, liver tissue with non-neoplastic lesions, and paracancerous liver tissues in dogs.

Methods

The expression levels of three markers underwent immunohistochemical analysis in 40 non-neoplastic liver tissues, 32 hepatocellular carcinoma tissues, and 11 paracancerous liver tissues. Scoring of each marker was performed semi-quantitatively.

Results

Arginase-1 and P-glycoprotein were significantly downregulated in hepatocellular carcinoma, compared with hepatic tissues with non-neoplastic diseases (p < 0.001). Expression levels of arginase-1 and P-glycoprotein were also significantly lower in hepatocellular carcinoma than in paracancerous liver tissues (arginase-1, p = 0.0195; P-glycoprotein, p = 0.047). Few cytokeratin 19-positive hepatocytes were detected and only in one hepatocellular carcinoma and one cirrhotic liver sample.

Conclusions

The results of this study suggest that downregulation of arginase-1 and P-glycoprotein is a feature of canine hepatocellular carcinoma; thus, those markers are potential candidates for use in differentiating hepatocellular carcinomas from non-neoplastic liver lesions in dogs.

Impact of iron deposit on the accuracy of quantifying liver fat fraction using multi-material decomposition algorithm in dual-energy spectral computed tomography

Objectives

To investigate the accuracy of using multi‐material decomposition (MMD) algorithm in dual‐energy spectral computed tomography (CT) for quantifying fat fraction (FF) in the presence of iron.

Materials

Nine tubes with various proportions of fat and iron were prepared. FF were divided into three levels (10%, 20%, and 30%), recorded as references (FF_ref). Iron concentrations (in mg/100 g) were divided into three ranges (25.25–25.97, 50.38–51.55 and 75.57–77.72). The nine‐tube phantom underwent dual‐energy CT and MR. CT attenuation was measured and FF were determined using MMD in CT (FF_CT) and Iterative Decomposition of water and fat with Echo Asymmetry and Least squares estimation (IDEAL‐IQ) in MR (FF_MR) for each tube. Statistical analyses used were: Spearman rank correlation for correlations between FF_ref and CT attenuation, FF_CT, and FF_MR; one‐way ANOVA, and one‐sample t‐test for the differences between FF_CT and FF_ref and between FF_MR and FF_ref. A multivariate linear regression model was established to analyze the differences between the corresponding values with different iron concentrations under the same FF_ref.

Results

Fat fraction on CT (FFCT) and FF_MR were positively correlated with FF_ref (all p < 0.001), while the CT attenuation was negatively correlated with FF_ref in the three iron concentration ranges. For a given FF_ref, FF_CT decreased and FF_MR increased as the iron concentration increased. The mean difference between FF_CT and FF_ref over the nine tube measurements was 0.25 ± 2.45%, 5.7% lower the 5.98 ± 3.33% value between FF_MR and FF_ref (F = 310.017, p < 0.01).

Conclusion

The phantom results indicate that MMD in dual‐energy CT can directly quantify volumetric FF and is less affected by iron concentration than MR IDEAL‐IQ method.

Quantitative multiparametric magnetic resonance imaging can aid non-alcoholic steatohepatitis diagnosis in a Japanese cohort

BACKGROUND

Non-invasive assessment of non-alcoholic steatohepatitis (NASH) is increasing in desirability due to the invasive nature and costs associated with the current form of assessment; liver biopsy. Quantitative multiparametric magnetic resonance imaging (mpMRI) to measure liver fat (proton density fat fraction) and fibroinflammatory disease [iron-corrected T1 (cT1)], as well as elastography techniques [vibration-controlled transient elastography (VCTE) liver stiffness measure], magnetic resonance elastography (MRE) and 2D Shear-Wave elastography (SWE) to measure stiffness and fat (controlled attenuated parameter, CAP) are emerging alternatives which could be utilised as safe surrogates to liver biopsy.

AIM

To evaluate the agreement of non-invasive imaging modalities with liver biopsy, and their subsequent diagnostic accuracy for identifying NASH patients.

METHODS

From January 2019 to February 2020, Japanese patients suspected of NASH were recruited onto a prospective, observational study and were screened using non-invasive imaging techniques; mpMRI with LiverMultiScan^®, VCTE, MRE and 2D-SWE. Patients were subsequently biopsied, and samples were scored by three independent pathologists. The diagnostic performances of the non-invasive imaging modalities were assessed using area under receiver operating characteristic curve (AUC) with the median of the histology scores as the gold standard diagnoses. Concordance between all three independent pathologists was further explored using Krippendorff’s alpha (a) from weighted kappa statistics.

RESULTS

N = 145 patients with mean age of 60 (SD: 13 years.), 39% females, and 40% with body mass index ≥ 30 kg/m² were included in the analysis. For identifying patients with NASH, MR liver fat and cT1 were the strongest performing individual measures (AUC: 0.80 and 0.75 respectively), and the mpMRI metrics combined (cT1 and MR liver fat) were the overall best non-invasive test (AUC: 0.83). For identifying fibrosis ≥ 1, MRE performed best (AUC: 0.97), compared to VCTE-liver stiffness measure (AUC: 0.94) and 2D-SWE (AUC: 0.94). For assessment of steatosis ≥ 1, MR liver fat was the best performing non-invasive test (AUC: 0.92), compared to controlled attenuated parameter (AUC: 0.75). Assessment of the agreement between pathologists showed that concordance was best for steatosis (a = 0.58), moderate for ballooning (a = 0.40) and fibrosis (a = 0.40), and worst for lobular inflammation (a = 0.11).

CONCLUSION

Quantitative mpMRI is an effective alternative to liver biopsy for diagnosing NASH and non-alcoholic fatty liver, and thus may offer clinical utility in patient management.

