Non-invasive diagnosis of severe alcoholic hepatitis: Usefulness of cross-sectional imaging.

PURPOSE: To describe the computed tomography (CT) and magnetic resonance imaging (MRI) features of severe acute alcoholic hepatitis (SAAH) and estimate the capabilities of CT and MRI in differentiating SAAH from alcoholic cirrhosis and non-alcoholic steato-hepatitis (NASH) cirrhosis. MATERIALS AND METHODS: Fifty patients with pathologically proven SAAH (SAAH group) who underwent CT or MRI examinations up to 30 days before or 15 days after liver biopsy between January 2008 and June 2018 were retrospectively included. There were 31 men and 29 women with a mean age of 52±9 (SD) years (range: 33-67 years). Imaging features of the SAAH group were compared to those obtained in two control groups including 62 patients with alcoholic cirrhosis without acute alcoholic hepatitis (control group 1) and 19 patients with NASH cirrhosis (control group 2) by two independent radiologists blinded to the final diagnosis. Univariate analyses were performed to compare imaging characteristics between the three groups, followed by diagnostic performance analysis for the diagnosis of SAAH of the main CT features. RESULTS: Heterogeneous steatosis was significantly more frequent in SAAH group than in the control groups (41/50; 82% vs. 7/62; 10% and 1/19; 5% in control groups 1 and 2, respectively for reader 1 and 34/50; 68% vs. 8/62; 13% and 1/19; 5% in control groups 1 and 2, respectively for reader 2; both P=0.01). Transient perfusion disorders were more frequent in SAAH group than in the control groups (35/50; 70% vs. 12/62; 21% and 5/19; 26% in control groups 1 and 2, respectively for reader 1 and 39/50; 78% vs. 14/62; 23% and 13/19; 6% in control groups 1 and 2, respectively for reader 2; both P=0.01). The combination of these two findings yielded 100% specificity (45/45; 95% CI: 92-100) for readers 1 and 2 for the diagnosis of SAAH vs. alcoholic cirrhosis and NASH cirrhosis. CONCLUSION: The imaging features of SAAH are specific and mainly associate transient heterogeneous steatosis and liver perfusion disorders. CT/MRI may be useful to differentiate SAAH from alcoholic cirrhosis and NASH cirrhosis.

In vivo imaging of hepatic neutrophil migration in severe alcoholic hepatitis with 111In-radiolabelled leucocytes.

The study's aim was to image severe alcoholic hepatitis (SAH) using 111In-labelled leucocytes with two objectives in mind: firstly for non-invasive diagnosis and secondly to provide a platform for experimental therapies aiming to inhibit intrahepatic neutrophil migration. 111In-leucocyte scintigraphy was performed 30 min and 24 h post-injection in 19 patients with SAH, 14 abstinent patients with alcohol-related cirrhosis and 11 normal controls. Eleven with SAH and seven with cirrhosis also had 99mTc-nanocolloid scintigraphy. Change in hepatic 111In radioactivity was expressed as decay-corrected 24 h:30 min count ratio and, in SAH, compared with histological grading of steatohepatitis and expression of granulocyte marker, CD15. Hepatic microautoradiography on biopsy specimens obtained 24 h post-injection of 111In-leucocytes was performed in one patient. Median 24 h:30 min hepatic 111In activity ratio was higher in SAH (2.5 (interquartile range (IQR): 1.7-4.0) compared with cirrhotics and normal controls (1.0 (0.8-1.1) and 0.8 (0.7-0.9) respectively, P<0.0001). In SAH, it correlated with CD15 expression (r = 0.62, P=0.023) and was higher in marked compared with mild/moderate steatohepatitis (4.0 (3.0-4.6) compared with 1.8 (1.5-2.6), P=0.006). Hepatic-to-splenic 99mTc count rate ratio was reduced in SAH (0.5 (0.4-1.4)) compared with cirrhotics (2.3( 0.6-3.0)) and three historic normal controls (4.2 (3.8-5.0); P=0.003), consistent with impaired hepatic reticuloendothelial function. Scintigraphic findings in SAH included prominent lung radioactivity at 30 min, likely the result of neutrophil primimg. Microautoradiography demonstrated cell-associated 111In in areas of parenchymal neutrophil infiltration. In conclusion, 111In-leucocyte scintigraphy can non-invasively diagnose SAH and could provide a platform for evaluation of novel treatments aiming to inhibit intrahepatic neutrophil migration.

