Clinical Ultrasound in Hepatology: Training for Hepatologists UCL Institute for Liver and Digestive Health, Royal Free Hospital, London, UK June 2018 CONFOUNDING FACTORS affecting the performance of US elastography IVICA GRGUREVIC Ass Prof, MD PhD, FEBGH Department of Gastroenterology, Hepatology and Clinical Nutrition University Hospital Dubrava University of Zagreb School of Medicine, CROATIA
CONFOUNDING FACTORS affecting the performance of US elastography Technical factors Different techniques and vendors Measurement location Operator s factors experience Patient s factors Inflammatory activity Biliary obstruction Hepatic venous congestion Liver infiltration Liver steatosis Deep inspiration Food intake Body habitus of patients
Different techniques and vendors Different techniques and vendors use different shear wave frequencies, the liver stiffness values from different vendors are consequently not exchangeable. Kennedy P. Radiology 2018; 286(3): 738-63
Adjusted SWS estimates obtained by the commercial system used Hall TJ, In: Ultrasonics Symposium (IUS), 2013. I.E. International. 2013: 397 400
Cut-off values for F2 and F4 by different US Elastography methods TE Cut-off (kpa) (AUC) F 2 7.3-7.7 (0.84-0.87) pswe (ElastPQ) Cut-off (kpa) (AUC) 7.04-7.06 (0.77-0.88) 2DSWE (SSI) Cut-off (kpa) (AUC) 7.1 (0.86) F=4 13-15 (0.93-0.96) 9.11-10.4 (0.88-0.91) 13 (0.93) Friedrich-Rust, M. Gastroenterology 2008; 134: 960 974 Tsochatzis E. J Hepatol 2011;54:650-659 Ferraioli G. Digestive and Liver Disease 2018; doi.org/10.1016/j.dld.2018.03.033 Fraquelli M. Aliment Pharmacol Ther 2016; 44: 356 365 Herrmann E. Hepatology 2018; 67 (1): 260-72.
Measurement location Right liver lobe by intercostal approach LSM in LL by subcostal approach>lsm RL i.c. At least 1 cm below liver capsule To avoid fibrotic extensions from the Gleason s capsule Decreasing tendency of LSM in the deeper portions of the liver The region of interest (ROIs) should be placed in a homogenous area without vessels and artifacts To ensure good shear wave propagation Karlas T. Scand J Gastroenterol 2011; Horster S. Clin Hemorheol Microcirc 2010; Shin HJ. Eur Radiol 2016; Ferraioli G. WFUMB guidelines. Ultrasound Med Biol 2015; Barr RG. Radiology 2015; EFSUMB guidelines 2017.
2.5 cm
Adjusted SWS estimates as a function of depth into the the soft phantoms obtained using Siemens S2000 systems Hall TJ, In: Ultrasonics Symposium (IUS), 2013. I.E. International. 2013: 397 400
Experience TE: 100*-500** examinations pswe: 130 # *EASL CPG. J Hepatol 2015; Kettaneh A. J Hepatol 2007;46:628 634. **Castéra L. Hepatology 2010;51:828 835. #Fraquelli M. Aliment Pharmacol Ther 2016; 44: 356 365
Factors that affect liver stifness Mueller S, Hepatic Medicine: Evidence and Research 2010
Liver under tension Mueller S, Hepatic Medicine: Evidence and Research 2010
Inflammatory activity US elastography is unreliable for detecting liver fibrosis in patients with acute hepatitis Not reliable in patients with ALT>5x ULN I=Peak ALT; II=50% of peak; III=<2xULN Sagir A. Hepatology 2008; Arena U. Hepatology 2008; EASL CPG. J Hepatol 2015
Biliary obstruction Millonig G. Hepatology 2008; Attia D. Dig Liver Dis 2014 Attia D et al., Euroson 2013; 42 patients with mechanical biliary obstruction 28 (67%) with cholangitis
Liver steatosis Some report have suggested that US elastography was less accurate for detecting severe fibrosis in NAFLD, other studies have reported that liver stiffness was not affected by the presence of hepatic steatosis Macaluso FS. Journal of Hepatology 2014;61:523 529; ( overestimate) Gaia S. J Hepatol 2011 (underestimate fibrosis) ; Wong VW. Hepatology 2010;51:454-462.
