Validation of Diagnostic Thresholds for Compensated Advanced Chronic Liver Disease Using Supersonic Shear Imaging.

Background The Society of Radiologists in Ultrasound (SRU) has proposed thresholds for acoustic radiation force impulse techniques to diagnose compensated advanced chronic liver disease (cACLD). However, the diagnostic performance of these thresholds has not been extensively validated. Purpose To validate the SRU thresholds in patients with chronic liver disease who underwent supersonic shear imaging and, if suboptimal diagnostic performance is observed, to identify optimal values for diagnosing cACLD. Materials and Methods This retrospective single-center study included high-risk patients with chronic liver disease who had liver stiffness (LS) measurements and had undergone endoscopy or liver biopsy between January 2018 and December 2021. Patients were randomly allocated to test and validation sets. cACLD was defined as varices at endoscopy and/or severe fibrosis or cirrhosis at liver biopsy. The diagnostic performance of the SRU guidelines was evaluated, and optimal threshold values were identified using receiver operating characteristic (ROC) curve analysis. Results A total of 1180 patients (median age, 57 years [IQR, 50-64 years]; 761 men), of whom 544 (46%) had cACLD, were included. With the SRU recommended thresholds of less than 9 kPa and greater than 13 kPa in the test set (n = 786), the sensitivity and specificity for ruling out and ruling in cACLD were 81% (303 of 374 patients; 95% CI: 77, 85) and 92% (380 of 412 patients; 95% CI: 89, 94), respectively. In ROC curve analysis, the identified optimal threshold values were less than 7 kPa and greater than 12 kPa, showing 91% sensitivity (340 of 374 patients; 95% CI: 88, 93) for ruling out cACLD and 91% specificity (373 of 412 patients; 95% CI: 87, 93) for ruling in cACLD, respectively. In the validation set (n = 394), the optimal thresholds showed 91% sensitivity (155 of 170 patients; 95% CI: 86, 95) and 92% specificity (206 of 224 patients; 95% CI: 88, 95). Conclusion Compared with the SRU guidelines, the dual LS threshold values of less than 7 kPa and greater than 12 kPa were better for diagnosing cACLD. © RSNA, 2024 Supplemental material is available for this article. See also the editorial by Barr in this issue.

Diagnosing Hepatocellular Carcinoma Using Sonazoid Contrast-Enhanced Ultrasonography: 2023 Guidelines From the Korean Society of Radiology and the Korean Society of Abdominal Radiology.

Sonazoid, a second-generation ultrasound contrast agent, was introduced for the diagnosis of hepatic nodules. To clarify the issues with Sonazoid contrast-enhanced ultrasonography for the diagnosis of hepatocellular carcinoma (HCC), the Korean Society of Radiology and Korean Society of Abdominal Radiology collaborated on the guidelines. The guidelines are de novo, evidence-based, and selected using an electronic voting system for consensus. These include imaging protocols, diagnostic criteria for HCC, diagnostic value for lesions that are inconclusive on other imaging results, differentiation from non-HCC malignancies, surveillance of HCC, and treatment response after locoregional and systemic treatment for HCC.

Omental infarction diagnosed by computed tomography, missed with ultrasonography: A case report.

BACKGROUND: Omental infarction (OI) is a surgical abdominal disease that is not common in adults and is very rare in children. Similar to various acute abdominal pain diseases including appendicitis, diagnosis was previously achieved by diagnostic laparotomy but more recently, ultrasonography or computed tomography (CT) examination has been used. CASE SUMMARY: A 6-year-old healthy boy with no specific medical history visited the emergency room with right lower abdominal pain. He underwent abdominal ultrasonography by a radiologist to rule out acute appendicitis. He was discharged with no significant sonographic finding and symptom relief. However, the symptoms persisted for 2 more days and an outpatient visit was made. An outpatient abdominal CT was used to make a diagnosis of OI. After laparoscopic operation, his symptoms resolved. CONCLUSION: In children's acute abdominal pain, imaging studies should be performed for appendicitis and OI.

Spleen stiffness-spleen size-to-platelet ratio risk score as noninvasive predictors of esophageal varices in patients with hepatitis B virus-related cirrhosis.