Acoustic radiation force impulse elastography as compared to transient elastography and liver biopsy in patients with chronic hepatopathies.

PURPOSE: To compare two methods of noninvasive assessment: transient elastography (TE) and acoustic radiation force impulse elastography (ARFI). PATIENTS AND METHODS: Our study included 114 subjects: 38 healthy volunteers, (considered to have no fibrosis - F 0) and 76 patients with chronic liver disease: 53 who had undergone liver biopsy (LB) (7 with F 1, 24 with F 2, 22 with F 3 Metavir) and 23 previously diagnosed with cirrhosis (F4 Metavir). In each patient we performed a liver stiffness measurement by means of TE and ARFI. ARFI (shear wave velocity quantification) was performed at 3 points: at 0 - 1 cm, at 1 - 2 cm and at 2 - 3 cm under the capsule. For each depth, 5 valid measurements were made, and a median value was calculated, measured in m/sec. RESULTS: A direct, strong, linear correlation (Spearman rho = 0.848) was found between TE and the stage of fibrosis (p < 0.001). A significant, direct correlation was found between ARFI measurements made 1 - 2 cm and 2 - 3 cm below the liver capsule and the severity of fibrosis (rho = 0.675 and 0.714 respectively). The subcapsularly measured ARFI values showed a poor correlation with fibrosis (rho = 0.469). The best test for predicting significant fibrosis (F ≥ 2) was TE, with the area under receiver-operating characteristic curve (AUROC) 0.908, significantly larger than the AUROCs for ARFI. If only ARFI is considered, measurements made 1 - 2 and 2 - 3 cm below the capsule have the best predictive value, with AUROCs not significantly different from each other (0.767 and 0.731, respectively). For predicting fibrosis (F > 0), TE had the best predictive value: optimized cut-off 5.65 kPa (AUROC -0.898). For ARFI, the cut-offs were: 1.4 m/sec, AUROC -0.747 (1 - 2 cm), and 1.26 m/sec AUROC -0.721 (2 - 3 cm). For predicting cirrhosis (F = 4 Metavir), the optimized cut-offs were: TE -12.9 kPa (AUROC -0.994); ARFI - 1.78 m/sec for measurements made 2 - 3 cm below the capsule, AUROC - 0.951. CONCLUSION: At present, liver elasticity evaluation by means of ARFI is not superior to TE for the assessment of liver fibrosis. For ARFI, the most reliable results are obtained if measurements are made 1 - 2 and 2 - 3 cm below the liver capsule. ARFI is an accurate test for the diagnosis of cirrhosis.

"Pseudotumoral" hepatic pattern in acute alcoholic hepatitis: a case report.

In acute alcoholic hepatitis (AAH), a "pseudotumoral" appearance of the liver parenchyma on computed tomography (CT) scan has been reported. The main findings are hypervascularized areas closely similar to those observed in large hepatocellular carcinomas. We report a case of a patient affected by AAH with an unusual appearance of these "pseudotumoral" areas on CT scan, close resembling a metastatic cancer rather than a primary hepatocellular carcinoma. In fact, in contrast with previous reports, the picture was characterized by the presence of many inhomogeneous, hypoattenuated areas highlighted during both pre- and post-contrast phases. Moreover, we report the first description of "pseudotumoral" lesions on ultrasound scan. This patient was successfully treated with corticosteroids, even if many controversies still exist regarding their efficacy in this setting.

[The usefulness of transient elastography to diagnose cirrhosis in patients with alcoholic liver disease].