Essential phospholipids for nonalcoholic fatty liver disease associated with metabolic syndrome: A systematic review and network meta-analysis

BACKGROUND

Essential phospholipids (EPL) are used for the supportive treatment of non-alcoholic fatty liver disease (NAFLD), but data are mostly from small-scale studies.

AIM

To evaluate the efficacy of EPL treatment in adult patients with NAFLD and type 2 diabetes and/or obesity.

METHODS

The MEDLINE, PubMed, Embase, and Cochrane databases were searched up to March 2019 for clinical trials and comparative observational studies. Eligible studies were those published in English or Chinese that enrolled adult patients (≥ 18 years) with NAFLD and type 2 diabetes mellitus and/or obesity receiving EPL as monotherapy or as add-on therapy to existing therapy, and that included at least one of the efficacy outcomes of interest. A variety of studies were identified; thus, direct, indirect and cohort meta-analyses were performed. Mean difference (MD) and 95% confidence interval (CI) were calculated for continuous variables, and relative risk with 95%CI for disease response and recovery. A random-effects model was used to address between-study heterogeneity.

RESULTS

Ten studies met the inclusion criteria (n = 22-324). EPL treatment duration ranged from 4 to 72 wk. In the direct meta-analysis (four randomized controlled trials), compared with antidiabetic therapy alone, EPL plus antidiabetic therapy was associated with a significantly greater reduction in [alanine aminotransferase (ALT); MD: 11.28 U/L (95%CI: -17.33, -5.23), P = 0.0003], triglyceride [MD: -49.33 mg/dL (95%CI: -66.43, -32.23), P < 0.0001] and total cholesterol levels [MD: -29.74 mg/dL (95%CI: -38.02, -21.45), P < 0.0001]. There was also a significant increase in the rate of overall improvement [relative risk 1.50 (95%CI: 1.26-1.79), P < 0.0001], and risk of no disease (P = 0.0091), and a reduction in moderate disease (P = 0.0187); there were no significant differences in severe disease, mild disease, or significant improvement. In the cohort meta-analysis of three non-randomized clinical trials, the MD in ALT levels was -16.71 U/L (95%CI: -24.94, -8.49) and 23% of patients had improved disease. In the cohort meta-analysis of five randomized trials, MD in ALT levels was –28.53 U/L (95%CI: -35.42, -21.65), and 87% (95%CI: 81%, 93%) and 58% (95%CI: 46%, 70%) of patients showed clinical improvement and significant clinical improvement.

CONCLUSION

This analysis provides evidence for a benefit of EPL in patients with NAFLD and diabetes and/or obesity. Further large-scale trials are warranted.

Hepatic pathological features in naïve patients with chronic hepatitis C who have developed thyroid disorder

Knowing the hepatic pathological features encountered in patients with chronic hepatitis C (CHC) and the fact that extrahepatic manifestations occur only in people with certain characteristics of the immune system, we tried to evaluate, qualitatively and semi-quantitatively, the liver pathological aspects encountered in 96 patients with CHC, previously untreated with Interferon (naïve), who showed or did not show signs of thyroid disorder (TD), hospitalized in the 2nd Medical Clinic of the Emergency County Hospital, Craiova, Romania, within a period of five years (2007-2012). Following hormonal, immunological, and thyroid ultrasound investigations, 14 (14.58%) of the 96 patients showed signs of TD. The main clinical forms of TD in the studied patients with CHC were autoimmune thyroiditis and subclinical hypothyroidism. In the patients with CHC with TD, we found mild chronic hepatitis in 14.28% of cases, the appearance of moderate chronic hepatitis was found in 71.42% patients, and the appearance of severe chronic hepatitis was found in 14.28% patients, while in the patients with CHC without TD we found chronic mild hepatitis in 62.19% of cases, the appearance of moderate chronic hepatitis was met in 32.92% patients, and the appearance of severe chronic hepatitis was found in 4.87% of patients. Mild and moderate fibrosis were found only in CHC patients without TD in a percentage of 25.6% and 65.85%, respectively, while severe fibrosis was found at 12.19% among CHC patients without TD and 92.85% among CHC patients with TD. The pathological aspect of liver cirrhosis was found only in those with TD (7.14%). In conclusion, the pathological features which define the liver necroinflammatory process, as encountered at the pathological examination in CHC patients with TD are the same as in any active chronic hepatitis, the differences being represented by the higher percentage of the periportal and the preseptal necrosis (piecemeal necrosis), as well as by the higher score of portal inflammation. In addition, the severe hepatic fibrosis and the histopathological appearance of the liver cirrhosis have only defined the cases of CHC with TD.

Quantitative assessment of liver fibrosis by digital image analysis reveals correlation with qualitative clinical fibrosis staging in liver transplant patients

Technologies for digitizing tissues provide important quantitative data for liver histopathology investigation. We aimed to assess liver fibrosis degree with quantitative morphometric measurements of histopathological sections utilizing digital image analysis (DIA) and to further investigate if a correlation with histopathologic scoring (Scheuer staging) exists. A retrospective study of patients with at least two post-liver transplant biopsies having a Scheuer stage of ≤ 2 at baseline were gathered. Portal tract fibrotic percentage (%) and size (μm²) were measured by DIA, while clinical fibrosis score was measured by the Scheuer system. Correlations between DIA measurements and Scheuer scores were computed by Spearman correlation analysis. Differences between mean levels of fibrosis (score, size, and percentage) at baseline versus second visit were computed by Student’s t-test. P values < 0.05 were considered significant. Of 22 patients who met the study criteria, 54 biopsies were included for analysis. Average levels ±standard error [S.E.] of portal tract fibrotic percentage (%) and size (μm²) progressed from 46.5 ± 3.6% at baseline to 61.8 ± 3.8% at the second visit (P = 0.005 by Student’s t-test), and from 28,075 ± 3,232 μm² at base line to 67,146 ± 10,639 μm² at the second visit (P = 0.002 by Student’s t-test), respectively. Average levels of Scheuer fibrosis scores progressed from 0.55±0.19 at baseline to 1.14±0.26 at the second visit (P = 0.02 by Student’s t-test). Portal tract fibrotic percentage (%) and portal tract fibrotic size were directly correlated with clinical Scheuer fibrosis stage, with Spearman correlation coefficient and P value computed as r = 0.70, P < 0.0001 and r = 0.41, P = 0.002, respectively. Digital quantitative assessment of portal triad size and fibrosis percentage demonstrates a strong correlation with visually assessed histologic stage of liver fibrosis and complements the standard assessment for allograft monitoring, suggesting the utility of future WSI analysis.

