Evaluation of Portal Hypertension and Varices by Acoustic Radiation Force Impulse Imaging of the Liver Compared to Transient Elastography and AST to Platelet Ratio Index

 

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Abstract

Background: Acoustic radiation force impulse imaging (ARFI) is a new method of liver stiffness measurement (LSM). The aim was to compare ARFI, transient elastography (TE) and AST to platelet ratio index (APRI) for the noninvasive diagnosis of clinically significant portal hypertension (CSPH, hepatic venous pressure gradient; HVPG ≥ 10 mmHg) and esophageal varices (EV).

Materials and Methods: LSM via ARFI and TE was performed in 88 consecutive patients with cirrhosis prior to HVPG measurement. The mean liver stiffness for ARFI was calculated out of 5 measurements for each lobe.

Results: LSM by TE and ARFI was not successful in 22 (25 %) patients and 1 (1 %) patient, respectively, due to ascites or obesity. Both TE (r = 0.765; p < 0.001) and ARFI (r = 0.646; p < 0.001) correlated significantly with HVPG. At the optimal cut-off (16.8kPa), TE (area under the curve, AUC 0.870) yielded a sensitivity and specificity of 89.7 % and 75 %, respectively, for predicting CSPH. At the optimal cut-off (2.58 m/s), the sensitivity and specificity for ARFI (AUC 0.855) were 71.4 % and 87.5 %, respectively. Using an APRI (AUC 0.838), the sensitivity and specificity were 69 % and 87.5 %, respectively. The AUC for the diagnosis of EV was 0.802 for TE (cut-off: 27.9kPa), 0.743 for ARFI (cut-off: 2.74 m/s), and 0.805 for APRI (cut-off: 1.90).

Conclusion: ARFI shows a higher applicability particularly in obese and ascitic patients. All three investigated methods show a high diagnostic accuracy for CSPH. Notably, APRI performed not significantly different compared to ARFI for the diagnosis of CSPH.

Zusammenfassung

Ziel: „Acoustic Radiation Force Impulse Imaging“ (ARFI) ist eine neue Methode zur Messung der Lebersteifigkeit. Ziel war es die Wertigkeit von ARFI und Transienter Elastografie (TE, Fibroscan(R)) sowie „AST to Platelet Ratio“ (APRI) für die Diagnose von klinisch signifikanter portaler Hypertension (CSPH = Lebervenendruckgradient über ≥ 10 mmHg) und Ösophagusvarizen (EV) zu evaluieren, welcher einen wesentlichen Prädiktor für den Krankheitsverlauf darstellt.

Material und Methoden: Bei 88 Patienten mit Leberzirrhose wurde ein Lebervenendruckgradient (HVPG), sowie die Lebersteifigkeit mittels TE und ARFI gemessen. Für ARFI wurde der Mittelwert aus jeweils 5 Messungen aus dem rechten und linken Leberlappen errechnet. Zudem wurde jeweils der APRI errechnet.

Ergebnisse: Die Messung der Lebersteifigkeit mittels TE konnte bei 22 Patienten (25 %) nicht durchgeführt werden, während nur bei einem Patienten mit Übergewicht und Aszites die Messung der Lebersteifigkeit mittels ARFI nicht möglich war. Sowohl TE (r = 0,765; p < 0,001) als auch ARFI (r = 0,646; p < 0,001) korrelierten mit den gemessenen Lebervenendruckgradienten. Sensitivität und Spezifität von TE (area under the curve (AUC 0,870) für die Diagnose einer CSPH bei einem Cut-off von 16,8 kPa waren 89,7 % und 75 %. Sensitivität und Spezifität für ARFI (AUC 0,855) bei einem Cut-off von (2,58 m/s) war 71,4 % und 87,5 %. Die AUC von APRI war 0,838, mit einer Sensitivität und Spezifität von 69 % und 87,5 % bei einem Cut-off von 1,48. Cut-offs und AUC für die Diagnose von Varizen waren 27,9 kPa (AUC 0,802) für TE, 2,74 m/s (AUC 0,743) für ARFI und ein Cut-off von 1,90 (AUC 0,805) für APRI.

Schlussfolgerung: ARFI kann im Gegensatz zu TE auch bei adipösen Patienten und Patienten mit Aszites erfolgreich durchgeführt werden. Es zeigt sich eine hohe Sensitivität und Spezifität für ARFI für die Diagnose einer klinisch signifikanten portalen Hypertension. Die Berechnung des APRI ist den nichtinvasiven Messmethoden der Lebersteifigkeit nicht unterlegen.