BACKGROUNDS/AIMS: It is not easy to differentiate between patients with cirrhosis and those with alcoholic liver disease. Liver biopsy is generally considered the gold standard for assessing hepatic fibrosis; however, this protocol frequently carries a risk of severe complications and false-negative results. Transient elastography (Fibroscan, Echosens, Paris, France), which is a noninvasive method of measuring liver stiffness, has become available for assessing liver fibrosis. Liver stiffness reportedly differs markedly with the cirrhosis etiology. The aim of this study was thus to determine the diagnostic accuracy of the Fibroscan in the detection of cirrhosis in patients with alcoholic liver disease. METHODS: We enrolled 45 patients with alcoholic liver disease. Fibroscan, abdominal ultrasonography, aspartate aminotransferase/platelet ratio index (APRI), and liver biopsy were performed on all patients. Fibrosis stage was assessed using the Batts-Ludwig scoring system. RESULTS: The stage of fibrosis (F1-F4) was distributed among the cohort as follows: 5 patients at F1, 4 patients at F2, 7 patients at F3, and 29 patients at F4. Liver stiffness differed significantly between each fibrosis stage (P<0.001). For the diagnosis of cirrhosis, the area under the receiver operating characteristic curve was 0.97 for transient elastography (95% confidence interval, CI, 0.93-1.01), 0.81 for ultrasonography (95% CI, 0.68-0.94), and 0.83 for APRI score (95% CI, 0.70-0.95). The optimal cut-off value of liver stiffness for detecting cirrhosis was 25.8 kPa, with a sensitivity of 90% and a specificity of 87%. CONCLUSIONS: Transient elastography is a useful method for diagnosing cirrhosis in patients with alcoholic liver disease.

"Pseudotumoral" hepatic areas in acute alcoholic hepatitis: a computed tomography and histological study.

Computed tomography (CT) findings in acute alcoholic hepatitis (AAH) have not been investigated and a "pseudotumoral aspect" of the liver parenchyma has rarely been reported as an exceedingly unusual finding. We observed 11 patients with AAH over a 1-yr period, five of whom underwent CT for concomitant clinical reasons. Arterial enhancement indicated areas of hypervascularized tissue in all cases, and the histological findings were fully consistent with AAH without any sign of malignancy. The present findings suggest that the above pattern is not uncommon in AAH and should be carefully considered in order to avoid diagnostic errors.

Discrepancy between pancreatographic and histopathological findings in the ventral pancreas of pancreas divisum.

CONTEXT: Pancreas divisum is a congenital anomaly in which the ventral and dorsal pancreatic ducts do not communicate. CASE REPORT: Autopsy case of pancreas divisum with a history of heavy consumption of alcohol was presented. Pancreatography via the major duodenal papilla showed a short ventral pancreatic duct of 1 cm in length, and hypoplasia of the ventral pancreas was suspected. As large cysts were confined to the dorsal pancreas, isolated dorsal pancreatitis was also suspected. At autopsy, extensive fibrosis was detected in both the ventral and dorsal pancreas. Immunohistochemical examination revealed that PP-rich islets were scattered in the fibrotic area between the ventral pancreatic parenchyma and the neck of the pancreas, suggesting that this fibrotic area originated from the ventral pancreas. These facts suggest that the short ventral pancreatic duct was not induced by hypoplasia of the ventral pancreas but was shortened secondarily by the alcohol-induced fibrosis. CONCLUSIONS: In pancreas divisum, a short ventral pancreatic duct resulting from secondary factors may be confused with that originating from hypoplasia of the ventral pancreas.

Potential for qualitative diagnosis of tumors and tumorous lesions in the liver with Tc-99m-GSA SPECT--correlation with pathological evaluation and MRI findings.

To evaluate the effect of technetium-99m-labeled DTPA-galactosyl human serum albumin (Tc-99m-GSA) SPECT imaging for qualitative diagnosis of hepatic lesions. The subjects were 29 patients with pathologically confirmed hepatic lesions (21 malignant and 8 benign lesions). SPECT data were obtained at about 30 minutes after injecting 185 MBq (5 mCi) of Tc-99m-GSA. The GSA SPECT findings were compared with those of pathological evaluation and T2-weighted MR images (T2WI). Of 29 lesions, 17 showed decreased accumulation, and three exhibited increased accumulation. The other nine lesions were undetectable. The malignant lesions which showed increased accumulation were all well differentiated hepatocellular carcinomas (HCCs). One of the eight benign lesions exhibited increased accumulation. The three lesions which showed increased accumulation of GSA exhibited hypointensity on T2WI, whereas the malignant lesions which showed decreased accumulation of GSA exhibited hyperintensity on T2WI. The GSA SPECT findings correlate well with those of T2WI. GSA SPECT may be useful for qualitative diagnosis of focal liver lesions. If a lesion is suspected of being HCC, increased accumulation may indicate well differentiated HCC.