Photoacoustic Imaging for Assessing Tissue Oxygenation Changes in Rat Hepatic Fibrosis

Chronic liver inflammation progressively evokes fibrosis and cirrhosis resulting in compromised liver function, and often leading to cancer. Early diagnosis and staging of fibrosis is crucial because the five-year survival rate of early-stage liver cancer is high. This study investigates the progression of hepatic fibrosis induced in rats following ingestion of diethylnitrosamine (DEN). Changes in oxygen saturation and hemoglobin concentration resulting from chronic inflammation were assayed longitudinally during DEN ingestion by photoacoustic imaging (PAI). Accompanying liver tissue changes were monitored simultaneously by B-mode sonographic imaging. Oxygen saturation and hemoglobin levels in the liver increased over 5 weeks and peaked at 10 weeks before decreasing at 13 weeks of DEN ingestion. The oxygenation changes were accompanied by an increase in hepatic echogenicity and coarseness in the ultrasound image. Histology at 13 weeks confirmed the development of severe fibrosis and cirrhosis. The observed increase in PA signal representing enhanced blood oxygenation is likely an inflammatory physiological response to the dietary DEN insult that increases blood flow by the development of neovasculature to supply oxygen to a fibrotic liver during the progression of hepatic fibrosis. Assessment of oxygenation by PAI may play an important role in the future assessment of hepatic fibrosis.

Vibration-controlled transient elastography for the detection of cirrhosis in chronic hepatitis D infection

Noninvasive detection of cirrhosis via vibration-controlled transient elastography (VCTE) has revolutionized the management of chronic hepatitis B virus (HBV) and hepatitis C virus (HCV) infection. However, VCTE has not been studied in chronic hepatitis D virus (HDV) infection and accuracy remains in question due to the significant hepatic inflammation associated with this infection. Consecutive HBV, HCV and HDV patients who underwent VCTE (2006-2019) were evaluated. Diagnosis of cirrhosis was made via liver biopsy or clinical findings. VCTE was compared with other noninvasive serum fibrosis tests using AUROC curves. The performance of VCTE in HBV/HCV/HDV was also compared. We evaluated 319 patients (HBV-112; HCV-132; HDV-75), 278(87%) patients had histology for evaluation. HDV patients had evidence of higher hepatic inflammation as evidence by aspartate aminotransferase, alanine aminotransferase and histology activity index. Cirrhotic HDV patients had higher mean liver stiffness measurements compared with noncirrhotic patients (29.0 vs 8.3 kPa, P < .0001). VCTE demonstrated excellent diagnostic accuracy for the detection of cirrhosis with an AUROC of 0.90 compared with APRI (0.83), FIB-4 (0.88), AAR (0.73) and RPR (0.85). Performance of VCTE in HDV was comparable with HBV (0.93) and HCV (0.94). At the optimized cut-off value of ≥14.0 kPa for determining cirrhosis in HDV, VCTE had a sensitivity of 0.78, specificity of 0.86, NPV of 0.93 and PPV of 0.64. Hence, VCTE is a useful noninvasive test in HDV for determining cirrhosis despite the presence of significant hepatic inflammation.

Validation of Novel Fibrosis Index (NFI) for assessment of liver fibrosis: comparison with transient elastography (FibroScan)

Background

In this study, we collated cheap and readily available non-invasive biomarkers and FibroScan score in predicting fibrosis stages in chronic hepatitis C virus (HCV) infection.

Methods

We studied 1898 patients with HCV infection confirmed by presence of HCV RNA in their serum. We compared the FibroScan score and fibrosis indices (FIs): aspartate transaminase (AST) to alanine transaminase (ALT) ratio (AAR), AST to Platelet Ratio Index (APRI), FI, fibrosis-4 (FIB-4), Age-Platelet Index (API), Pohl score, Fibrosis Cirrhosis Index (FCI). We developed a new FI, named Novel Fibrosis Index (NFI) calculated by the following formula: NFI=[(bilirubin×(ALP)²)/(platelet count (albumin)²)]−n.

Results

AAR, APRI, FI, FIB-4, API, Pohl score, FCI and NFI were able to predict fibrosis stage with correlation coefficient indices 0.848, 0.711, 0.618, 0.741, 0.529, 0.360, 0.477 and 0.26, respectively. Receiver operating characteristic curves showed sensitivity and specificity for predicting F3 by NFI=75.1% and 41.1% and F4 for NFI=72.1% and 47.1%, AAR=62.8% and 37.6%, APRI=74.6% and 87.6%, FIB-4=53.2% and 72.3%, FI=78.1% and 92.3%, API=78.1% and 60%, Pohl score=38.1% and 78.1% and FCI=78.1% and 88.1%.

Conclusions

Our NFI predicted F3 and has been found to have more sensitivity and specificity in predicting F4 fibrosis stage than other FIs.

Inter-observer Variability in Histomorphological Evaluation of Non-neoplastic Liver Biopsy Tissue and Impact of Clinical Information on Final Diagnosis in Shahid Beheshti University of Medical Sciences Affiliated Hospitals

Background & Objective:

Liver biopsy is the main method for grading and staging liver disorders, but the effects of clinical information and optimal biopsy specimen size on interpretation remain contentious. The aim of the study was to evaluate the impact of clinical information and quality of liver specimen on inter-observer agreement for liver disease.

