Conscious sedation using propofol versus midazolam in cirrhotic patients during upper GI endoscopy: A comparative study.

AIM: We aimed to assess the safety and efficacy of propofol versus midazolam in cirrhotic patients undergoing upper GI endoscopy. METHODS: Ninety compensated cirrhotic patients (all met class I-III criteria according to the American Society of Anesthesia) were enrolled in this comparative study. They were classified into three groups according to scheduled pre-endoscopy sedation drugs; the midazolam group, which included 30 patients who received IV weight-dependent midazolam (0.05 mg/kg with additional doses of 1 mg every 2 min when necessary, up to a maximum dose of 0.1 mg/kg or 10 mg); the propofol group, which included 30 patients who received a propofol bolus dose according to age and weight (0.25 mg/kg with additional doses of 20-30 mg every 30-60 s when necessary, up to a maximum dose of 400 mg); and the combined group, which included 30 patients who received half a dose of midazolam and of propofol. RESULTS: Prolonged postendoscopy recovery times were reported in the midazolam group, while shorter recovery times were reported in the propofol and combined groups. All patients in the propofol and combined groups gained consciousness shortly postendoscopy; however, only half of the midazolam group's patients gained consciousness after the standard recovery time (10-30 min). Highly significant differences were found among the three groups regarding consciousness level according to the Glasgow coma scale, as well as regarding the occurrence of hypoxia during endoscopy. CONCLUSION: Considering safety and efficacy issues, propofol is better than midazolam in gastrointestinal endoscopy, especially in patients with liver cirrhosis.

The utility of diffusion-weighted imaging in improving the sensitivity of LI-RADS classification of small hepatic observations suspected of malignancy.

PURPOSE: We investigated the added value of diffusion-weighted imaging (DWI)/apparent diffusion coefficient (ADC) in the categorization of small hepatic observation (≤ 20 mm) detected in patients with chronic liver disease in reference to LI-RADS (liver imaging reporting and data system) classification system. METHODS: We prospectively evaluated 165 patients with chronic liver disease with small hepatic observations (≤ 20 mm) which were previously categorized as LI-RADS grade 3-5 on dynamic contrast-enhanced CT (DCE-CT). All patients were submitted to a functional MRI including DCE and DWI. Using LI-RADS v2017, two radiologists independently evaluated the observations and assigned a LI-RADS category to each observation using DCE-MRI alone and combined DCE-MRI and DWI/ADC. In the combined technique, the radiologists assigned a LI-RADS category based on a modified LI-RADS criteria in which restricted diffusion on DWI was considered a major feature of HCC. We evaluated the inter-reader agreement with Kappa statistics and compared the diagnostic performance of the LI-RADS with two imaging techniques by Fisher's exact test using histopathology as the reference standard. RESULTS: Combined technique in LI-RADS yielded better sensitivities (reader 1, 97% [65/67]; reader 2, 95.5% [64/67]) for HCC diagnosis than DCE-MRI alone (reader 1, 80.6% [54/67], p = 0.005; reader 2, 83.6% [56/67], p = 0.04). The specificities were insignificantly lower in combined technique (reader 1, 88.4% [107/121]; reader 2, 77.7% [94/121]) than in DCE-MRI alone (reader 1, 90.9% [110/121], p = 0.67; reader 2, 79.3% [96/121], p = 0.88). The inter-reader agreement of the LI-RADS scores between combined technique and DCE-MRI was good (κ = 0.765). CONCLUSION: The use of DWI/ADC as an additional major criterion, improved the sensitivity of LI-RADS in the diagnosis of HCC while keeping high specificity.

Does a combined CT and MRI protocol enhance the diagnostic efficacy of LI-RADS in the categorization of hepatic observations? A prospective comparative study.

OBJECTIVE: To compare diagnostic performance and agreement between CT, MRI and combined CT/MRI in reference to LI-RADS classification system to categorize hepatic observations detected in hepatic patients during screening ultrasound. METHODS: 240 patients with 296 liver observations detected during ultrasound surveillance underwent hepatic CT and MRI examinations, histopathology, and clinical and radiological follow-up. Using LI-RADS v2014, six radiologists evaluated the observations independently and assigned a LI-RADS category to each observation using CT, MRI and combined CT/MRI. RESULTS: Combined CT and MRI in LI-RADS yielded better accuracy (91.29 %), sensitivity (90.71 %) and specificity (92.31 %) for hepatocellular carcinoma (HCC) diagnosis than using MRI or CT alone; accuracy, sensitivity and specificity decreased to 85.37 %, 86.34 %, and 83.65 %, respectively, for MRI and 67.6 %, 54.10 % and 91.35 %, respectively, for CT. The intraclass agreement of the LI-RADS scores between CT, MRI and combined CT/MRI was excellent (κ=0.9624 (95 % CI: 0.9318-0.9806)). CONCLUSION: CT and MRI are complementary to each other. Combined CT/MRI enabled a more precise determination of LI-RADS category of hepatic observations; however, due to the expense and minor increase in accuracy, the combined methodology should only be utilized in cases of suspected HCC. KEY POINTS: • Hepatic observation may be categorized differently depending on the imaging modality used. • We compared LI-RADS categorization between CT, MRI and combined CT/MRI. • MRI produces higher accuracy and sensitivity, while CT produces higher specificity. • Combining CT and MRI improves LIRADS categorization reports. • Considering additional cost, combined methodology could be restricted to challenging cases.