ABSTRACT: This study was conducted to evaluate the predictive value of spleen stiffness-spleen size-to-platelet ratio risk score (SSPS) as a noninvasive predictor of esophageal varices (EVs) and to compare it with others.In this retrospective study, from April 2017 to October 2018, a total of 65 patients with hepatitis B virus-related cirrhosis who underwent the liver and spleen stiffness (LS, and SS) measurements by 2 dimensional-shear wave elastography and endoscopic evaluation for EVs were enrolled. Liver stiffness-spleen size-to-platelet ratio risk score (LSPS) and SSPS were calculated. The prognostic values were assessed by the area under the receiver operating characteristic curve (AUC).Twenty-six patients had no EV on endoscopy. Among 39 patients who had EVs, 12 patients had high risk EVs. The AUCs of the LS value, SS value, LSPS, and SSPS for predicting EVs were 0.72, 0.77, 0.80, and 0.85, respectively. The AUCs of the LS value, SS value, LSPS, and SSPS for predicting high-risk EVs were 0.55, 0.78, 0.67, and 0.80, respectively. SSPS had the highest specificity, at 96.15%, for predicting EVs.SSPS may be beneficial to exclude from having EVs and it is expected that the frequency of performing endoscopies for screening EVs can be reduced.

Application of Supersonic Shear Imaging to the Baveno VI Criteria and a Combination Model with Spleen Stiffness Measurement to Rule Out High-Risk Varices in Compensated Advanced Chronic Liver Disease.

PURPOSE: Recently, Colecchia et al. reported that by adding a spleen stiffness (SS) criterion sequentially to the Baveno VI criteria, screening endoscopy could be safely avoided. We aimed to compare the Baveno VI criteria, SS values and a sequential combination of the Baveno VI and SS values, measured by supersonic shear imaging (SSI), as approaches for safely avoiding screening endoscopy for high-risk varices (HRV). MATERIALS AND METHODS: Between April 2017 and July 2018, we enrolled 274 compensated advanced chronic liver disease patients who had successfully undergone liver stiffness (LS) and SS measurements with SSI and esophagogastroduodenoscopy (EGD). 52 HRV patients were included, and we analyzed risk factors for HRV and compared proportions of patients who were spared EGD when Baveno VI criteria, SS cut-off and the combination of the two approaches were used. RESULTS: The AUROC values for estimating HRV by platelet count, LS and SS were 0.701, 0.757 and 0.844, respectively, and all three measures were found to be independent predictors of HRV. The SS cut-off value for excluding HRV was ≤ 27.3 kPa. The percentages of patients spared EGD were 18.6 % for Baveno VI, 28.8 % for SS cut-off and 36.1 % for the sequential combination of Baveno VI and SS cut-off. Less than 2 % of HRV patients were missed when using all of the criteria. CONCLUSION: The Baveno VI criteria can be applied to LS measurement by SSI. SS measurement by SSI is an excellent predictor of HRV. Screening endoscopy can be safely avoided when Baveno VI criteria and SS cut-off are applied together.

Computed Tomography-Determined Body Composition Abnormalities Usefully Predict Long-term Mortality in Patients With Liver Cirrhosis.

OBJECTIVE: We evaluated the prognostic impacts of body composition components measured by computed tomography (CT) in patients with liver cirrhosis. METHODS: A total of 160 cirrhotic patients who underwent CT and hepatic venous pressure gradient measurements were retrospectively enrolled. Cross-sectional areas of skeletal muscle, visceral and subcutaneous fat, and mean CT attenuation of trabecular bone of the fourth lumbar vertebral level (L4HU) were measured. RESULTS: Multivariate analysis showed model for end-stage liver disease score [hazard ratio (HR), 1.086; 95% confidence interval (CI), 1.020-1.156; P = 0.010], hepatic venous pressure gradient (HR, 1.076; 95% CI, 1.021-1.135; P = 0.006), sarcopenia (HR, 1.890; 95% CI, 1.032-3.462; P = 0.039), and L4HU (HR, 1.960 for L4HU <145 Hounsfield units; 95% CI, 1.094-3.512; P = 0.024) were independently associated with long-term mortality. In patients with decompensated cirrhosis, subcutaneous adipose tissue index was the only independent predictor (HR, 0.984; 95% CI, 0.969-0.999; P = 0.039). CONCLUSION: Body composition abnormalities determined by CT are associated with long-term prognosis in cirrhotic patients.