Methods:

A total of 289 consecutive biopsy specimens from 2010 to 2017 were re-evaluated by five pathologists using the modified Ishak and non-alcoholic fatty liver diseases (NAFLD) activity score (NAS) systems. Detailed clinical information was extracted from medical records of patients and the size of all liver biopsy samples was recorded.

Results:

Full agreement between primary diagnosis and final diagnosis was obtained in 214 cases (74%). The remaining cases, namely 22 (7.6%) and 53 (18.3%) biopsies had minor and major diagnostic discrepancies, respectively. The results showed that the overall agreement was significantly higher in cases with complete clinical information than patients without any clinical information and even with partial clinical information (P<0.001). Interestingly, no significant difference in inter-observer agreement was achieved with a length over 20 mm (P=0.181). However, the inter-observer variation significantly decreased when the number of portal tract was more than 10 (P=0.001).

Conclusion:

This study identified the impact of clinical information and the number of portal tracts as the key factors to diagnosis. Therefore, request forms for liver biopsies should always be accompanied with the clinical history. Moreover, adequacy of biopsy specimens is very useful for accurate evaluation of samples by pathologists.

Diagnosis and management of non-alcoholic fatty liver disease

Non-alcoholic fatty liver disease (NAFLD) is the most common chronic liver disease in Western industrialised countries. The prevalence of NAFLD is increasing in parallel with the global rise in obesity and type 2 diabetes mellitus. NAFLD represents a spectrum of liver disease severity. NAFLD begins with accumulation of triacylglycerols in the liver (steatosis), and is defined by hepatic fatty infiltration amounting to greater than 5% by liver weight or the presence of over 5% of hepatocytes loaded with large fat vacuoles. In almost a quarter of affected individuals, steatosis progresses with the development of liver inflammation to non-alcoholic steatohepatitis (NASH). NASH is a potentially progressive liver condition and with ongoing liver injury and cell death can result in fibrosis. Progressive liver fibrosis may lead to the development of cirrhosis in a small proportion of patients. With the growing prevalence of NAFLD, there is an increasing need for a robust, accurate and non-invasive approach to diagnosing the different stages of this condition. This review will focus on (1) the biochemical tests and imaging techniques used to diagnose the different stages of NAFLD; and (2) a selection of the current management approaches focusing on lifestyle interventions and pharmacological therapies for NAFLD.

Automated detection and classification of liver fibrosis stages using contourlet transform and nonlinear features

BACKGROUND AND OBJECTIVE

Liver fibrosis is a type of chronic liver injury that is characterized by an excessive deposition of extracellular matrix protein. Early detection of liver fibrosis may prevent further growth toward liver cirrhosis and hepatocellular carcinoma. In the past, the only method to assess liver fibrosis was through biopsy, but this examination is invasive, expensive, prone to sampling errors, and may cause complications such as bleeding. Ultrasound-based elastography is a promising tool to measure tissue elasticity in real time; however, this technology requires an upgrade of the ultrasound system and software. In this study, a novel computer-aided diagnosis tool is proposed to automatically detect and classify the various stages of liver fibrosis based upon conventional B-mode ultrasound images.

METHODS

The proposed method uses a 2D contourlet transform and a set of texture features that are efficiently extracted from the transformed image. Then, the combination of a kernel discriminant analysis (KDA)-based feature reduction technique and analysis of variance (ANOVA)-based feature ranking technique was used, and the images were then classified into various stages of liver fibrosis.

RESULTS

Our 2D contourlet transform and texture feature analysis approach achieved a 91.46% accuracy using only four features input to the probabilistic neural network classifier, to classify the five stages of liver fibrosis. It also achieved a 92.16% sensitivity and 88.92% specificity for the same model. The evaluation was done on a database of 762 ultrasound images belonging to five different stages of liver fibrosis.

CONCLUSIONS

The findings suggest that the proposed method can be useful to automatically detect and classify liver fibrosis, which would greatly assist clinicians in making an accurate diagnosis.

Differentiating Cystic Liver Lesions: A Review of Imaging Modalities, Diagnosis and Management

Hepatic cysts (HCs) are frequently discovered incidentally on abdominal imaging. The prevalence of HCs has been reported as high as 15-18% in the United States. Although most cysts are benign, some are malignant or premalignant. It is important to diagnose cystic lesions in order to properly manage them. Imaging with conventional ultrasound, computed tomography, magnetic resonance imaging, or contrast-enhanced ultrasound can be used to further characterize and diagnose HCs. Ultrasound is typically the first-line imaging modality, whereas more advanced imaging can help narrow down the specific lesion. Contrast-enhanced ultrasound is a newer modality, recently approved in the United States, which offers non-invasive evaluation in real-time. The first step in diagnosis is stratifying risk by differentiating simple and complex cysts. There are several features that can help identify HCs, including septae, mural consistency, calcifications, and quality of cystic fluid. Simple cysts are mainly congenital cysts, but also occur in polycystic liver disease. Complex cysts include mucinous neoplasms, echinococcal cysts, hemorrhagic cysts, cystic hepatocellular carcinoma and other rare lesions. Treatment is indicated in symptomatic cysts or those suspicious for malignant or premalignant features. Treatment modalities include fenestration, aspiration sclerotherapy, or surgical resection.

Delayed hepatic rupture post ultrasound-guided percutaneous liver biopsy: A case report

RATIONALE

Hemorrhage, one of complications after liver biopsy, is often identified immediately after the procedure while delayed liver rupture is relatively rare.

