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Progressive fibrosis is encountered in almost all chronic liver diseases. Its clinical signs are diagnostic in advanced cirrhosis, but compensated liver cirrhosis is harder to diagnose. Liver biopsy is still considered the reference method for staging the severity of fibrosis, but due to its drawbacks (inter and intra-observer variability, sampling errors, unequal distribution of fibrosis in the liver, and risk of complications and even death), non-invasive methods were developed to assess fibrosis (serologic and elastographic). Elastographic methods can be ultrasound-based or magnetic resonance imaging-based. All ultrasound-based elastographic methods are valuable for the early diagnosis of cirrhosis, especially transient elastography (TE) and acoustic radiation force impulse (ARFI) elastography, which have similar sensitivities and specificities, although ARFI has better feasibility. TE is a promising method for predicting portal hypertension in cirrhotic patients, but it cannot replace upper digestive endoscopy. The diagnostic accuracy of using ARFI in the liver to predict portal hypertension in cirrhotic patients is debatable, with controversial results in published studies. The accuracy of ARFI elastography may be significantly increased if spleen stiffness is assessed, either alone or in combination with liver stiffness and other parameters. Two-dimensional shear-wave elastography, the ElastPQ technique and strain elastography all need to be evaluated as predictors of portal hypertension.

Aim: To identify severe adverse events (SAEs) leading to treatment discontinuation that occur during antiviral therapy in hepatitis C virus (HCV)-infected cirrhotic patients., Methods: We identified all the articles published prior to December 2011 in the PubMed, Medline, Lilacs, Scopus, Ovid, EMBASE, Cochrane and Medscape databases that presented these data in cirrhotic patients. These studies evaluated the rate of SAEs leading to discontinuation of standard care treatment: Pegylated interferon (PegIFN) alpha 2a (135-180 μg/wk) or PegIFN alpha 2b (1 or 1.5 μg/kg per week) and ribavirin (800-1200 mg/d). Patients with genotype 1 + 4 underwent treatment for 48 wk, whereas those with genotypes 2 + 3 were treated for 24 wk., Results: We included 17 papers in this review, comprising of 1133 patients. Treatment was discontinued due to SAEs in 14.5% of the patients. The most common SAEs were: severe thrombocytopenia and/or neutropenia (23.2%), psychiatric disorders (15.5%), decompensation of liver cirrhosis (12.1%) and severe anemia (11.2%). The proportion of patients who needed to discontinue their therapy due to SAEs was significantly higher in patients with Child-Pugh class B and C vs those with Child-Pugh class A: 22% vs 11.4% (P = 0.003). A similar discontinuation rate was found in cirrhotic patients treated with PegIFN alpha 2a and those treated with PegIFN alpha 2b, in combination with ribavirin: 14.2% vs 13.7% (P = 0.96). The overall sustained virological response rate in cirrhotic patients was 37% (95%CI: 33.5-43.1) but was significantly lower in patients with genotype 1 + 4 than in those with genotype 2 + 3: 20.5% (95%CI: 17.9-24.8) vs 56.5% (95%CI: 51.5-63.2), (P < 0.0001)., Conclusion: Fourteen point five percent of HCV cirrhotic patients treated with PegIFN and ribavirin needed early discontinuation of therapy due to SAEs, the most common cause being hematological disorders.

Background: Acute pancreatitis (AP) is an acute inflammation of the pancreas with an unpredictable evolution. The aim of this study was to assess the factors associated with severe evolution of AP and to create a new score for predicting a severe outcome., Methods: The initial group included 334 patients hospitalized in 2006-2009. The validation group included 195 patients admitted in 2010-2011. AP was classified according to the Atlanta criteria., Results: In the initial group, C-reactive protein (CRP), creatinine, white blood count, body mass index (BMI), age and male gender were correlated with severe evolution of AP. Using only parameters available in emergency, by multiple regression analysis we obtained in the initial group the following score for predicting severe evolution of AP: Prediction pancreatic severity I score (PPS I score) = -1.038 + 0.119 × creatinine (mg/dL) + 0.012 × BMI (kg/m²) + 0.027xwhite blood count/1000 (cells/mm³) + 0.195 × gender (1-women, 2-men) + 0.005 × age (years). For a cut-off value >0.325, PPS I score had 71.8% accuracy (AUC=0.790) for predicting a severe evolution of AP. In the validation group the accuracy was 71.7%. Since CRP was proven to be a good predictor of severe evolution in AP, we calculated another score, PPS II, obtained using PPS I and CRP: PPS II score = -0.192 + 0.760 x PPS I + 0.003 x CRP (mg/L). For a cut-off value >0.397, PPS II score had 87.1% accuracy (AUROC=0.942) in the initial group and 75.3% accuracy in the validation group for predicting severe AP., Conclusions: PPS I and especially PPS II score are accurate predictors of severe outcome in patients with AP.