Ultrasonographic morphological diagnosis of chronic liver disease: 2-dimensional shear wave elastography as an add-on test.

PURPOSE: This study investigated the impact of liver stiffness measurements (LSM) made using 2-dimensional (2D) shear wave elastography (SWE) on the diagnosis and grading of hepatic fibrosis and liver cirrhosis (LC) using grayscale ultrasonography (US). METHODS: This retrospective study included 46 patients who underwent liver biopsy for chronic liver disease and 33 non-biopsied subjects with no or mild fibrosis (an aspartate aminotransferase-to-platelet ratio index <0.50 and a Forns score <4.21). Two abdominal radiologists reviewed randomized grayscale hepatic sonogram sets with and without LSM, separated by a 4-week interval. They graded the features of echogenicity, echotexture, surface nodularity, and edge blunting and classified patients by fibrosis grade. Interobserver agreement and correlations with the fibrosis grades were compared before and after the reviewers were informed regarding LSM, and the impact of LSM on diagnostic performance was evaluated. RESULTS: The standard diagnoses were no or mild fibrosis (F0-1, n=39), moderate to advanced fibrosis (F2-3, n=23), or LC (n=17). The correlations between US and the diagnostic reference standard increased significantly with LSM incorporation (0.499 and 0.312 to 0.782 and 0.804, P<0.01 for both reviewers), as did interobserver agreement (0.318 to 0.753, P<0.01). The areas under the receiver operating characteristic curve (AUCs) for the diagnosis of significant fibrosis increased when LSM was included (0.682 and 0.591 to 0.855 and 0.907, P<0.01 for both reviewers), while the AUCs for the diagnosis of LC did not change significantly (0.891 and 0.783 to 0.904 and 0.900, P=0.849 and P=0.166). CONCLUSION: Incorporating LSM values obtained by 2D-SWE improved the diagnostic accuracy and interobserver agreement of grayscale US for hepatic fibrosis.

Combined effect of hepatic venous pressure gradient and liver stiffness on long-term mortality in patients with cirrhosis.

BACKGROUND/AIMS: Both hepatic venous pressure gradient (HVPG) and liver stiffness (LS) are useful tools for predicting mortality in patients with cirrhosis. We investigated the combined effect of HVPG and LS on long-term mortality in patients with cirrhosis. METHODS: We retrospectively collected data from 103 patients with cirrhosis, whose HVPG and LS were measured between November 2009 and September 2013. The patients were divided into four groups according to the results of the HVPG and LS measurements. Long-term mortality and the risk factors for mortality were analyzed. RESULTS: Of the 103 patients, 35 were in group 1 (low HVPG and low LS), 16 in group 2 (high HVPG and low LS), 24 in group 3 (low HVPG and high LS), and 28 in group 4 (high HVPG and high LS). Over a median follow-up of 47.3 months, 18 patients died. The mortality rate of patients in group 4 was significantly higher than in the other three groups (vs. group 1, p = 0.005; vs. group 2, p = 0.049; vs. group 3, p = 0.004), but there were no significant differences in survival between groups 1, 2, and 3. In multivariable analyses, both HVPG and LS were identified as independent risk factors for mortality (hazard ratio [HR], 1.127, p = 0.018; and HR, 1.062, p = 0.009, respectively). CONCLUSION: In patients with cirrhosis, those with concurrent elevation of HVPG and LS had the highest long-term mortality rates. However, when either HVPG or LS alone was elevated, mortality did not increase significantly.

Abdominal Wall Thickness Affects Liver Stiffness Measurements by 2-D Shear Wave Elastography in Patients with Chronic Liver Disease.