PATIENT CONCERNS

A 45-year-old woman was diagnosed with undetermined liver cirrhosis and abnormal liver function. To determine the etiology and severity of liver cirrhosis, ultrasound-guided liver biopsy was arranged. The patients did not complain any pain during the procedure. Ultrasound examination on postoperative day1 (POD 1) and MRI on POD 3 showed no evidence of hematoma and ascites. On POD 7, however, the patient was taken to the hospital with a sudden onset of pain in the right upper quadrant of the abdomen.

DIAGNOSES

Contrast-enhanced computed tomography revealed liver rupture of right inferior segment of the liver with subcapsular hematoma.

INTERVENTIONS

Patient was treated with infusion of 2-unit red blood cell suspension, fluid and hemostatics.

OUTCOMES

The vital signs of the patient were stabilized after the therapy. The follow-up ultrasound 1 month later showed a shrunken subcapsular hematoma measuring 4.2 × 2.1 cm at the right lobe.

LESSONS

Whenever a liver biopsy procedure is performed, the care should be taken to avoid puncturing those areas that may have liver incisure. Moreover, the patient need to rest for several days and to avoid heavy activities, which is one of the major risk factors for post-procedure bleeding.

Vitamin D receptor gene methylation in hepatocellular carcinoma

Worldwide, hepatocellular carcinoma (HCC) is the major subtype of primary liver cancers. HCC is typically diagnosed late in its course. With respect to cancer, the genomic actions of vitamin D are mediated through binding to the Vitamin D Receptor (VDR), which allows it to modulate the expression of genes in a cell-and tissue-specific manner. Epigenetics is a rapidly evolving field of genetic study applicable to HCC. Changes in DNA methylation patterns are thought to be early events in hepatocarcinogenesis. Curcumin has great potential as an epigenetic agent. Accordingly, the current study has been designed to study the methylation status of VDR gene promoter for the first time in HCC aiming to find its clinical significance and potential screening role in chronic Liver Disease (CLD). Additionally, we aimed to investigate, the effect of Curcumin on HCC cell line, aiming to discover new therapeutic targets through epigenetics. This study was conducted on 45 formalin-fixed, paraffin-embedded liver tissue blocks including 15 HCC samples (group A), 15 CLD samples (group B) and 15 apparently normal tissue taken from around benign lesions (group C). Methylation Specific Restriction Digestion and qPCR were done on all samples after DNA extraction. The percentage of VDR gene promoter methylation was significantly higher in the HCC group compared to both CLD and control groups (p < 0.01). VDR promoter methylation by (MS-qPCR) was decreased and the relative expression of VDR by (qRT-PCR) was markedly increased in a dose-dependent fashion in cells grown in Curcumin-adequate medium. In conclusion, this study may open a new gate for the use of VDR promoter methylation as a potential biomarker in HCC.

Shear-wave ultrasound elastography of the liver in normal-weight and obese children

Background The identification and subsequent management of liver diseases in children is challenging due to the lack of non-invasive imaging biomarkers. Ultrasound shear-wave elastography (US-SWE) is an emerging imaging technique which can quantitatively assess liver stiffness and may be useful as a tool in the management of liver disease in overweight and obese children. Purpose To evaluate US-SWE velocities of the liver in normal-weight and obese children, to correlate US-SWE findings with age and body-mass-index (BMI), and to compare US-SWE values with qualitative assessment (i.e. normal versus abnormal echogenicity) of the liver by conventional US. Material and Methods A cohort of 300 children (mean age, 9.9 ± 5.3 years; age range, 0.06-18.9 years) were studied, comprising 176 normal-weight and 124 obese participants. In each patient, both US-SWE and conventional US of the liver were obtained. Three pediatric radiologists individually and in consensus determined whether liver parenchyma was of normal or abnormal echogenicity. Results US-SWE velocities differed between normal-weight and obese children (1.08 ± 0.14 versus 1.44 ± 0.39 m/s; P < 0.001), but not by gender. Multivariate linear regression demonstrated US-SWE velocity to be primarily associated with age in normal-weight children ( P < 0.05) and with BMI in obese children ( P < 0.001). In the obese group, mean US-SWE velocity was statistically higher in participants with abnormal echogenic livers than in those with normal-appearing livers (1.53 ± 0.38 vs. 1.17 ± 0.27). The difference was not significant in the normal-weight group. Conclusion US-SWE provides a useful quantitative imaging biomarker for evaluating liver stiffness in children.

Reproducibility of 2-Dimensional Shear Wave Elastography Assessment of the Liver: A Direct Comparison With Point Shear Wave Elastography in Healthy Volunteers

OBJECTIVES

Two-dimensional shear wave elastography (2D-SWE) imaging for the noninvasive assessment of tissue stiffness was assessed for reproducibility in healthy volunteers in quantifying liver elasticity, compared with an established point shear wave elastography (p-SWE) technique also known as virtual touch quantification (VTQ) (SIEMENS).

METHODS

Eleven healthy volunteers were examined by four experienced operators on two occasions, separated by two weeks (sessions A and B). Ten 2D-SWE using LOGIQ E9 and p-SWE measurements using VTQ (in meters per second) were consecutively taken from deep portions of liver segments 5 or 6 away from vascular structures, using standard techniques. Inter- and intra-observer agreement was assessed by intraclass coefficient (ICC).

RESULTS

A total of 880 2D-SWE and p-SWE velocities were recorded. Mean values from the four operators ranged between 1.188 and 1.196 m/s for 2D-SWE and 1.170 to 1.207 m/s for p-SWE. Interobserver reproducibility was good for both sessions with ICCs of 0.88 and 0.93 (2D-SWE) and 0.87 and 0.93 (p-SWE). The overall intra-operator reproducibility between sessions A and B was good for both p-SWE and 2D-SWE with ICC of 0.87 and 0.83, respectively. For inter- and intra-observer variability, the ICC was more than or equal to 0.71, indicating that the results were reliable. There was a strong and significant correlation between the 2D-SWE and p-SWE measurements (r = 0.87, P = .0006), but their velocities did not agree equally across different velocities.