Usefulness of scintigraphy with Tc-99m phytate for the diagnosis of alcoholic foamy degeneration.

PURPOSE: Alcoholic foamy degeneration (AFD) is a liver disease causing temporary hepatocyte dysfunction. The prognosis is usually good, but liver biopsy is needed for diagnosis. We report the usefulness of liver-spleen scintigraphy with the radiocolloid Tc-99m phytate for the diagnosis of AFD. PATIENTS AND METHODS: We used liver scintigraphy with Tc-99m phytate to study three patients with AFD diagnosed on the basis of findings from a liver biopsy. RESULTS: Liver-spleen scintigraphy showed hepatomegaly and splenomegaly, and bone marrow was visible, but radioisotope uptake by the liver was uniform. CONCLUSIONS: This pattern of scintigraphic findings is different from that reported for patients with alcoholic fatty livers or severe alcoholic hepatitis, and seems to be specific for AFD.

[Ultrasound-guided puncture-biopsy of the liver could replace blind puncture-biopsy in diffuse hepatopathies. Retrospective study of 1293 patients]. / La ponction-biopsie hépatique échoguidée pourrait remplacer la ponction-biopsie à l'aveugle dans les hépatopathies diffuses. Une étude rétrospective chez 1,293 patients.

OBJECTIVES: The aim of this retrospective study was to compare the efficiency and complications of percutaneous hepatic biopsy either guided by ultrasonography in the left lobe, or blindly by the intercostal route in the right lobe, in the diagnosis of diffuse liver diseases. PATIENTS AND METHODS: Liver biopsy was performed in 1,293 patients for 5 years. In group 1 (289 patients, including 140 out-patients), liver biopsy was guided by ultrasound. In group 2, blind intercostal liver biopsy was performed in 1,004 patients. Patients were observed for 6 hours after biopsy in both groups. RESULTS: The failure rate of liver biopsy was significantly lower in group 1 (1.7%) than in group 2 (9.25%, P < 0.01). The prevalence of the histological lesions was similar in both groups. No related-biopsy death occurred. Complications were more serious after blind biopsy (1 acute pancreatitis with a hematoma of the liver, 1 bile leakage around the gallbladder, 1 hemoperitonitis, 1 large intrahepatic hematoma), than after guided biopsy (1 small hematoma of the liver, 1 acute biliary pain on the 10th day). CONCLUSION: Hepatic biopsy guided by ultrasonography could replace blind biopsy in the diagnosis of diffuse liver diseases.

Ultrasonographic diagnosis of acute alcoholic hepatitis 'pseudoparallel channel sign' of intrahepatic artery dilatation.

BACKGROUND: In an ultrasound pilot study of acute alcoholic hepatitis (AAH), parallel tubular structures within the liver subsegments were observed. Pulse-Doppler flowmetry revealed that these structures were formed by a dilated hepatic arterial branch and an adjacent portal venous branch. This finding was termed the "pseudoparallel channel sign" (PPCS). The aims of this study were to assess the significance of this sign and show the characteristic ultrasound findings of AAH. METHODS: PPCS was specifically searched for on ultrasonography by two physician operators in consecutive patients (77 AAH, 119 other alcoholic liver disease, 49 nonalcoholic liver disease, and 15 healthy patients). RESULTS: PPCS was observed in 90% of patients with AAH and in 23% of patients with other alcoholic liver disease. This sign was not detected in nonalcoholic liver disease or healthy patients. Biopsy specimens were available in 100 patients, 51 of whom were patients with alcoholism. In those 51 patients, PPCS gave a sensitivity of 82%, a specificity of 87%, and an accuracy of 84% in diagnosing AAH. Patients with criteria of AAH had more segments involved with PPCS than patients without. CONCLUSIONS: PPCS may be an important diagnostic finding in AAH.

Ultrasonography and water content of the liver in chronic diffuse liver disease.

Water content in the liver in vivo was determined in 89 patients (33 with normal liver and 56 with chronic liver disease), simultaneously with ultrasonography and histopathological examination. A part of each biopsy specimen was used for this purpose. The difference between wet and dry weights was calculated from the pre- and post-lyophilization weights. According to the attenuation type of ultrasonic images, the patients were divided into two groups, viz., patients of low attenuation type (i.e. patients with type I bright liver) and those of high attenuation type (i.e. with type II bright liver). As to water content, no significant difference was observed between the two groups. No correlation was found between liver water content and histopathology either. It is concluded that knowledge of correlation between numerous parameters is needed to clarify the reason of attenuation differences.