• References

• 1 Bosch J, Garcia-Pagan JC. Complications of cirrhosis. I. Portal hypertension. J Hepatol 2000; 32: 141-156
  CrossrefPubMedGoogle Scholar
• 2 Abraldes JG, Tarantino I, Turnes J et al. Hemodynamic response to pharmacological treatment of portal hypertension and long-term prognosis of cirrhosis. Hepatology 2003; 37: 902-908
  CrossrefPubMedGoogle Scholar
• 3 de Franchis R, Baveno VF. Revising consensus in portal hypertension: report of the Baveno V consensus workshop on methodology of diagnosis and therapy in portal hypertension. J Hepatol 2010; 53: 762-768
  CrossrefPubMedGoogle Scholar
• 4 Castera L, Le Bail B, Roudot-Thoraval F et al. Early detection in routine clinical practice of cirrhosis and oesophageal varices in chronic hepatitis C: comparison of transient elastography (FibroScan) with standard laboratory tests and non-invasive scores. J Hepatol 2009; 50: 59-68
  CrossrefPubMedGoogle Scholar
• 5 Lemoine M, Katsahian S, Ziol M et al. Liver stiffness measurement as a predictive tool of clinically significant portal hypertension in patients with compensated hepatitis C virus or alcohol-related cirrhosis. Aliment Pharmacol Ther 2008; 28: 1102-1110
  CrossrefPubMedGoogle Scholar
• 6 Castera L, Vergniol J, Foucher J et al. Prospective comparison of transient elastography, Fibrotest, APRI, and liver biopsy for the assessment of fibrosis in chronic hepatitis C. Gastroenterology 2005; 128: 343-350
  CrossrefPubMedGoogle Scholar
• 7 Reiberger T, Ferlitsch A, Payer BA et al. Noninvasive screening for liver fibrosis and portal hypertension by transient elastography-a large single center experience. Wien Klin Wochenschr 2012; 124: 395-402
  CrossrefPubMedGoogle Scholar
• 8 Castera L, Pinzani M, Bosch J. Non Invasive Evaluation of Portal Hypertension Using Transient Elastography. J Hepatol 2012; 56: 696-703
  CrossrefPubMedGoogle Scholar
• 9 Akima T, Tamano M, Hiraishi H. Liver stiffness measured by transient elastography is a predictor of hepatocellular carcinoma development in viral hepatitis. Hepatol Res 2011; 41: 965-970
  CrossrefPubMedGoogle Scholar
• 10 Millonig G, Friedrich S, Adolf S et al. Liver stiffness is directly influenced by central venous pressure. J Hepatol 2010; 52: 206-210
  CrossrefPubMedGoogle Scholar
• 11 Millonig G, Reimann FM, Friedrich S et al. Extrahepatic cholestasis increases liver stiffness (FibroScan) irrespective of fibrosis. Hepatology 2008; 48: 1718-1723
  CrossrefPubMedGoogle Scholar
• 12 Chan HL, Wong GL, Choi PC et al. Alanine aminotransferase-based algorithms of liver stiffness measurement by transient elastography (Fibroscan) for liver fibrosis in chronic hepatitis B. J Viral Hepatol 2009; 16: 36-44
  CrossrefPubMedGoogle Scholar
• 13 Castera L, Foucher J, Bernard PH et al. Pitfalls of liver stiffness measurement: A 5-year prospective study of 13,369 examinations. Hepatology 2010; 51: 828-835
  PubMedGoogle Scholar
• 14 Friedrich-Rust M, Wunder K, Kriener S et al. Liver fibrosis in viral hepatitis: noninvasive assessment with acoustic radiation force impulse imaging versus transient elastography. Radiology 2009; 252: 595-604
  CrossrefPubMedGoogle Scholar
• 15 Sporea I, Silri RL. Hepatic elastography for the assessment of liver fibrosis--present and future. Ultraschall in Med 2012; 33: 550-558
  Article in Thieme ConnectPubMedGoogle Scholar
• 16 Piscaglia F, Salvatore V, Di Donato R et al. Accuracy of VirtualTouch Acoustic Radiation Force Impulse (ARFI) imaging for the diagnosis of cirrhosis during liver ultrasonography. Ultraschall in Med 2011; 32: 167-175
  Article in Thieme ConnectPubMedGoogle Scholar
• 17 Sporea I, Bota S, Peck-Radosavljevic M et al. Acoustic Radiation Force Impulse Elastography for fibrosis evaluation in patients with chronic hepatitis C: An international multicenter study. Eur J Radiol 2012; 81: 4112-4118
  CrossrefPubMedGoogle Scholar
• 18 Rifai K, Cornberg J, Bahr M et al. ARFI elastography of the spleen is inferior to liver elastography for the detection of portal hypertension. Ultraschall in Med 2011; 32: E24-E30
  Article in Thieme ConnectPubMedGoogle Scholar
• 19 Bota S, Sporea I, Sirli R et al. Can ARFI elastography predict the presence of significant esophageal varices in newly diagnosed cirrhotic patients?. Ann Hepatol 2012; 11: 519-525