CONCLUSIONS

Two-dimensional SWE using LOGIQ E9 is a reliable and reproducible method for measuring elasticity in healthy volunteers and has a similar degree of reliability as p-SWE using VTQ, but absolute measurements from the two techniques should not be used interchangeably.

Performance of magnetic resonance elastography in primary sclerosing cholangitis

BACKGROUND AND AIM

Liver stiffness (LS) measured by magnetic resonance elastography (MRE) is emerging as an important biomarker in chronic liver diseases. We examined the diagnostic performance of MRE, factors associated with an increased LS and the prognostic value of LS as measured by MRE among patients with primary sclerosing cholangitis (PSC).

METHODS

We performed a retrospective review of 266 patients with PSC to examine whether LS was associated with the primary endpoint of hepatic decompensation (ascites, variceal hemorrhage and hepatic encephalopathy). The ability of MRE to differentiate stages of fibrosis was examined in a subset of patients who underwent a liver biopsy (n = 20).

RESULTS

An LS of 4.93 kPa was the optimal point to detected F4 fibrosis (sensitivity, 1.00; 95% confidence interval (CI), 0.40-1.00; specificity, 0.94; 95%CI, 0.68-1.00). While a serum alkaline phosphatase <1.5 times the upper limit of normal excluded the presence of advanced LS, it was not associated with the primary endpoint (hazard ratio, 0.26; 95%CI, 0.01-1.33). However, LS was associated with the development of decompensated liver disease (hazard ratio, 1.55; 95%CI, 1.41-1.70). The optimal LS thresholds that stratified patients at a low, medium and high risk for hepatic decompensation were <4.5, 4.5-6.0 and >6.0 kPa (respectively).

CONCLUSION

Magnetic resonance elastography is able to detect cirrhosis with high specificity and an alkaline phosphatase <1.5 times the upper limit of normal makes the presence of advanced LS unlikely. Moreover, LS obtained by MRE is predictive of hepatic decompensation in PSC.

Multiple approaches to assess fourteen non-invasive serum indexes for the diagnosis of liver fibrosis in chronic hepatitis C patients

BACKGROUND

The aim of this study was to compare fourteen non-invasive indexes/scores: AAR, APRI, Fibroindex, MODEL3, Forns index, FIB4, GUCI, FI, FCI, Pohl score, AP index, CDS, HGM-1 and HGM-2, in order to diagnose the hepatic fibrosis stage in a survey of patients with chronic hepatitis C.

METHODS

84 patients with chronic hepatitis C were studied. Liver fibrosis was staged according to the Scheuer scoring system. The diagnostic accuracy of these indexes/scores was evaluated by AUROC, contingency tables and logistic regression analysis.

RESULTS

The best AUROCs (>0.9) to discriminate cirrhosis (F=4), were observed for CDS, FI, AAR, MODEL3, FIB4, HGM-2 and FCI. To discriminate at least advance fibrosis (F≥3), the best AUROCs (>0.89) were for CDS, FI, FIB4, HGM2-2, MODEL3 and FCI. To discriminate at least significant fibrosis (F≥2), the best AUROCs (>0.8) were for FIB4, GUCI, APRI, FI, Forns index, HGM-2 and FCI. Contingency tables and logistic regression analysis supported the results obtained by AUROC.

CONCLUSIONS

This study compares the diagnostic performance of fourteen indexes for the diagnosis of liver fibrosis stage in the same group of CHC patients. These results allow the selection of the best indexes for further studies in larger populations, in order to build diagnostic algorithms as an alternative to liver biopsy for fibrosis staging in patients with chronic HCV infection. These algorithms would allow to take therapeutical decisions and the continuous follow-up of hepatic fibrosis in these patients.

New combined parameter of liver and splenic stiffness as determined by elastography in healthy volunteers

BACKGROUND

The diagnosis of chronic liver disease (CLD) leading to fibrosis, cirrhosis, and portal hypertension had witnessed dramatic changes after the introduction of noninvasive figure accessible tools over the past few years. Imaging techniques that are based on evaluation of the liver stiffness was particularly useful in this respect. Acoustic radiation force impulse (ARFI) emerged as an interesting figure tool with reliable repute and high precision.

AIMS

To evaluate liver stiffness measurement (LSM) and splenic stiffness measurement (SSM) in healthy volunteers as concluded by the ARFI technique and to out a numeric calculated ratio that may reflect their correlation in the otherwise healthy liver.

PATIENTS AND METHODS

A ratio (splenic stiffness/liver stiffness in kPa) was determined in 207 consenting healthy subjects and was investigated with respect to age, gender, ethnic origin, body mass index (BMI), liver and spleen sizes healthy volunteers, alanine aminotransferase (ALT), aspartate aminotransferase (AST), platelet count (PLT), APRI, and FIB-4 scores.

RESULTS

Data from this work led to computing an index of 4.72 (3.42-7.33) in healthy persons on an average. Females had a higher index than males 6.37 vs 4.92, P=0.002. There was not any significant difference of the ratio in different age groups; ethnic origins; any correlation between SSM/LSM ratio and BMI; liver and spleen sizes; or ALT, AST, PLT, APRI, and FIB-4 scores.

CONCLUSIONS

A quantifiable numeric relationship between splenic and liver stiffness in the healthy subjects could be computed to a parameter expressed as SSM/LSM ratio. We believe that this ratio can be a useful reference tool for further researches in CLD.

FibroScan, aspartate aminotransferase and alanine aminotransferase ratio (AAR), aspartate aminotransferase to platelet ratio index (APRI), fibrosis index based on the 4 factor (FIB-4), and their combinations in the assessment of liver fibrosis in patients with hepatitis B

OBJECTIVES

The aim of this study was to assess the effects of FibroScan, aspartate aminotransferase and alanine aminotransferase ratio (AAR), aspartate aminotransferase to platelet ratio index (APRI), fibrosis index based on the 4 factor (FIB-4) and their combinations on liver fibrosis in patients with hepatitis B.