This study was conducted to define the effect of abdominal wall thickness (AWT) and its composition on the level of confidence in liver stiffness (LS) measurements obtained with 2-D shear wave elastography (2-D-SWE) in patients with chronic liver disease. In this retrospective study, a total of 1291 patients who underwent LS measurement by 2-D-SWE were enrolled. The abdominal wall was divided into three layers: layer 1 extended from the skin to the subcutaneous fat layer; layer 2 was the muscle layer; and layer 3 extended from the peritoneum to the liver capsule (including the omental fat layer, if present). We regarded the sums of layers 1-3 and layers 1 and 3 as the AWT and non-muscular layer thickness (NMT). Age/sex/body mass index-adjusted multivariate logistic regression analysis was performed to identify factors influencing the level of confidence of LS measurements. Three hundred eighty-six patients (29.9%) were classified in the unreliable LS group (standard deviation/median LS > 0.1). The fourth quartile of AWT and third and fourth quartiles of NMT/AWT were significantly associated with unreliable LS values (odds ratios = 2.103, 1.753 and 1.695, respectively). In conclusion, high AWT and NMT/AWT ratios reduce the confidence in LS measurements obtained with 2-D-SWE.

Spleen Stiffness Measurement Using 2-Dimensional Shear Wave Elastography: The Predictors of Measurability and the Normal Spleen Stiffness Value.

OBJECTIVES: To investigate the success rate of spleen stiffness measurement and factors that affect measurement success and to determine the spleen stiffness value of normal individuals by 2-dimensional shear wave elastography. METHODS: The spleen and liver stiffnesses of 313 consecutive patients were measured with SWE. The body mass index, abdominal wall thickness, spleen size, and liver stiffness of the patients were evaluated to identify factors associated with successful measurement of spleen stiffness. Patients were grouped by body mass index, spleen size, and liver stiffness, and the success rates and mean spleen stiffness values of the groups were compared. Independent predictors for successful spleen stiffness measurement and their cutoff values were evaluated. The mean spleen stiffness values of patients considered to have normal spleen stiffness were investigated. RESULTS: The overall success rate of spleen stiffness measurement was 52.9%. It was significantly higher in nonobese than in obese patients and in patients with splenomegaly and liver cirrhosis. The spleen stiffness value was higher in the splenomegaly group than the nonsplenomegaly group (P < .001) and increased as liver stiffness increased (P < .001). There was no significant difference in spleen stiffness values between the obese and nonobese groups. Abdominal wall thickness and splenic longitudinal diameter were identified as independent predictors of successful spleen stiffness measurement, and their cutoff values were 17.2 mm or less and greater than 9.4 cm, respectively. The mean spleen stiffness value ± SD of the normal patient group was 20.5 ± 5.4 kPa. CONCLUSIONS: The success rate of spleen stiffness measurement is lower than that of liver stiffness measurement. Spleen stiffness measurement is affected by abdominal wall thickness and spleen size.

Role of two-dimensional shear wave elastography in chronic liver diseases: A narrative review.

Liver biopsy is the gold standard for evaluating the degree of liver fibrosis in patients with chronic liver disease. However, due to the many limitations of liver biopsy, there has been much interest in the use of noninvasive techniques for this purpose. Among these techniques real-time two-dimensional shear wave elastography (2D-SWE) has the advantage of measuring tissue elasticity with the guidance of B-mode images. Recently, many studies have been conducted on the application of 2D-SWE in patients with various liver diseases, and their validity has been confirmed. Here, we briefly discuss the role of 2D-SWE in patients with chronic liver diseases, particularly aspects of the examination techniques and clinical applications.

Coefficient of Variance as Quality Criterion for Evaluation of Advanced Hepatic Fibrosis Using 2D Shear-Wave Elastography.