Aim: To assess whether acoustic radiation force impulse (ARFI) elastography can differentiate normal from pathological thyroid parenchyma., Methods: We evaluated 136 subjects (mean age 45.8 ± 15.6 years, 106 women and 30 men): 44 (32.3%) without thyroid pathology, 48 (35.3%) with Basedow-Graves' disease (GD), 37 (27.2%) with chronic autoimmune thyroiditis (CAT; diagnosed by specific tests), 4 (2.9%) with diffuse thyroid goiter and 3 (2.2%) cases with thyroid pathology induced by amiodarone. In all patients, 10 elastographic measurements were made in the right thyroid lobe and 10 in the left thyroid lobe, using a 1-4.5 MHZ convex probe and a 4-9 MHz linear probe, respectively. Median values were calculated for thyroid stiffness and expressed in meters/second (m/s)., Results: Thyroid stiffness (TS) assessed by means of ARFI in healthy subjects (2 ± 0.40 m/s) was significantly lower than in GD (2.67 ± 0.53 m/s) (P < 0.0001) and CAT patients (2.43 ± 0.58 m/s) (P = 0.0002), but the differences were not significant between GD vs CAT patients (P = 0.053). The optimal cut-off value for the prediction of diffuse thyroid pathology was 2.36 m/s. For this cut-off value, TS had 62.5% sensitivity, 79.5% specificity, 87.6% predictive positive value, 55.5% negative predictive value and 72.7% accuracy for the presence of diffuse thyroid gland pathology (AUROC = 0.804). There were no significant differences between the TS values obtained with linear vs convex probes and when 5 vs 10 measurements were taken in each lobe (median values)., Conclusion: ARFI seems to be a useful method for the assessment of diffuse thyroid gland pathology.

Aim: To assess the feasibility of performing acoustic radiation force impulse (ARFI) elastography in patients with ascites and its predictive value for the cirrhotic or non-cirrhotic etiology of ascites., Methods: Our study included 153 patients with ascites, mean age 58.8 ± 13.1 years. One hundred and fifteen (75.2%) patients had ascites in the context of cirrhosis, 29 (18.9%) had non-cirrhotic ascites (diagnosed by clinical, ultrasound, endoscopic and/or laparoscopic criteria) and in 9 (5.9%) cases we could not establish the etiology of ascites. We performed 10 ARFI measurements and the median value was calculated and expressed in meters/second (m/s). Among the 29 patients with non-cirrhotic ascites were included: 20 laparoscopically demonstrated peritoneal carcinomatosis with histological confirmation, 7 acute pancreatitis with ascites which later resolved, and one case each of lymphatic ascites and ascites in the context of a liver abscess. In 11 of the 20 patients with peritoneal carcinomatosis, the liver structure was homogenous in the ultrasound examination and in 9 patients the ultrasound exam revealed liver metastases., Results: We could not obtain valid ARFI measurements in 5 patients (3.2%). The mean liver stiffness measurements by means of ARFI were statistically significantly higher in patients with cirrhotic ascites than in those with non-cirrhotic ascites: 3.04 ± 0.70 vs 1.45 ± 0.59 m/s (P < 0.001). For a cut-off value of 1.8 m/s for predicting cirrhosis (and ascites in the context of cirrhosis), as obtained in a previous study, ARFI had 98.1% sensitivity, 86.2% specificity, 96.4% positive predictive value, 92.5% negative predictive value and 95.6% accuracy for predicting cirrhotic ascites. For a cut-off value of 1.9 m/s the accuracy was 94.9% and for a 2 m/s cut-off value it was 92.8%., Conclusion: ARFI elastography is feasible in most patients with ascites and has a very good predictive value for the cirrhotic or non-cirrhotic etiology of ascites.

Aim: To determine whether acoustic radiation force impulse (ARFI) elastography is a reliable method for predicting fibrosis severity in patients with chronic hepatitis C virus (HCV) hepatitis., Methods: We performed a multicenter study including 274 subjects with HCV chronic hepatitis in which we compared ARFI with liver biopsy (LB). In each patient we performed LB (evaluated according to the Metavir score) and ARFI measurements (using a Siemens Acuson S2000™ ultrasound system: 10 valid measurements were performed and median values were calculated and expressed in meters/second (m/s)., Results: A direct, strong, correlation (Spearman r = 0.707) was found between ARFI measurements and fibrosis (P < 0.0001). For predicting the presence of fibrosis (F ≥ 1 Metavir), significant fibrosis (F ≥ 2), severe fibrosis (F ≥ 3) and cirrhosis (F = 4), the cut-off values of 1.19, 1.21, 1.58 and 1.82 m/s were determined, respectively, liver stiffness measurements had 73%, 84%, 84% and 91% Se respectively; 93%, 91%, 94%, 90% Sp, respectively; with AUROCs of 0.880, 0.893, 0.908 and 0.937, respectively., Conclusion: ARFI measurement is a reliable method for predicting the severity of fibrosis in HCV patients.