METHODS

406 hospitalized patients with chronic hepatitis B (CHB) and cirrhosis in our hospital were analyzed retrospectively and collected patients clinical indicators, including liver stiffness (LS), AAR, APRI and FIB-4, and then compared the differences of these indicators between CHB group and hepatitis B with cirrhosis group. Receiver operating curve (ROC) was used to evaluate the differentiating capacity of these indicators on CHB and liver cirrhosis.

RESULTS

Four indicators related to liver cirrhosis had a statistical significance between two groups (P < 0.01); the under ROC curve areas of LS, AAR, APRI and FIB-4 for differential diagnosis of CHB and liver cirrhosis were 0.866, 0.772, 0.632 and 0.885, respectively. The under ROC curve areas of LS, AAR, APRI and FIB-4 for differential diagnosis of liver cirrhosis at compensatory stage and de-compensatory stage were 0.627, 0.666, 0.795 and 0.820, respectively.

CONCLUSION

LS, AAR, APRI and FIB-4 were good indicators as clinical diagnosis and differential diagnosis on hepatitis B related cirrhosis.

Serum Basal Paraoxonase 1 Activity as an Additional Liver Function Test for the Evaluation of Patients with Chronic Hepatitis

BACKGROUND

The diagnostic accuracy of currently available standard panel of liver function tests is not satisfactory for the reliable diagnosis of chronic liver disorders. Earlier studies have reported that serum basal paraoxonase 1 (PON1) activity measurement may add a significant contribution to the liver function tests.

AIM

To assess whether the measurement of serum basal paraoxonase 1 (PON1) activity would be useful as an index of liver function status in chronic hepatitis patients.

MATERIALS AND METHODS

The study included 50 chronic hepatitis patients and 50 apparently healthy controls based on inclusion & exclusion criteria. In all the subjects, standard liver function tests were analysed by using standard methods. Basal PON1 activity was estimated using spectrophotometric method by the hydrolysis of p-nitrophenylacetate. Student t-test, Pearson's correlation coefficient, diagnostic validity tests and ROC curve analysis were the methods used for the statistical analysis of the data.

RESULTS

The serum basal PON1 activity was significantly decreased in chronic hepatitis cases when compared to controls (p< 0.001). Also basal PON1 activity was positively correlated with serum total protein and albumin, and negatively correlated with serum total bilirubin, alanine amino transferase (ALT), and alkaline phosphatase (ALP) (p< 0.001) in chronic hepatitis cases but not in healthy controls. Diagnostic validity tests showed, basal PON1 activity was a better discriminator of chronic hepatitis than total protein, albumin and ALP with sensitivity of 68%, specificity of 100%, positive predictive value of 100% and negative predictive value of 75%. ROC curve analysis demonstrated highest diagnostic accuracy for ALT (AUC = 0.999) followed by PON1 (AUC = 0.990), total bilirubin (AUC = 0.977), ALP (AUC = 0.904), total protein (AUC = 0.790) and albumin (AUC = 0.595).

CONCLUSION

Diagnostic accuracy of serum PON1 activity is better than total bilirubin, total protein, albumin and ALP. PON1 activity measurement could significantly improve the current efficiency of a laboratory's evaluation of patients with suspected chronic hepatitis.

[Usefulness of procalcitonin for diagnosing infection in critically ill patients with liver cirrhosis]

OBJECTIVE

To evaluate the usefulness of procalcitonin (PCT) for diagnosing infection in patients with liver cirrhosis admitted to an Intensive Care Unit.

DESIGN

A retrospective study was carried out.

SCOPE

Intensive Care Unit. Versatile, twenty-four beds. Participants Patients with liver cirrhosis admitted to our Intensive Care Unit in the last four years with suspected infection and measurement of PCT.

RESULTS

Among the 255 patients with cirrhosis admitted to our unit, PCT was determined for the differential diagnosis of infection in 69 cases (27%). Three patients were excluded from analysis due to a lack of clinical data. The average stay was 10.6 ± 9.2 days, with a mortality rate of 65%. The origin of cirrhosis was mainly viral (57%) or alcoholic (37%). The Child-Pugh and MELD scores were 9.5 ± 2 and 23 ± 8, respectively. Infection was diagnosed in 54 patients (82%). The most common infection was pneumonia (72%), followed by intraabdominal infections (18%) and bacteremia (5%). In patients without infection, the median PCT concentration was 0.57 ng/ml (range 0.28 to 1.14) versus 2.99 (1.31 to 9.4) in those with infection (p<.001). Diagnostic capacity was maintained in patients with intraabdominal infections. The diagnostic cutoff point was set at 0.8 ng/ml (sensitivity 83%, specificity 75%, AUC 0.82 [0.702-0.93]).

CONCLUSIONS

In patients with liver cirrhosis, PCT is useful for identifying bacterial infections, including intraabdominal processes.

Stratification of patients with liver fibrosis using dual-energy CT

Assessing the severity of liver fibrosis has direct clinical implications for patient diagnosis and treatment. Liver biopsy, typically considered the gold standard, has limited clinical utility due to its invasiveness. Therefore, several imaging-based techniques for staging liver fibrosis have emerged, such as magnetic resonance elastography (MRE) and ultrasound elastography (USE), but they face challenges that include limited availability, high cost, poor patient compliance, low repeatability, and inaccuracy. Computed tomography (CT) can address many of these limitations, but is still hampered by inaccuracy in the presence of confounding factors, such as liver fat. Dual-energy CT (DECT), with its ability to discriminate between different tissue types, may offer a viable alternative to these methods. By combining the "multi-material decomposition" (MMD) algorithm with a biologically driven hypothesis we developed a method for assessing liver fibrosis from DECT images. On a twelve-patient cohort the method produced quantitative maps showing the spatial distribution of liver fibrosis, as well as a fibrosis score for each patient with statistically significant correlation with the severity of fibrosis across a wide range of disease severities. A preliminary comparison of the proposed algorithm against MRE showed good agreement between the two methods. Finally, the application of the algorithm to longitudinal DECT scans of the cohort produced highly repeatable results. We conclude that our algorithm can successfully stratify patients with liver fibrosis and can serve to supplement and augment current clinical practice and the role of DECT imaging in staging liver fibrosis.