OBJECTIVES: To compare the diagnostic performance for advanced hepatic fibrosis measured by 2D shear-wave elastography (SWE), using either the coefficient of variance (CV) or the interquartile range divided by the median value (IQR/M) as quality criteria. METHODS: In this retrospective study, from January 2011 to December 2013, 96 patients, who underwent both liver stiffness measurement by 2D SWE and liver biopsy for hepatic fibrosis grading, were enrolled. The diagnostic performances of the CV and the IQR/M were analyzed using receiver operating characteristic curves with areas under the curves (AUCs) and were compared by Fisher's Z test, based on matching the cutoff points in an interactive dot diagram. All P values less than 0.05 were considered significant. RESULTS: When using the cutoff value IQR/M of 0.21, the matched cutoff point of CV was 20%. When a cutoff value of CV of 20% was used, the diagnostic performance for advanced hepatic fibrosis ( ≥ F3 grade) with CV of less than 20% was better than that in the group with CV greater than or equal to 20% (AUC 0.967 versus 0.786, z statistic = 2.23, P = .025), whereas when the matched cutoff value IQR/M of 0.21 showed no difference (AUC 0.918 versus 0.927, z statistic = -0.178, P = .859). CONCLUSIONS: The validity of liver stiffness measurements made by 2D SWE for assessing advanced hepatic fibrosis may be judged using CVs, and when the CV is less than 20% it can be considered "more reliable" than using IQR/M of less than 0.21.

Influence of ultrasound contrast agents on spectral Doppler analysis in recipients of liver transplantation.

BACKGROUND/AIMS: Clinical validation is required to determine whether Doppler measurements are comparable before and after administering ultrasound contrast agent (USCA). The purpose of this study is to explore whether the use of USCA affects spectral Doppler analysis in recipients of liver transplantation (LT). METHODS: For this study, 36 patients were examined using Doppler ultrasonography (US) along with a contrast-enhanced US for surveillance of vascular complications after LT. The following spectral Doppler US parameters were measured before and after administration of USCA: peak systolic velocity, end-diastolic velocity, resistive index, and systolic acceleration time of the graft hepatic artery; peak flow velocity of the graft portal vein; and peak flow velocity and venous pulsatility index of the graft hepatic vein. RESULTS: The mean peak systolic and end-diastolic velocities of the hepatic artery and the peak flow velocity of the portal and hepatic veins were increased after intravenously administration of the USCA, ranging from 10% to 13%. However, the changes were not statistically significant (P=0.097, 0.103, 0.128, and 0.190, respectively). There were no significant differences in other measured parameters, including the resistive index (P=0.205) and systolic acceleration time (P=0.489) of the hepatic artery and venous pulsatility index (P=0.494) of the hepatic vein. CONCLUSIONS: The measured velocities of graft hepatic vessels tended to increase after administration of USCA, but without statistical significance. The comparison of serial Doppler parameters with or without injection of USCA is valid during Doppler surveillance in recipients of LT.

Various factors contribute to graft extrusion in lateral meniscus allograft transplantation.

PURPOSE: Lateral meniscus allograft transplantation (LMAT) is a feasible surgical option for young meniscus-deficient patients. Although several studies have explored the factors that contribute to graft extrusion, they have not been fully elucidated. The aim of this study was to determine the various factors that contribute to graft extrusion. METHODS: Patients with knees that had received LMAT using a keyhole technique (n = 87 knees in 82 patients) were reviewed. The median age of these patients was 22 years (range 19-54 years), and the median postprocedural follow-up interval was 5 days (range 1-136 days). Twelve magnetic resonance imaging (MRI) measurement parameters (axial and coronal location of the bone block) that could potentially influence graft extrusion were evaluated, along with absolute graft extrusion and relative percentage of extrusion (RPE). RESULTS: A significant correlation was found between 8 of the 12 MRI measurement parameters and both the absolute extrusion and RPE (r = 0.241-0.438, p < 0.05). The absolute middle distance and depth of the bone block were independent predictors of the absolute extrusion (ß = 0.30 and 0.15, respectively; p < 0.05), and the relative middle distance and relative bone-block elevation were found to be predictors of RPE (ß = 2.29 and 1.44, respectively; p < 0.05). CONCLUSION: The rate of graft extrusions after LMAT was high in this study. Both the coronal and axial locations of the bone block were found to influence graft extrusion in LMAT. Therefore, correct positioning of the bone block, including in both the axial and coronal planes, is essential to minimize graft extrusion. Future studies need to investigate the long-term clinical outcome and longevity of extruded menisci after transplantation. LEVEL OF EVIDENCE: Therapeutic case series, Level IV.