Serum alphaphetoprotein in chronic hepatitis. Scintigraphic correlations.

On studying a number of 59 patients with chronic active hepatitis and with hepatic cirrhosis, with 37% and 41% cases respectively our research-works have proved increased serum AFP concentrations varying between 30-45 ng/ml, their values being much larger in active hepatic cirrhosis. The significant increase in aminotransferase and bilirubin has been correlated with a more severe stage of the hepatic disease. The gamma glutamyltranspeptidase (GGTP) assays for 9 of the 17 cases with active chronic hepatitis and for 17 cases with alcoholic hepatitis have shown a 6-15 times increase of this enzyme as compared to the other cases. Very high values of AFP, ranging between 300-900 ng/ml, have been found in the hepatic adenocirrhosis cases. A certain correlation between the AFP modifications and the scintigraphy has been found in 5 of the cases with malignant changes, in contrast with the AFP low and sporadic increase in the case of other gastrointestinal tract tumors. The scintigraphic modifications have been evident with low or multiple lacunary fixations, in considerable sizes and forms, with irregular edges, their dimensions, depending upon the disease evolution stage.

The clinical value of 201Tl per rectum scintigraphy in the work-up of patients with alcoholic liver disease.

The clinical value of thallium 201 per rectum scintigraphy in the work-up of patients with alcoholic liver disease was evaluated using data obtained in 104 patients. The 25th min ratio of heart to liver activities was used as an index of portal systemic shunting. This ratio was found to be normal in alcoholic patients with normal liver biopsy and also in those presenting only steatosis. It was slightly higher in patients with liver fibrosis and significantly higher values were observed in patients with liver cirrhosis. High values of the ratio were associated with a higher risk of portal systemic encephalopathy and/or gastrointestinal bleeding. The prognostic value of the test was supported by the fact that good correlations were observed between the ratio and widely accepted prognostic scores such as the Child score or the Orrego index. Moreover, high ratios were associated with an increased mortality risk at one year. We conclude that this simple test is interesting in the screening of cirrhotics at risk of encephalopathy, gastrointestinal hemorrhage, or early death.

The need for routine delayed radionuclide hepatobiliary imaging in patients with intercurrent disease.

A retrospective review was made of all radionuclide hepatobiliary studies performed in a major trauma center over a 27-month period and correlated with the patients' clinical course. In a population of 42 patients (27 of whom were on total parenteral nutrition [TPN]) who had severe intercurrent illness (primarily trauma), and an additional 18 patients who had hepatocellular dysfunction, hepatobiliary imaging confirmed a patent cystic duct in 43 of 60 patients (72%). Fourteen of these 43 patients (33%) had gallbladder visualization at later than one hour after radiotracer administration, and seven of these 14 required imaging from four to 24 hours. Of 17 patients who had nonvisualization of the gallbladder, four had surgically proved acute cholecystitis. Images of nine of the remaining 13 patients with gallbladder nonvisualization were not obtained for 24 hours. The presence of gallstones, wall thickening, or sludge on sonograms did not correlate with cystic duct patency, and was not specific for acute cholecystitis. Though gallbladder function is compromised in the population with severe intercurrent disease, radionuclide hepatobiliary imaging is still valuable; it can confirm a patent cystic duct in at least 72% of patients if routine imaging is continued for up to 24 hours.

Angiography in diagnosis and therapy of diffuse hepatocellular disease.

Angiography is of value in the diagnosis and interventional therapy of diffuse hepatocellular disease. Hepatic arteriography is the primary diagnostic method; hepatic venography, portal venography, transvenous liver biopsy and direct cholangiography are complementary. They allow the assessment of type and stage of diseases, their hemodynamic consequences and permit the differentiation of diffuse diseases from tumorous processi. Selective vasopressin infusion and transhepatic catheter obliteration of varices are interventional techniques used to control massive bleeding from gastroesophageal varices--one of the most serious complications of diffuse hepatocellular diseases.