Options of non-invasive assessment of liver fibrosis based on the clinical data

Liver cirrhosis is one of the leading causes of death worldwide. Liver biopsy is considered as the gold standard for the diagnosis of chronic liver diseases. Studies have focused on non-invasive markers for liver fibrosis because of the dangers and complications of liver biopsy. The authors review the non-invasive direct as well as indirect methods for liver fibrosis assessment and present the positive and negative predictive value, sensitivity and specificity of those. Clinical utilities of transient elastography (Fibrsocan) is also reviewed. Non-invasive methods are useful in the assessment of liver fibrosis, monitoring disease progression and therapeutic response. Their accuracy can be increased by the combined or sequential use of non-invasive markers. Orv. Hetil., 2015, 156(2), 43–52.

Role of 13C methacetin breath test for non invasive staging of liver fibrosis in patients with chronic hepatitis C

BACKGROUND & OBJECTIVES

The development and evaluation of non invasive tests to assess liver fibrosis have been an active field of research. The present study was carried out to evaluate the role of 13C-methacetin breath test 13C-MBT) as a non invasive tool for liver fibrosis staging in patients with chronic hepatitis C (CHC).

METHODS

13C-Methacetin breath test was performed in 115 patients with CHC histologically proven and in 55 healthy controls. All patients and controls underwent routine liver function tests. The CHC patients underwent histological assesment of liver by percutaneous liver biopsy. The correlation between the 13C-methacetin breath test and liver biopsy was tested using Kendall's rank correlation coefficients. The overall validity was expressed as area under receiver operating characteristic curve (AUROC) with 95%CI.

RESULTS

Delta over baseline values (DOB) of CHC patients at 20 min were significantly reduced compared with control (16. 2 vs. 21. 06%, p <0.001). There were also significant differences between CHC patients and controls as regard the metabolization speed (dose/h at 20 min (17.80 vs 28.6, p <0.001) and metabolization capacity (cumulative recovery after 60 min (13.8 vs 20.4 p <0.001). The best 13C-MBT parameter correlated with fibrosis was DOB at 20 min (r = -0.596). The optimal cut-off for the diagnosis of advanced fibrosis (F ≥ 3) was 15.2 per cent, with AUROC = 0.902, 95%CI: (0.851-0.938), a sensitivity of 82 per cent and a specificity of 80 per cent. DOB at 20 min predicted even better cirrhosis: AUROC = 0.932 95 per cent CI = 0.901-0.953, a sensitivity of 96 per cent and a specificity of 92 per cent.

INTERPRETATION & CONCLUSIONS

Based on our findings the 13C-methacetin breath test appears to be a promising tool to identify CHC patients with advanced fibrosis and to replace liver biopsy. Further studies need to be done to assess its potential to be used in regular clinical practice.

A Flexible Method for Multi-Material Decomposition of Dual-Energy CT Images

The ability of dual-energy computed-tomographic (CT) systems to determine the concentration of constituent materials in a mixture, known as material decomposition, is the basis for many of dual-energy CT's clinical applications. However, the complex composition of tissues and organs in the human body poses a challenge for many material decomposition methods, which assume the presence of only two, or at most three, materials in the mixture. We developed a flexible, model-based method that extends dual-energy CT's core material decomposition capability to handle more complex situations, in which it is necessary to disambiguate among and quantify the concentration of a larger number of materials. The proposed method, named multi-material decomposition (MMD), was used to develop two image analysis algorithms. The first was virtual unenhancement (VUE), which digitally removes the effect of contrast agents from contrast-enhanced dual-energy CT exams. VUE has the ability to reduce patient dose and improve clinical workflow, and can be used in a number of clinical applications such as CT urography and CT angiography. The second algorithm developed was liver-fat quantification (LFQ), which accurately quantifies the fat concentration in the liver from dual-energy CT exams. LFQ can form the basis of a clinical application targeting the diagnosis and treatment of fatty liver disease. Using image data collected from a cohort consisting of 50 patients and from phantoms, the application of MMD to VUE and LFQ yielded quantitatively accurate results when compared against gold standards. Furthermore, consistent results were obtained across all phases of imaging (contrast-free and contrast-enhanced). This is of particular importance since most clinical protocols for abdominal imaging with CT call for multi-phase imaging. We conclude that MMD can successfully form the basis of a number of dual-energy CT image analysis algorithms, and has the potential to improve the clinical utility of dual-energy CT in disease management.

Contrast-independent liver-fat quantification from spectral CT exams

The diagnosis and treatment of fatty liver disease requires accurate quantification of the amount of fat in the liver. Image-based methods for quantification of liver fat are of increasing interest due to the high sampling error and invasiveness associated with liver biopsy, which despite these difficulties remains the gold standard. Current computed tomography (CT) methods for liver-fat quantification are only semi-quantitative and infer the concentration of liver fat heuristically. Furthermore, these techniques are only applicable to images acquired without the use of contrast agent, even though contrast-enhanced CT imaging is more prevalent in clinical practice. In this paper, we introduce a method that allows for direct quantification of liver fat for both contrast-free and contrast- enhanced CT images. Phantom and patient data are used for validation, and we conclude that our algorithm allows for highly accurate and repeatable quantification of liver fat for spectral CT.