Steatosis increases LSM N=324 NAFLD pts, all LB Petta S. Hepatology 2017
Hepatic venous congestion 10 pts Before After recomp. Millonig G. J Hepatol 2010;52:206-210. Frulio N. Hepatology 2009;50:1674-1675
Liver infiltration Diffuse infiltrative liver disease, such as amyloidosis, can also increase the liver stiffness. LS with tumours is best measured at >2 cm away from the tumour edge. The AUCs of LSM at 1 cm, 2 cm and >2 cm from the tumour edge for diagnosing cirrhosis were 0.760, 0.833 and 0.940. Loustaud-Ratti VR. Amyloid 2011;18:19-24.
Deep inspiration Deep inspiration has been shown to increase stiffness measurements compared with a resting expiratory position. Karlas T. Scand J Gastroenterol 2011;46:1458-1467; Dietrich CF. EFSUMB guidelines. Ultraschall Med 2017
Food intake Food intake significantly increase LSM associated with an increase in splanchnic and hepatic blood circulation. Fasting at least 2-3h prior to LSM Mederacke I. Liver Int 2009; Popescu A. Ultrasound Med Biol 2013;39:579-584. Gersak MM. Ultrasound Med Biol 2016;42:1295-1302.
Alcohol intake LSM cut-off 22.7 kpa suggests cirrhosis if actively drinking (AUROC 0.87) LSM cut-off 12.5 kpa suggests cirrhosis if abstinent (AUROC 0.91) Nahon P. J Hepatol 2008;49:1062 1068. Mueller S. World J Gastroenterol 2010;16:966 972.
Body habitus narrow intercostal space and severe obesity, can affect all US elastography methods Sandrin L. Ultrasound Med Biol 2003;29:1705-1713. Foucher J. Gut 2006;55:403-408. Castéra L. Hepatology 2010;51:828-835.
Failure to measure liver stiffness -impact of body weight- N=13 369 examinations N= 7 261 pts Castera L. Hepatology 2010; 51(3): 828
Failure to measure liver stiffness LSM not interpretable in 18.9% of cases LSM failure in 3.1%... independently associated with: BMI > 30 kg/m2 operator experience < 500 examinations age > 52 years type 2 diabetes Unreliable results in 15.8%...independently associated with: BMI >30 kg/m2 operator experience < 500 examinations age > 52 years female sex hypertension type 2 diabetes N=7 261 pts Different etiologies Castera L. Hepatology 2010
Čimbenici povezani s neuspješnim LSM pomoću TE i 2D-SWE Reliable LSM were similar for TE and 2D-SWE (73.9% vs 79.9%) N=383 No LB; TE as a reference Sporea I. Eur J Radiol 83 (2014) e118 e122
M vs XL probe M XL Ultrasound frequency 3.5 MHz 2.5 MHz Vibration amplitude 2 mm 3 mm Tip diameter 9 mm 12 mm Measurement depth 25-65 mm 35-75 mm The manufacturer recommends that the XL probe be used in patients with a skin-capsular distance 25 mm.
M vs XL probe *p<0.05 Myers RP. Hepatology 2012
M vs XL probe Myers RP. Hepatology 2012 M=XL+(1-2kPa)
Summary/Conclusion Tapper EB. Clinical Gastroenterology and Hepatology 2015 13, 27-36DOI: (10.1016/j.cgh.2014.04.039)
Journal of Hepatology 2015 Chairmen: Laurent Castera & Henry Lik Yuen Chan (EASL), Marco Arrese (ALEH). Clinical Practice Guidelines Panel members: Nezam Afdhal, Pierre Bedossa, Mireen Friedrich-Rust, Kwang-Hyub Han, Massimo Pinzani
Ultraschall in Med/Eur J Ultrasound 2017