  PubMedGoogle Scholar
• 20 Gao J, Ran HT, Ye XP et al. The stiffness of the liver and spleen on ARFI Imaging pre and post TIPS placement: a preliminary observation. Clin Imaging 2012; 36: 135-141
  CrossrefPubMedGoogle Scholar
• 21 Lackner C, Struber G, Liegl B et al. Comparison and validation of simple noninvasive tests for prediction of fibrosis in chronic hepatitis C. Hepatology 2005; 41: 1376-1382
  CrossrefPubMedGoogle Scholar
• 22 Batts KP, Ludwig J. Chronic hepatitis. An update on terminology and reporting. Am J Surg Pathol 1995; 19: 1409-1417
  CrossrefPubMedGoogle Scholar
• 23 Bedossa P, Poynard T. An algorithm for the grading of activity in chronic hepatitis C. Hepatology The METAVIR Cooperative Study Group. 1996; 24: 289-293
  CrossrefPubMedGoogle Scholar
• 24 Wai CT, Greenson JK, Fontana RJ et al. A simple noninvasive index can predict both significant fibrosis and cirrhosis in patients with chronic hepatitis C. Hepatology 2003; 38: 518-526
  PubMedGoogle Scholar
• 25 Nightingale K, Soo MS, Nightingale R et al. Acoustic radiation force impulse imaging: in vivo demonstration of clinical feasibility. Ultrasound Med Biol 2002; 28: 227-235
  CrossrefPubMedGoogle Scholar
• 26 Groszmann RJ, Wongcharatrawee S. The hepatic venous pressure gradient: anything worth doing should be done right. Hepatology 2004; 39: 280-282
  CrossrefPubMedGoogle Scholar
• 27 Ferlitsch A, Teml A, Reinisch W et al. 6-thioguanine associated nodular regenerative hyperplasia in patients with inflammatory bowel disease may induce portal hypertension. Am J Gastroenterol 2007; 102: 2495-2503
  CrossrefPubMedGoogle Scholar
• 28 Hanley JA, McNeil BJ. The meaning and use of the area under a receiver operating characteristic (ROC) curve. Radiology 1982; 143: 29-36
  CrossrefPubMedGoogle Scholar
• 29 Carrion JA, Navasa M, Bosch J et al. Transient elastography for diagnosis of advanced fibrosis and portal hypertension in patients with hepatitis C recurrence after liver transplantation. Liver Transpl 2006; 12: 1791-1798
  CrossrefPubMedGoogle Scholar
• 30 Thabut D, Moreau R, Lebrec D. Noninvasive assessment of portal hypertension in patients with cirrhosis. Hepatology 2011; 53: 683-694
  CrossrefPubMedGoogle Scholar
• 31 Ferlitsch M, Reiberger T, Hoke M et al. Von willebrand factor as new non-invasive predictor of portal hypertension, decompensation and mortality in patients with liver cirrhosis. Hepatology 2012; 56: 1439-1447
  CrossrefPubMedGoogle Scholar
• 32 Vermehren J, Polta A, Zimmermann O et al. Comparison of acoustic radiation force impulse imaging with transient elastography for the detection of complications in patients with cirrhosis. Liver Int 2012; 32: 852-858
  CrossrefPubMedGoogle Scholar
• 33 Bamber J, Cosgrove D, Dietrich CF et al. EFSUMB guidelines and recommendations on the clinical use of ultrasound elastography. Part 1: Basic principles and technology. Ultraschall in Med 2013; 34: 169-184
  Article in Thieme ConnectPubMedGoogle Scholar
• 34 Cosgrove D, Piscaglia F, Bamber J et al. EFSUMB guidelines and recommendations on the clinical use of ultrasound elastography. Part 2: Clinical applications. Ultraschall in Med 2013; 34: 238-253
  Article in Thieme ConnectPubMedGoogle Scholar
• 35 Karlas T, Pfrepper C, Wiegand J et al. Acoustic radiation force impulse imaging (ARFI) for non-invasive detection of liver fibrosis: examination standards and evaluation of interlobe differences in healthy subjects and chronic liver disease. Scand J Gastroenterol 2011; 46: 1458-1467
  CrossrefPubMedGoogle Scholar
• 36 Bolognesi M, Sacerdoti D, Merkel C et al. Noninvasive grading of the severity of portal hypertension in cirrhotic patients by echo-color-Doppler. Ultrasound Med Biol 2001; 27: 901-907
  CrossrefPubMedGoogle Scholar
• 37 Berzigotti A, Piscaglia F. EFSUMB Education and Professional Standards Committee.. Ultrasound in portal hypertension--part 2--and EFSUMB recommendations for the performance and reporting ofultrasound examinations in portal hypertension. Ultraschall in Med 2012; 33: 8-32
  Article in Thieme ConnectPubMedGoogle Scholar
• 38 Han JY, Cho JH, Kwon HJ et al. Predicting portal hypertension as assessed by acoustic radiation force impulse: correlations with the Doppler ultrasound. Br J Radiol 2012; 85: e404-e409
  CrossrefPubMedGoogle Scholar